Objectives Discuss the impact of surgical site infections (SSIs) - - PDF document

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Objectives Discuss the impact of surgical site infections (SSIs) - - PDF document

Jan 23, 2024 457 likes •680 views

Infection Prevention Boot Camp I for the Novice January 16 17, 2020 Infection Preventionist Surgical Site Infections; Evidence and Engagement Linda R. Greene, RN, MPS,CIC,FAPIC Manager, Infection Prevention UR Highland Hospital Rochester,

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 1 Surgical Site Infections; Evidence and Engagement

Linda R. Greene, RN, MPS,CIC,FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu

Objectives

 Discuss the impact of surgical site infections (SSIs)  Discuss technical and behavioral issues which may

impact SSIs

 Identify strategies to reduce SSIs

Current Burden

Burden (US)

 160,000 - 300,000 SSIs per year  2-5% of patients undergoing inpatient surgery  Most common and costly HAIs

Mortality

 2-11 fold higher risk of death  Length of stay  7-11 additional post-op days

Anderson D et.al Strategies to Prevent Surgical Site Infections in Acute Care hospitals

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 2

Burden

 Cost $3.5 -$10 Billion annually  Estimated cost per infection ranges from $11,000 - $35,000  Colon and Hysterectomy contribute to HAC reduction and

Value Based Purchasing

 Contribute to 30 day unplanned readmissions

Changes in SSI Surgical Risks

Most Common Complications during surgery:

 Surgical site infection  Postoperative sepsis  Thromboembolic complications  Cardiovascular  Respiratory ( pneumonia)

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 3

Patient Risk Factors for Infections

Perioperative serum glucose 180-200mg/dl Smoking BMI ≥ 30 Nutritional status Depth of subcutaneous tissue ≥ 3cm Co-existing infection at remote body site American society of anesthesiologist physical status classification system Immunodeficiency ( Chronic steroid use, chemotherapy) MRSA status

Modifiable Risk Factors

Pre-operatively

 Weight loss  Nutritional status  Diabetes  Tobacco use  Prolonged steroid use  Remote infections

Basic Practices

Pre-Testing/Office Setting

  • 1. Education
  • Give patient the patient education tools (SSI Prevention Sheet).
  • Provide education about hand hygiene.
  • Document receipt and understanding of the material.
  • 2. Smoking Cessation (Office setting)
  • Encourage Smoking Cessation for at least 30 days.
  • 3. Screen for Infections
  • Screen for infections during preadmission testing – refer for treatment.
  • Document history of MDRO (multi-drug resistant organism).
  • 4. Nutrition/Pre-Op Diet
  • NPO for solids 8 hours pre-operatively and 2 hours pre-operatively for clear liquids.
  • 5. Pre-Op Skin Prep
  • Require bathing or showering night before and morning of surgery.
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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 4

Preoperative Measures

 Treat remote infections

 Manage UTI, URI and skin infection before an elective

surgery

Treat all infections appropriately in elective surgery

 Encourage weight loss and improve nutrition

 In planned surgery, recommend weight loss

 Immunodeficiency should be corrected if possible

 Collaboration with other specialist(s) in patients on

prolonged steroids

 Improve immune status

Evidence Based Guidelines

  • Optimal hemoglobin A1C targets levels
  • Advise patients to shower or bathe (full body) with soap (antimicrobial or non-antimicrobial)
  • r an antiseptic agent on at least the night before the operative day

The intra-operative period

Procedural variables that affect risk of SSI: Antibiotic prophylaxis Duration of Surgical scrub Pre-op hair removal Choice of pre-op skin preparation- need both fast acting and sustained effect Wound class

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 5

Variables

Sterilization of instrument and the environment Foreign material in the surgical site Surgical technique Elevated Glucose- high Glucose levels with or without diabetes Hypothermia – vasoconstriction limits blood flow and oxygen https://www.infectiousdiseaseadvisor.com/home/decision- support-in-medicine/hospital-infection-control/surgical-site- infections/

Observations

 All surgical wounds are contaminated by bacteria but

  • nly a few get infected

 Different operations have different inoculums of

bacteria

 Similar operations performed by the same surgeon in

different populations have different rates of infection

 SSIs have varying degrees of severity

Bacteria get into wounds

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 6

Where are the Pathogens ?

