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Best Prac*ces to Prevent Surgical Site Infec*ons

Jacqueline Daley HBSc., MLT, CIC, CSPDS Director Infec*on Preven*on and Control Sinai Hospital of Bal*more

Conflict of Interest Statement

•   Speaker’s Bureau –  Sage –  3M

Learning Objec*ves

1.   Understand the financial and people burden of surgical site infec*on.

2.   List 3 best prac*ces for reducing the risk of surgical site infec*ons.

3.   List 3 outcomes resul*ng from implemen*ng best prac*ces.

Burden of Surgical Site Infec*on (SSI)

CDC -‐ “USA -‐ ~46.5 million surgical procedures are performed each year.”

SSIs are the most common adverse event for surgical paCents.

Second most common type of adverse event occurring in hospitalized paCents

2%-‐5% of paCent undergoing inpaCent surgery in the USA will have an SSI.

Rutala, Weber and HICPAC. CDC Guidelines for Disinfec*on and Steriliza*on in Healthcare Facili*es, 2008 5 Million Lives Campaign. Ge3ng Started Kit:: Prevent Surgical Site Infec?ons How to Guide. Cambridge, MA: Ins?tute of Health Care Improvement; 2008 Anderson, DJ, Kaye, KS et al. Strategies to Prevent Surgical Site Infec?ons in Acute Care Hospitals. SHEA/IDSA Prac?ce Recommenda?ons Preven?on Compendium 2008 Kurtz, Steven, Lau, Edmund et. al. Infec?on Burden for Hip and Knee Arthroplasty in the United States. The Journal of Arthroplasty. 2008; 23(7):984-‐991)

Burden of Surgical Site Infec*ons (SSI) Outcomes Associated with SSI

–   approx. 7-‐10 addi*onal post-‐op hospital days (deep and organ-‐space infec*on much longer)

–   Are 5 *mes more likely to be re-‐admi^ed –   Have a 60% increase in ICU admissions –   2-‐11 *mes higher risk of death –   77% of deaths among pa*ents with SSI are directly a^ributable to SSI.

–   A^ributable cost es*mates range from $3,000-‐$29,000 (maybe more for deep and organ-‐space infec*ons)

–   SSIs are believed to account for up to $10 billion annually in healthcare expenditures.

EsCmated that 40%-‐60% of SSIs are preventable! Anderson, DJ, Kaye, KS et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. SHEA/IDSA Practice Recommendations Prevention Compendium 2008 The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections (SSIs)

CMS Medicare Program -‐ Proposed Rule -‐ FY 2015 – Cost Impact

•   Reports 1.4 million total hip and knee arthroplas*es -‐ Medicare fee for service (FFS) pa*ents aged 65 or older 2008 -‐ 2010

•   Proposed rule -‐ THA / TKA measure in the Hospital Readmissions Reduc*on Program beginning in FY 2015

•   Medicare costs are very high –   THA and TKA procedures, combined -‐ largest procedural cost in the Medicare budget.

•   Median 30-‐day risk -‐standardized readmission rate pa*ents aged 65 or older undergoing THA/TKA 2008 -‐2010 -‐ 5.7 percent; ranged from 3.2% -‐ 9.9% across 3,497 hospitals.

Burden of Orthopedic SSIs §  Findings

–   Annual cost of Joint Replacement is $250 million –   Cost of revision is due to infec*on is 2.8x higher than asep*c loosening and 4.8x higher than cost of a primary total hip arthroplasty

–   Total cost of a total knee arthroplasty revision due to infec*on ranges from $15,000 to $30,000

–   Total hip arthroplasty revision due to infec*on as compared to asep*c loosening results in:

•   Increase hospitaliza*ons •   Increase length of stay •   Increase number of opera*ve procedures •   Increase outpa*ent visits and charges

•   CDC NHSN 2006-‐2008 •   Knee replacement postopera*ve infec*ons rates ranged from 0.68% -‐ 1.60% based on pa*ent risk

•   Hip replacement postopera*ve infec*on rates ranged from 0.67% -‐ 2.4%

Guide to the Elimination of Orthopedic Surgical Site Infections. APIC Elimination Guide 2010.

