Kathleen Kohut, RN, MS, CIC, [email protected]
Speaker Disclosures
3M
AMN Healthcare
BESmith
The Compass Group
1. Name the 2 most common mechanisms for wound contamination
2. Discuss 7 areas of opportunity for improvement
3. Describe the use of glycemic control and nasal decolonization initiatives for the reduction of SSIs.
4. List 3 ways to facilitate process improvements in the Operating Room
National Healthcare Safety Network (NHSN)
1999 HICPAC SSI Guidelines
AORN Guidelines
Surgical Care Improvement Project (SCIP) Measures
1. Antibiotic Prophylaxis Drug, Timing, Dosing
2. Hair Removal
3. Glycemic Control
4. “Normothermia” Expanded in June All surgical patients
Qualitynet.org
1. Aseptic Technique2. Traffic
Aseptic Technique
3. SterilizationAseptic Technique
4. ABX ProphylaxisAseptic Technique
5. Hair RemovalAseptic Technique
6. Skin AntisepsisAseptic Technique
7. Dressings
Principles were developed to reduce the risk of wound contamination.
Defining the Risk of SSI
Risk of SSI = Dose of Bacterial Contamination X VirulenceResistance of Host (patient)
Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254
1. Exogenous sources Cleanliness of environment, lack of proper
airflow, shedding by the Surgical Team
2. Endogenous sources Patient’s own skin/hair Infection at a remote site
People = Shedding4000-10,000 particles per minute
(Berry & Kohn’s, Operating Room Technique, 11th ed., p. 252)
Carried by wind currents to the sterile field which results in wound contamination.
1. Patient2. Surgical Team 3. Ancillary Personnel4. Sales Reps5. Students6. Passersby
Shedding plus Wind Currents
Requires the control of: Amount of Traffic Traffic Patterns
Sherertz, et al. “Cloud” HCWs. Emerging Infect Dis. 2001;7(2): 241-44.
Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6): 1169-1183.
Essential personnel only
One foot (min) perimeter around sterile field
Sterile fields should be a destination, not a thoroughfare
Limit students and observers The right of the student to learn vs. the right of the patient
to receive safe patient careDeKastle, R. Telesurgery: Providing Remote Surgical Observations for Students.
AORN 2009; 90 (1): 93-101.
Utilize alternative methods of communication
Kohut SSI EquationPeople + Wind + (-) Aseptic Technique
> ABX + Skin Prep =
Wound Contamination =
SSI
1. Patient Pre-op Showers Hat and clean gown/linen for patient
2. Surgical Team Hand Hygiene Nocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998)
Proper aseptic technique
Properly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire)
Ban Skull Caps
Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov) 1157-59.
Lack of Containment
BAD VERY BAD
Standards of Excellence
PETA APPROVED GOLD STANDARD
Room Requirements Ventilation System (15/hr – 3 fresh)
▪ Positive pressure Temperature (68-73° F) Humidity (30-60%)
Room Cleaning Between cases Terminal cleaning Types of construction materials Clutter
AORN, Recommended Practices for Perioperative Nursing: Safe Environment of Care. (2008 ed., p 357)
Requires strict adherence to the principles of aseptic technique by all team members for every patient on every case.
ORs that value these principles create a patient centered culture.
Girard, NJ. Surgical Conscience: Still Pertinent. AORN (2007):86 (1); 13-14.
3. Sterilization
Proper Management of Sterile Processing Departments Technology Workflow Staff certification
Proper Sterilization Processes Focus area for The Joint Commission Cleaning, sterilization, and storage
www.jointcommission.org/Library/WhatsNew/steam_sterilization.htm
Utilized for: Dropped instruments Poorly designed work processes
Lack of instrumentation Surgeon scheduling
Results in contamination due to: Poor cleaning due to lack of time Methods of delivery to the sterile field
Closed containers are best practice TJC will be looking for them
Carlo, A. The New Era of Flash Sterilization. AORN 2007: 86(1); p 58-70.
Flash Data
Calculation: # of flash events = rate x 100 # of cases/month
OR Flash Rate 2004- 1st Q 2007
42
33
15
22
16
23
16
11 11 11
14
12 11
14
12
1516
10
61 60
0
10
20
30
40
50
60
70
Fla
sh
Rate
SCIP Measures INF 1,2,3
Goal >90%
Best Practice- Anesthesiologists Proper dosage for obese population (BMI>30) Don’t forget redosing q 3 hours
OR ABX Compliance
72
88 89 91
93 95 9497 98
95 94 93 94 9495 96
92
97 97
0
10
20
30
40
50
60
70
80
90
100
Co
mp
lian
ce
Ra
te
SCIP INF 6: Surgery patients with appropriate hair removal.