Pathogen source for most SSIs is endogenous flora of the patient’s skin, mucous membranes or GI tract. 20% of the skin’s pathogens live beneath the epidermal layer in hair follicles and sebaceous glands. Any incision can carry some of the bacteria directly to the

  • perative site.

Leading SSI Pathogens

Gram Positive Bacteria MRSA MSSA

  • Coag. Negative Staph

Enterococci Streptococci Species Gram Negative Bacteria Enterobacter Pseudomonas Ecoli Other Bacteria Anaerobic Bacteria Fungi

Etiology

Exogenous sources:

 Hands of care givers  Exposure to non sterile environment  Contamination of fluid, supplies or equipment  Air flow

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 7

Etiology

Surgical Site Infections can be attributed to the patient’s

  • wn endogenous flora or from exogenous sources.

Example:

 Patient’s skin  Contamination during surgery  Oropharyngeal contamination  Patient’s natural immunity

Risk Factors for SSIs

Host Factors Host Factors Surgical/ Environmental Factors Microbial Flora Host

Obesity Age ASA Cancer Immunosuppression

Microbial

Nasal Carriage Virulence Inoculum

Surgical / Environmental

Procedure Hair Removal Prophylaxis Technique Contamination Urgency

Reviewing what we know

 Most infections are seeded at the time of surgery  There are several procedural risk factors  Monitoring of Risk factors may help identify

  • pportunities for opportunities
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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 8

SSIs

Majority of SSIs are seeded at the time of surgery while the wound is open examples:

Microorganisms Examples Patients own skin flora Microorganisms colonizing skin or other body parts, infection present Surgical Team Colonized member of team Breaks in aseptic technique Wound contact with unsterile environment Sterility failures High bioburden. Contaminated instruments Door openings Interruption of positive pressure Other endogenous flora Bowel flora, etc.

Skin Scales

Antibiotics for penicillin allergy ?

 Cephalosporin if no immediate hypersensitivity reactions

Bratzler DW et al. Am J Health Syst Pharm 2013 Pichichero ME. et al. Ann Allergy Asthma Immunol 2014

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 9

Antibiotics for MRSA

 Patients with a hx or known methicillin-resistant

staphylococcus aureus ( MRSA)  Single preoperative dose of vancomycin is

recommended plus Cephalosporin

Bratzler DW et al. Am J Health Syst Pharm 2013 Schweizer M.et al. BMJ 2013

Revisit Hair Removal

AORN Edmiston et. al May 2019

AORN Guidelines 2019 GUIDELINE FOR STERILE TECHNIQUE

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 10

AORN Continued Are there gaps between policy and practice? Direct Observation

One of out most powerful tools is direct observation: Examples:

 Patients surgical scrub were performed either by a PA

  • r RN that were not sufficient.

Long sleeves on when prepping, but gown was flapping loose and touched prep area. Gowns worn while prepping should be tired to prevent inadvertently grazing the prepped area

 Insufficient number of prep sticks used to cover

  • perative area. Found provider prepping patient did

not perform in sterile fashion. Prep stick touched non sterile areas and was brought back to “sterile” area.

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 11

Observations Continued

 Clipping of surgical site was done on OR table. Hairs

were pushed on floor and some left on the sheet or on patient’s limb.

Gloves should be changed after patient has been draped, again prior to touching the implant, and every 60 to 90 min. throughout case.

 Turnover started when patient was still in the room.  Anesthesia was noted to have removed his mask and

peering over the operative drape.

Etiology

Surgical Site Infections can be attributed to the patient’s

  • wn endogenous flora or from exogenous sources.

Example:

 Patient’s skin  Contamination during surgery  Oropharyngeal contamination  Patient’s natural immunity

Etiology

Exogenous sources:

 Hands of care givers  Exposure to non sterile environment  Contamination of fluid, supplies or equipment  Air flow

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 12

Challenges

  • Time
  • Turnover
  • Surgeon preference
  • Adherence factors

Leading SSI Pathogens

Gram Positive Bacteria MRSA MSSA

  • Coag. Negative Staph

Enterococci Streptococci Species Gram Negative Bacteria Enterobacter Pseudomonas Ecoli Other Bacteria Anaerobic Bacteria Fungi

SSIs

Majority of SSIs are seeded at the time of surgery while the wound is open examples:

Microorganisms Examples Patients own skin flora Microorganisms colonizing skin or other body parts, infection present Surgical Team Colonized member of team Breaks in aseptic technique Wound contact with unsterile environment Sterility failures High bioburden. Contaminated instruments Door openings Interruption of positive pressure Other endogenous flora Bowel flora, etc.