Project JOINTS: Enhanced SSI Preven*on Bundle: Hip and Knee Arthroplasty How-‐to

Guide

Project JOINTS (Joining Organiza*ons in Tackling SSIs) •   Voluntary ini*a*ve funded by HHS and supported by

American Academy of Orthopaedic Surgeons (AAOS) •   Bundle includes:

–   Use of alcohol-‐containing an*sep*c agent for preopera*ve skin prepara*on

–   Preopera*ve bathing or showering with chlorhexidine gluconate (CHG) soap for 3 days prior to surgery

–   Staph aureus screening and use of 5 days intranasal mupirocin and 3 days CHG bathing or showering to decolonize Staph aureus carriers

–   Appropriate use of prophylac*c an*bio*cs –   Appropriate hair removal

IHI. How-‐to Guide: Project JOINTS Enhanced Surgical Site Infec*on Preven*on Bundle: Hip and Knee Arthroplasty. Updated March 2012; pp. 1-‐33

The Joint Commission and SSI

2014 Na*onal Pa*ent Safety Goal 7 •   Reduce the risk of health care-‐associated infec*ons (HAI) •   NPSG.7.01.01 Comply with current WHO or CDC hand

hygiene guidelines

•   NPSG.07.05.01 Implement evidence-‐based prac*ces for preven*ng surgical site infec*ons

–   Implement policies and prac*ces aimed at reducing the risk of surgical site infec*ons. These policies and prac*ces meet regulatory requirements and are aligned with evidence-‐based guidelines (e.g. CDC and/or professional organiza*on guidelines)

www.jointcommission.org

Opera*ve Risk Factors Skin

ü  Dura*on of scrub -‐ hands ü  Skin an*sepsis ü  Pre-‐op hair removal ü  Pa*ent pre-‐op skin prepara*on

Surgeon/Surgical Team ü Surgical technique ü Dura*on of surgery (exceeding

75th percen*le or >3 hours) ü Foreign material in site ü Use of drains ü An*bio*c prophylaxis

Environment ü OR ven*la*on ü Traffic control ü Doors open

Steriliza*on of instruments ü Immediate use steam

steriliza*on (IUSS) ü Loaner instrumenta*on ü IUSS of implants ü Release of load before the results

of biological indicator

Mangram, Alicia J. et. Al. Guideline For Prevention of Surgical Site Infections, 1999 Bratzler D, Dellinger, E. Patchen, et. al.Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283

Periprosthe*c Joint Infec*ons -‐ Opera*ve Risk Factors

Greatest risk of developing an infec*on (excluding the presence of a systemic an*microbial prophylaxis)

Dura*on of surgery (exceeding 75th percen*le or >3 hours) Ø  Site classifica*on

§  Contaminated or dirty Ø  No systemic an*microbial prophylaxis

Contribu*ng factor to SSI Ø  Forma*on of biofilm with Staph aureus or Staph epidermidis on inert surfaces of orthopedic devices §  An?microbial resistance §  Poor an?microbial penetra?on

Bratzler D, Dellinger, E. Patchen, et. al.Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283

PRE-‐OP -‐ Evidence-‐based Prac*ces

v  Hair removal as close to surgery as possible §  Op*on for depilatory or clippers

v  An*sep*c showering – night before and morning of surgery §  Decrease bioburden on skin at *me of surgery §  Clean linen and clean clothing

v  Pa*ent skin prep in the OR §  Use according to manufacturer’s instruc*ons and allow prep to dry

v  Pre-‐op nasal decontamina*on

Mangram, AJ, Horan, TC et al. Guideline for Preven*on of Surgical Site Infec*on, 1999

Exogenous sources of SSI pathogens People = shedding; 4,000 –

10,000 par<cles/minute1

Surgical personnel

Primarily Gram posi<ve organisms (staph, strep)

Air, OR traffic, doors propped open

Wind current carry par<cles to the sterile field resul<ng in wound contamina<on

Tools, instruments, equipment, materials brought

into sterile field

1.   Berry & Kohn’s, Opera*ng Room Technique, 11th ed., p. 252 2.   Mangram, AJ, Horan, TC et al. Guideline for Preven*on of Surgical Site Infec*on, 1999

Hair Removal •   Tanner (2006)

–   Cochrane review of shaving, clipping, depilatory cream, and no hair removal

–   Meta-‐analysis –   11 randomized controlled trials

à Incidence of infec*on higher with shaving versus clipping RR=2.02 (CI 1.21-‐3.36)

Thanks to Dr. Aaron Johnson and Dr. Michael Mont for making this slide available for use.