Minimize as much as possible Clippers only Not in the OR!
The attributes of an appropriate surgical skin antiseptic require:
The ability to significantly reduce microorganisms (2 log, 3 log)
Provide broad spectrum activity Be fast acting Have a persistent effect
All products with FDA approval meet this criteria
AORN, Recommended Practices for Perioperative Nursing: Skin Antisepsis. (2008 ed., pp537-555)
Other Skin Antisepsis Considerations
1. Procedure2. Prep area3. Application Methodology
Scrubbing vs. Painting4. Length of the procedure5. Challenges to the prep area
-blood, saline, friction6. Patient Safety
Critical Thinking is Required
Ultimately, the OR nurse decides at the point of care by assessing the patient to insure that the skin antisepsis planned for will be appropriate for that patient based on allergy status, body site, and skin integrity.
CDC SSI guideline states to “use an appropriate antiseptic”
SHEA Compendium - “Optimal preparation and disinfection of the operative site”
AORN compares products but does not provide specific product recommendations
Current Research
Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes
The majority of the literature compares microbial counts
The correlation between microbial counts and SSI outcomes is unclear
Current Research
1. Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91:1949053
Microbial culture study of 150 patientsCompared 3 methods
Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™
ResultMicrobial counts were less using ChloraPrep®SSI Outcome was no SSIs in any of the groups
Current Research2. Swenson, et al. Preoperative skin preparation on
postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30:964-971
SSI Outcome study of 3209general surgery patients
Compared 3 methods Iodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™
ResultSSI Outcomes- A statistical difference with lower SSI
rates using iodine based products.
Current Research
3. Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362(1):18-26.
Microbial culture study of 849 patientsCompared 2 methods
Iodophor Scrub/Paint vs. Chlorhexidine-alcohol
ResultSignificantly lower SSI rates with Chlorhexidine-alcohol
prep for surperficial and deep incisional wounds
Clear as Mud……..
Prewash prior to application
Follow manufacturer’s directions
Utilize proper aseptic technique during application & gloves to contain shedding
Optimal dressings are:
Permeable to gas exchange
Impermeable to microbes/contamination
Create a moist healing environment (37°C)
Stay in place Good adherence properties Change on day 2-3 unless drainage, dirty, or
damaged
Use proper aseptic technique when applying the dressings before the drapes are removed
Partner with Wound Care SpecialistsSussman, C, Bates-Jensen, B. Wound Care: A Collaborative Practice Manual
for Health Professionals 2006; (Chap11)
The “New Basics”
Glycemic Control
Nasal Decolonization
30-35% of cardiac patients are diabetics
SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.
The OR cannot be a black hole
Between 25-30% of all patients are colonized Another 60% carry it intermittently
85% of S. aureus infections were endogenous in SSI study populations
Nasal decolonization should be considered due to the risk of S. aureus SSIs
Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61:254-261.
Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24): 1871-7.
Speciality Specific Opportunities
Cardiac
Spinal Fusions
Labor and Delivery
Cath Lab
Cardiac Surgery
2 concurrent surgeries
Skin antisepsis
Bone wax
Traffic and # of people
Hypothermia
Spinal Surgery Equipment
Amount, position, cleanlinessWeiner, BK, Kilgore, WB. Bacterial shedding in common spine procedures: headlamp/loupes
and the operative microscope. Spine 2007;32(8):918-20. Biswas, D, et al. Sterility of C-arm fluroscopy during spinal surgery. Spine 2008; 33(17):1913-
17.
Antibiotics Redosing
Time Longer surgeries, waiting for X-ray
Dressings Posterior incisions (higher risk)
L&D and Cath Lab
Aseptic technique
Skin antisepsis
Facilitating Process Improvements
1. Provide the data Trend and report ABX and flash data monthly SSI Outcome data Quarterly
2. Utilize data to implement change NPSGs
3. Multidisciplinary- IP, Quality, nurses, techs, surgeons, anesthesia, schedulers, housekeeping
Process Improvements
Make regular observations of aseptic technique
Standardize
Use forms to quantify when possible
Simplify- pick one thing to get started
Process Improvements
Implement Changes Seek out champions Communication is essential Get feedback from staff and re-evaluate prn
Insure that new outcome data is communicated to staff
Celebrate Success!
Total Knee SSI 1st Q CY 2007
0.49
0 0
2.23
0.65
0
1.04
0 0 0 0 0
2.04
2.31
0.850.66
0.34
1.09
0
0.5
1
1.5
2
2.5
2004 2005 2006 1st Q '07 Overall NNIS
SS
I Rat
e 0
1
2,3