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 13 Evidence Based Practices

HICPAC Guidelines for Prevention of SSI-? Compendium of Strategies -2014 WHO -2016

http://www.who.int/gpsc/ssi-guidelines/en/

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 14

Compendium of Strategies 2014

2 levels of recommendations Basic – Recommended for all hospitals Special – Consider if there is still a problem based on surveillance data or risk assessment

Basic Practices

Maintain intra-operative temp > 35.5

Use an alcohol containing skin prep unless contraindicated

Use a surgical safety checklist

Maintain post-operative blood glucose ≤ 180 mg/dL. Cardiothoracic surgical procedures (High ) Non-cardiac procedures ( Moderate)

Use impervious wound protectors in GI and biliary procedures

Dronge Arch Surg 2006; Golden Diabetes care 1999; Olsen MA J BoneJoint Surg Am 2008

http://apic.org/Resource_/TinyMceFileManager/Implementation_Guides/APIC_ImplementationPreventionGuide_Web_FIN03.pdf

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 15

Complex Practice Setting

Selected Elements of Surgical Care Bundle from Literature

https://www.dhs.wisconsin.gov/hai/ssi-prevention.htm

Colorectal Bundle

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 16

Strategies to Prevent SSIs

You must consider whether any given risk is : Modifiable: i.e. glucose, antimicrobial administration, hair removal Non Modifiable: i.e. age, co-morbidities, severity of illness, wound class

General Cleaning Recommendations

Beginning of the day Wipe down:

 Horizontal features  Furniture  Equipment

After each procedure Frequently touched areas

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 17

Traffic Control

Tracers in OR Primary Hip observed- 27 different entries into OR room Hysterectomy Davinci - 31 entries What does the evidence tell us?

  • Doors open average of 9.5 minutes per case
  • Loss of positive pressure
  • 77 of 191 cases had doors open long enough to

defeat positive pressure

  • Enhancing air quality by reducing airborne contamination has been

shown to be of great importance, especially in relation to implant surgery.,

  • Suggested levels be maintained at <10 CFU/m during implant

surgery, and that clinical benefits can be expected by reducing it to 1 CFU/m

  • Very low levels of clinically relevant coagulase-negative staphylococci

can initiate a device-related infection

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 18

Traffic Flow Strategies Pre Cleaning of Instruments

 Issues with bioburden  Must be cleaned or wiped down at point of use  Instruments must be kept moist  Hinged instruments kept open

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 19

Instrumentation

Dancer S J, Stewart M, Coulombe C, Gregori A, and Virdi M.: Surgical site infections linked to contaminated surgical instruments. J Hosp Infect. 2012; 81(4): 231–238

  • Sudden increase in surgical site infection rate following 'clean' surgery.
  • 15 orthopedic patients following metal insertion
  • 5 ophthalmology patients who developed endophthalmitis

Findings:

  • Lapses in sterilization
  • Lack of pre - cleaning by OR staff

Conclusions:

  • Collaboration
  • Cooperation
  • Standardization

Instrumentation

 Preparation for decontamination of instruments should

begin at the point of use

 During the procedure, the scrub person should remove

gross soil from instruments by wiping the surfaces with a sterile surgical sponge moistened with sterile water Every case, Every patient, Every time?

Rounding

 Observed room turnover  Equipment cleaning  Terminal cleaning

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 20

Findings

  • 1. Inconsistent cleaning practices
  • 2. Special cleaning of major equipment lacking
  • 3. Initial pre-cleaning of equipment

Actions

  • 1. Review of terminal cleaning with EVS
  • 2. Delineation of cleaning procedures
  • 3. Pre-cleaning procedure

Standards

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Infection Prevention Boot Camp I for the Novice Infection Preventionist January 16‐17, 2020 Florida Hospital Association | Mission to Care Hospital Improvement Innovation Network 21

Tools

ATP Fluorescent Marker

Example Final Strategies

 Engage surgeons and OR staff in case reviews  Share definitions  Provide input  Team approach