Hair – Remove or Not Remove? •   CDC recommenda*ons

–  Do not remove unless hair at or around the incision site would interfere with the opera*on (CDC 1A) (AII)

–   If necessary, then should be performed immediately before the opera*on, preferably with electric clippers (CDC 1A) (AII)

•   Clipping to be done outside the OR –  Difficult to control loose hair

•   This has become the standard of prac*ce Mangram, AJ, Horan, TC et al. Guideline for Preven*on of Surgical Site Infec*on, 1999 Periopera*ve Nursing Clinics 3 (2) (2008) 107-‐113

Surgical Site Infec*on Pathogenesis

•   Microbial contamina*on of surgical site –   Incising skin creates a portal

of entry for bacteria –   Contamina*on with >105

organisms/gram of *ssue increases risk of infec*on

–   Dose of organism is less if foreign material/body in place, 100 organisms/gram of *ssue

Skin An<sepsis

•   Pa*ent – Pre-‐op An*sep*c Showers

•   Skin prep needs to be used to reduce endogenous flora and reduce the risk of SSI

•   Pa*ent – An*sep*c Skin Prep prior to incision

•   Surgical Team – Hand An*sepsis

Skin An*sepsis -‐ Professional Guidelines Recommenda*ons?

CDC -‐ Strongly Recommended (Category 1B) that pa<ents shower with an an<sep<c agent before

undergoing an elec<ve surgical procedure.

2014 AORN Guidelines for Preopera<ve Pa<ent Skin An<sepsis -‐ Pa<ents undergoing open class I surgical

procedures below the chin should have two (2) preopera<ve showers with CHG before surgery,

when appropriate.

SHEA/IDSA Compendium: SSI Preven<on Prac<ce Recommenda<on -‐ To gain maximum an<sep<c effect of Chlorhexidine, it must be allowed to dry

completely and not be washed off.

Prevent Surgical Site Infec*on Pre-‐Opera<ve An<sep<c Showering •   Decreases skin microbial count •   Two pre-‐op showers -‐ CHG vs.

povidone-‐iodine vs. triclocarban medicated soap = 7 fold vs. 1.3 vs 1.9 respec*vely

•   CHG maximum an*bacterial benefit with repeated applica*ons – binds to skin –   Cumula*ve effect –   Residual effect –   Effec*ve against Gram posi*ve

and Gram nega*ve organisms

Pre-‐op Skin Prep with CHG

•   CHG is persistent, ac*ve for up to 6 hours 1

•   Edmiston et. al showed that use of a 2% CHG cloth resulted in higher skin concentra*ons compared to 4% liquid CHG 5

•   Literature shows repeat applica*ons will maximize an*microbial effect 2

•   CHG has rapid bactericidal ac*on3 •   Excellent ac*vity against Gram-‐

posi*ve as well as excellent residual ac*vity 4

Ra*onale for Use •   Shower vs. Cloth

–   Poor compliance with liquid

–   Ryder et al. (2009) •   More chlorhexidine les on skin aser applica*on with cloth than when applied as a liquid

–   Possibility that chlorhexidine may preferen*ally bind to co^on in washcloth

•   Why 2 applica*ons? –   Cumula*ve effect –  Maki (2009)

•   Advance prep at 12 AND 3 hours prior to surgery significantly reduced microorganisms at surgical site

–   Ryder et al. (2009) •   More chlorhexidine les on skin when applied in PM and AM, as opposed to just AM


Is it worth the cost? – YES!

A deep total hip / knee infec<on

Major morbidity for the pa*ent (mul*ple opera*ons,

tremendously-‐increased mortality, substandard

outcomes)

Es*mated economic impact of one deep SSI in hospital costs alone1 •   Total hip arthroplasty = $100,000 •   Total Knee arthroplasty = $60,000

Financial Jus<fica<on

2% CHG cloth: $6 X 2 à $12 per use •  è ~8,300 pa*ents treated with CHG cloth

•   Hospital: 400 joints per year (1 infec*on saved would pay for CHG Cloth for > 20 years!)


