Prevalence of SSIs Magill ID week abstract Oct. 2017 Results point - - PDF document

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 1

Surgical Site Infections (SSI): The Perfect Storm: Current Guidelines Including Environmental & Sterilization Challenges

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

Prevalence of SSIs

Magill ID week abstract Oct. 2017 Results point prevalence study 2015

 Now 3rd most common HAI from 2015 data  SSI HAI among all hospitalized patients in the survey

fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001).

 Attributed to better adherence to guidelines

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association 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

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

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 3

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

Challenges

• Time
• Turnover
• Surgeon preference
• Adherence factors

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 4

Bacteria get into wounds

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 5

Topics

 Core :

Antibiotic Prophylaxis Glycemic control Normothermia Tissue oxygenation Skin Preparation

 Arthroplasty

Transfusion Immunosuppresive therapy Anticoagulation Orthopedic space suit Antimicrobial prophylaxis with drains biofilm

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 6

Recommendations

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 7

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 8

Improvement Opportunities Are there gaps between policy and practice?

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 9

Where to Start

 Gap analysis  Evidence based guidelines  Cleaning  Sterilization

Etiology

Exogenous sources:

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

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 10

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.

Risk Factors for SSI

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 11

Surgical Technique

 May have to look beyond the bundle  Sterile fluids  Soaking  Wound closure technique  Intraoperative management

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 12

Gaps in OR Cleaning

 Many persons involved in OR cleaning:

EVS Nurses Multiple turnovers Equipment moved from room to room Multiple patients

General Review Standards and Guidelines

• Beginning of day:

 Horizontal surfaces  Furniture  Equipment  Surgical lights

• After each procedure:
• Frequently touched areas
• Appropriate disinfectant or detergent

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 13

How about Cleaning?



Tiered approach



Direct practice observation



Environmental Monitoring Swabs ATP Fluorescent Markers PCR

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 14

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 15

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

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 16

• 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

Traffic Flow

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 17

Strategies 2018 Top Ten Health Hazards

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 18

Decontamination Decontamination

 Starts in surgery  If initial decontamination does not take place in

surgery; it may be impossible to properly clean instruments

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 19

Looking Clean What about IUSS?

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 20

Do you track IUSS Use?

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 21

Implants

Implants should be free of all contaminants and residues which could harm a patient

Lubrication Issues

Chasing Zero Infections Connecting the Dots to Reduce Patient Harm: Hot Topics in Infection Prevention November 16, 2017 Mission to Care | Florida Hospital Association Hospital Improvement Innovation Network 22

Other issues

 Walking rounds  When does decontamination occur  Appropriate PPE  Vendors  Instructions for Use ( IFUs)  Appropriate cleaning

Conclusion

 SSIs are a complex problem  Need a team approach  Start with the basics and move forward