1. Bratzler D, Dellinger, E. Patchen, et. al.Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283

Results: Total Hip Arthroplasty Johnson, Daley, Zywiel, Mont; J Arthroplasty, 2010

Group A: Advance Skin Prep

157 pa*ents

0 infec*ons

Group B: No advance skin prep

897 pa*ents

14 infec*ons

1.6% infec*on rate


Updated Results: Cases to end of 2010 AAOS 2011

Advance skin prep

•   468 procedures •   2 infec*ons •   0.5%

No advance skin prep

•   1,676 procedures •   34 infec*ons •   2.2% infec*on rate

•   1,040 procedures •   6 infec*ons •   0.5%

•   3,571 procedures •   56 infec*ons •   1.6% infec*on rate

KNEES KNEES + HIPS

p=0.029 p=0.022


Financial Impact •   Infec*on Rates

–   with CHG: 0.5% (1 out of 200 cases)

–   Without CHG: 1.6% (1 out of 62 cases)

•   62nd case à $100,000 in infec*on treatment

•   62 cases with CHG Cloth: $744 •   With CHG Cloth

–   1 infec*on in 200 ($100,000) –   Versus 3 infec*ons without

CHG Cloth ($300,000) –   Cost of CHG Cloth: $2,400 –   Net difference: ~$200,000

•   Based on data between 2005 and 2006 –   ~15,000 revision TKA for infec*on

(Bozic et al., CORR 2010) –   ~7,500 revision THA for infec*on

(Bozic et al., JBJS 2009) –   1.5% infec*on rate –   à ~22,500 revisions for infec*on

per year –   ~$100,000 per revision $2.2 billion per year Reduce to 0.5% with CHG Prep (reduce by

2/3)

à Save $1.5 billion per year


Pa*ent Skin An*sepsis in the Opera*ng Room

•   Most commonly used to prep the opera*ve site –   Iodophors (e.g., povidone-‐iodine) –   Alcohol containing products

•   Ethyl alcohol (60%-‐95%) •   Isopropyl alcohol (50%-‐91.3%) •   Two types of skin prep available for use appear to have superior efficacy (iodine povacrylex in 74% w/w isopropyl alcohol (IPA) and 2% CHG w/v in 70% IPA

•   Issues with flammability –   Chlorhexidine gluconate (CHG)

•   Greater residual ac*vity aser a single applica*on •   Not inac*vated by blood or serum proteins compared to Iodophors

Mangram, AJ, Horan, TC et al. Guideline for Preven*on of Surgical Site Infec*on, 1999 APIC Elimina*on Guide. Guide to the Elimina*on of Orthopedic Surgical Site Infec*ons. 2010

Pa*ent Skin An*sepsis in the Opera*ng Room

–  Method of applica*on on the skin – follow the manufacturer's wri^en instruc*ons for use

•   Concentric circles vs. back and forth mo*on –  Newer products on the market rival the residual ac*vity of CHG

–  Other skin prep •   Removing or wiping off the skin prep aser applica*on •   Using an an*sep*c impregnated drape •   Pain*ng the skin with an*sep*c •   Using a clean vs. sterile surgical skin prep kit

Mangram, AJ, Horan, TC et al. Guideline for Prevention of Surgical Site Infection, 1999 APIC Elimination Guide. Guide to the Elimination of Orthopedic Surgical Site Infections. 2010

Surgical Hand An*sepsis •   Follow manufacturer’s wri^en instruc*ons

for use of surgical scrub products •   Natural nail *ps should be kept to ¼ inch in

length (CDC II) •   Subungual area of fingernails has large

number of microorganisms •   Ar*ficial nails should not be worn when

having direct contact with high-‐risk pa*ents (e.g., ICU, OR) (CDC 1A)

•   Any fingernail enhancements or resin bonding product is considered ar*ficial

–   Includes all extensions or *ps, gels and acrylic overlays, resin wraps or acrylic fingernail

•   Avoid wearing of hand jewelry (rings, watches, bracelets

•   Lo*ons may be used but should be compa*ble with products (an*sep*cs and barrier products) used in the OR

Nasal Decontamina*on •   S. aureus coloniza*on

–   Carriage is the most important independent risk factor for developing an SSI2

–   Usually associated with the nares (~70%) –   Other sites includes the skin, axilla, groin / perineal space –   Carriers of high numbers of S. aureus are at 3-‐6 *mes the risk of HAIs1

•   Swabbing the nares iden*fies 80%-‐90% of MRSA carriers2

•   Pa*ents may have S. aureus on the skin and other sites and not in the nose

•   Decoloniza*on of nasal and extranasal sites may reduce infec*on risk4 –   ASHSP report -‐ mupirocin should be used intranasally for all pa*ents

with documented coloniza*on with Staph aureus (Strength of evidence for prophylaxis = A)3

1.   Bode, Lonneke G. M. et. al. Preven*ng Surgical-‐Site Infec*ons in Nasal Carriers of Staphylococcus aureus. N Engl J Med 362;1 January 7, 2010 2.   Prokuski, Laura. Prophylac*c An*bio*cs in Orthopaedic Surgery. J Am Acad Orthop Surg 2008;16:283-‐293 3.   Bratzler D, Dellinger, E. Patchen, et. al.Clinical prac*ce guidelines for an*microbial prophylaxis in surgery. Am J Health-‐Syst Pharm.2013; 70:195-‐283 4.   Courville, Xan, Tomek, Ivan et. al. Cost-‐Effec*veness of Preopera*ve Nasal Mupirocin Treatment in Preven*ng Surgical Site Infec*ons in Pa*ents Undergoing Total Hip and Knee Arthroplasty: A Cost-‐

Effec*veness Analysis.ICHE February 2012; 33(2):152-‐159.

Nasal Decontamina*on •   New product on the market – Skin and Nasal An*sep*c –  Reduces 99% of S. aureus in the nares according to the company’s literature

–  Effec*ve in one hour –  Persistent for up to 12 hours –  Ac*ve ingredient is an an*sep*c, not an an*bio*c

•   Supports an*microbial stewardship –  27%-‐50% resistance found to topical an*bio*cs for MRSA

Simor An*microbial Agents in Chemotherapy 2007 Rotger Journ of Clin Micro 2005

Surgical A{re •   Clean surgical a{re, including scrub suits, shoes, head

covering (caps/hoods), masks, gloves, gowns and jackets •   An iden*fica*on badges should be worn in the semi-‐restricted

and restricted areas of the surgical or invasive procedure se{ng –   Facility-‐approved, clean and freshly laundered or disposable a{re

should be donned daily in a designated area –   Jewelry should be contained, if not, do not wear –   All personnel should cover head and facial hair including sideburns and

the nape of the neck when in the semi-‐restricted and restricted areas. –   Fresh surgical mask should be worn for every procedure

AORN Periopera*ve Standards and Recommended Prac*ces For Inpa*ent and Ambulatory Se{ngs. 2014 Edi*on

Surgeon A{re •   Pasquarella (2003)

–   Body exhaust suits (31 pa*ents)

–   Occlusive clothing (31 pa*ents)

–   Bacteria measured using se^le plates throughout the OR

à No significant difference in surface contamina*on between the two groups (p=0.01 to 0.07)


The Joint Commission IC.02.02.01

•   The hospital reduces the risk of infec*ons associated with medical equipment, devices and supplies

•   Elements of Performance related to … –   Cleaning and performing low-‐level

disinfec*on or medical equipment, devices and supplies

–   Performing intermediate and high-‐level disinfec*on and steriliza*on of medical equipment, devices, and supplies

–   Disposing of medical equipment, devices and supplies

•   Single use devices

ANSI/AAMI ST79:2010 & A1:2010 & A2:2011 & A3:2012 & A4:2013 (Consolidated Text)

Immediate-‐Use Steam Steriliza*on (IUSS)

•   Used only when there is insufficient *me to processed items by the preferred wrapped or container method intended for terminal steriliza*on

•   Should not be used as a subs*tute for insufficient inventory

•   Item for IUSS should go through the same cleaning and decontamina*on process

•   IUSS should only be performed if the

following condi*ons are met –   Device and containment manufacturer’s

instruc*ons (validated for use of IUSS) –   Transfer to the sterile field without

contamina*on –   Monitoring the process Not used for

implantable devices –   Documenta*on for tracking to the

pa*ent

•   Not to be used on the following devices:

•   Implants except in a documented emergency situa*on when no other op*on available

•   Instruments used on pa*ents who may have Creutzfeld-‐Jakob Disease (CJD)

•   Devices or loads that have not been validated with the specific cycle

•   Devices that are sold as sterile and intended for single-‐use only

Periopera*ve Standards and Recommended Prac*ces for inpa*ent and Ambulalatory Se{ngs. AORN 2014

Periopera*ve Strategies ü An*bio*c Prophylaxis

ü Proper inser*on of central lines ü Asep*c technique during Foley placement ü Glycemic control ü Prevent wound contamina*on by prac*cing the principles of

asep*c technique ü Decrease the length of surgery ü Prevent hypothermia ü Use closed drainage system when needed ü Incision closure – surgical staples vs. subcu*cular sutures

Mangram, et al. The Hospital Infec*on Control Prac*ces Advisory Commi^ee (HIPAC).

Guideline for the Preven*on of Surgical Site Infec*on. Infect Control Hosp Epidemiol 1999;20:247-‐80. Dunbar, Michael and Richardson, Glen. Minimizing Infec*on Risk: Fortune Favors the Prepared Mind. Abstract. Full ar*cle at OrhtoSuperSite.com Search 2010714-‐31

An*microbial Prophylaxis E   Op*mal dosing *me is within 60

minutes (120 for Vancomycin) before surgical incision

E   Weight-‐based dosing especially in obese pa*ents •   e.g., cefazolin – 2g; 3g for pa*ents

weighing > 120 kg E   Re-‐dosing -‐ dura*on of the procedure

exceeds two half-‐lives of the drug or there is excessive blood loss. E  Single dose post-‐op or

con*nua*on for less than 24 hours aser incision closure

E  No evidence of benefits for con*nua*on of an*microbial administra*on un*l drains and catheters are removed.

Bratzler D, Dellinger, E. Patchen, et. al.Clinical prac*ce guidelines for an*microbial prophylaxis in surgery. Am J Health-‐Syst Pharm. 2013; 70:195-‐283

Thanks to Dr. Jeremy Gradon, Infec*ous Diseases, Sinai Hospital

Normothermia

•   Normothermia: the body’s ideal thermal state

•   Core temperature: –   37.0°C (98.6°F)

•   Temperature gradient: –   2-‐4°C between the core and periphery

•   Modali*es –   Ac*ve -‐ forced-‐air warming or conduc*ve warming

–   Passive – insula*ve techniques •   Goal > 36C

Core:37°C

Periphery: 2-‐4°C cooler

Sessler DI. Current concepts: Mild Periopera*ve Hypothermia. New Engl J Med. 1997; 336(24):1730-‐1737.

Periopera*ve Strategies -‐ Environment

•   Environmental Factors (Class B and C surgery) –   Posi*ve pressure with respect to corridor and adjacent

areas. –   Air changes -‐ minimum of 20 air changes per hour with 4

minimum outdoor air changes/hour (20% must be fresh air)

–   Rela*ve humidity of 30% -‐ 60% –   Temperature -‐ 20°C -‐ 24°C (68°F -‐ 75°F) –   Introduce air at the ceiling and exhaust near the floor. –   Keep OR doors closed except as needed for passage of

equipment, personnel and pa*ent. –   Limit the number of personnel in the opera*ng room to

necessary personnel.

AORN Periopera*ve Standards and Recommended Prac*ces For Inpa*ent and Ambulatory Se{ngs. 2013 Edi*on ANSI/ASHRAE/ASHE Standard 170-‐2008 Ven*la*on of Health Care Facili*es

Opera*ng Room Traffic •   Traffic pa^erns should be designed to

facilitate movement of pa*ent and personnel into, through, and out of defined areas within the surgical suite

•   Signs posted to clearly indicate environmental controls and surgical a{re required

•   OR suite should be secure •   Movement of personnel should be kept to a

minimum while invasive and non-‐invasive procedures are in progress

•   Doors to the opera*ng or procedure room are to be kept closed except during movement of pa*ent , personnel, supplies and equipment

•   Talking and the number of people should be minimized

AORN Periopera*ve Standards and Recommended Prac*ces For Inpa*ent and Ambulatory Se{ngs. 2013 Edi*on Lynch, Raymond, Englesbe, Michael et. al. Measurement of Foot Traffic in the Opera*ng Room: Implica*ons for Infec*on Control. American Journal of Medical Quality 2009; 24:45 DOI: 10.1177/1062860608326419

Mangram, et al. The Hospital Infection Control Practices Advisory Committee (HIPAC). Guideline for the Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol 1999;20:247-80.

Post-‐Op Strategies ü Discon*nue an*bio*cs within 24 hours of incision closure

ü Hand hygiene before and aser dressing changes ü Maintain closed suc*on drainage system if used ü Protect incision with sterile dressing for 24 hours – 48 hours that has been primarily closed

ü Manage early, persistent wound drainage aggressively

ü Educate pa*ents and families about proper incision care, symptoms of SSI and the need to report such symptoms

Mangram, et al. The Hospital Infection Control Practices Advisory Committee (HIPAC). Guideline for the Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol 1999;20:247-80.

Outcome of SSI Preven*on Strategies

ü Reduce risk for surgical site infec*ons ü Reduce morbidity and mortality ü Reduce costs associated with SSI

–   Reduce length of stay –   Reduce readmissions

ü Reduce development of mul*-‐drug resistant organisms (MRSA, VRE, etc.)

ü Improved pa*ent sa*sfac*on / quality of life ü Reduce the risk of li*ga*on

Summary – Keys to Success •   Surgical site infec*ons

–   increase mortality and morbidity –   Increase financial impact

•   Properly and consistently applied preven*on strategies can reduce the risk of surgical site infec*ons and ensuing morbidity and mortality –   Pre-‐opera*ve an*sep*c bath –   Skin an*sepsis before incision –   Appropriate selec*on, administra*on and discon*nua*on of an*bio*c prophylaxis –   Environmental Control

•   Keep traffic to a minimum and keep door s closed during the case •   Proper ven*la*on

–   Proper steriliza*on and monitoring of surgical instrumenta*on including implants

•   Synergism –   Effec*ve team work and communica*on will improve pa*ent outcome

References •   Klevens RM, Edwards JR, et al. Es*ma*ng health care-‐associated infec*ons and deaths in U.S. hospitals, 2002.

Public Health Reports 2007;122:160-‐166. •   Rutala, William, Weber, David and HICPAC. CDC Guidelines for Disinfec*on and Steriliza*on in Healthcare

Facili*es, 2008. h^p://www.cdc.gov/hicpac/pdf/guidelines/Disinfec*on_Nov_2008.pdf •   5 Million Lives Campaign. Ge3ng Started Kit:: Prevent Surgical Site Infec?ons How to Guide. Cambridge, MA:

Ins?tute of Health Care Improvement; 2008 •   Anderson, Deverick J, et. al. Strategies to Prevent Surgical Site Infec*ons in Acute Care Hospitals 2008; 29(Suppl.

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Prac*ce Guidelines by the Infec*ous Disease Society of America. CID 2013;56:1-‐25. •   Lynch, Raymond, Englesbe, Michael et. al. Measurement of Foot Traffic in the Opera*ng Room:

Implica*ons for Infec*on Control. American Journal of Medical Quality 2009; 24:45 DOI: 10.1177/1062860608326419

•   de Lissovoy, Gregory, Fraeman, Kathy, et. al. Surgical Site Infec*on: Incidence and impact on hospital u*liza*on and treatment costs. AJIC June 2009; 37(5):387-‐397

•   Sessler DI. Periopera*ve Heat Balance. Anesth. 2000;92:578-‐596. •   Sessler DI. Current concepts: Mild Periopera*ve Hypothermia. New Engl J Med. 1997; 336(24):1730-‐1737.

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