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Working Toward Zero Infection Rate

Maureen Spencer, RN, M.Ed, CICInfection Control Manager

New England Baptist Hospital,Boston, Mass. 02120

617 754-5332 mpspence@nebh.org

Disclosure: Ethicon and Cardinal Health Speaker’s Bureau

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Topics:

• New England Baptist Hospital and Orthopedics• Multidisciplinary Team Work• Identifying Problems:

▫ OR Environment▫ Central Supply▫ Housekeeping▫ Hand Hygiene

• Action Plans: ▫ Innovative Technologies

• The Evidence: ▫ What Were The Outcomes

NEBH SSI Rates 2003 – 2010(outpatient and inpatient infections)

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GENERAL SSI FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10(Oct-Jul)

# Infections 6 1 3 4 2 2 1 0# Procedures 1073 920 780 692 567 467 369Infection Rate 0.6 0.1 0.4 0.5 0.3 0.3 0.2 0

ORTHOPEDIC SSI# Infections 63 60 49 46 39 37 28 27# Procedures 8837 9669 9216 8986 9027 8884 8890 8256Overall Infection Rate 0.7 0.6 0.5 0.5 0.4 0.4 0.3 0.3#Hip Infections 14 5 4 7 5 5 10 8 Hip Prosthesis Rate 1.0 0.3 0.2 0.4 0.3 0.3 0.5 0.4#Knee Infections 21 14 11 7 7 11 9 7 Knee Prosthesis Rate 1.6 1.0 0.7 0.4 0.3 0.5 0.4 0.3#Laminectomy Infec. 6 9 7 7 12 4 0 3 Laminectomy Rate 0.7 0.9 0.6 0.8 1.3 0.5 0.0 0.6#Spinal Fusions Infec. 5 15 12 12 5 5 3 3 Spinal Fusion Rate 0.8 2.0 1.4 1.1 0.4 0.4 0.3 0.4

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Orthopedic Surgical Site Infection

Orthopedic Total Joint Infections: Hip or Knee aspiration under

fluoroscopy If positive – irrigation and

debridement – liner exchange or Removal of hardware may be

necessary Insertion of antibiotic spacers Revisions at future date Long term IV antibiotics in

community or rehab Future worry about the joint In other words:

DEVASTATING FOR THE PATIENT AND THE SURGEON

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2003 - Established a Multidisciplinary TeamThe team included representatives from • OR nursing, CSS• Orthopedic surgeons (Joint, Spine) & Anesthesia• Managers from infection control, healthcare quality,

facilities and environmental services 

Evaluated n Procedures and Practicesn Facility design and Environment of Care Issuesn Patient Risk Factorsn Infection Ratesn Innovative Infection Prevention Products and

Practices

Spencer M, et al. A Multidisciplnary Team Working Toward Zero Infection Rate. Poster presented

AORN 2006; March 19-23, 2006; Washington DC. Spencer M., et al. A Multidisciplinary Team working toward Zero Orthopedic Infection Rate. Global

Infectious Disease Conference, Tufts Medical School, Boston, MA October 2009

Team Intent: Zero Healthcare-associated Infections

The teams: SSI, VAP, CLABSI, UTI, MRSA, C.difficile

Books: Power Versus Force – David Hawkins, MD 48 Laws of Power – Robert Greene

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Issues Identified By Team

2003: The Operating Room:• Traffic control• Surgical attire• Operating room cleaning• Processing of instruments• Air handling system and laminar flow• Surgical hand scrub

2004: Surgical infection prevention (SIP) core measures• Silver postoperative dressings for Spine Service• CHG for central line care

2005: Antibacterial sutures – full year evaluation

2006-2007 MRSA and MSSA Eradication Program - 2 ½ year process CHG biopatch for central lines and Maximal Barrier Kits

2008• Chlorhexidine preop, intraop, postop • Clostridium difficile – room decontamination and bleach • V.A.P. checklist and prevention guidelines

2009-2010:• Post-op anitmicrobial dressings – all incisions covered• Central line checklist and patient education on prevention of HAIs

Operating Room - 2003

Re-training proper use of CHG/alcohol surgical scrub solution (6 hr residual activity)2006 changed to an 80%

alcohol based waterless hand scrub (6 hr residual activity also)

Distribution of 4 oz chlorhexidine (eg Hibiclens) in prescreening for all inpatient surgeries

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Operating Room - 2003

Reviewed orderlies - room turnover procedures

Improved traffic control: new signage and monitoring system

Cloth cap use – if worn it must be covered when in room and total hair coverage monitored Hair harbors organisms Sweat in cloth caps? How often do they get

washed? Where are they stored? Would you eat a meal with

hair in it? Why then allow hair to potentially fall into surgical incisions?

Too many in this room, hair not adequately covered

Lab Coat Contamination

NEBH Lab coat study – cultured 6 coats in OR – 2 cultured Staph aureus (33%)

visibly soiled, pockets stuffed with books, food, scissors – even prescription pads!

Now offer fee for service cleaning physician lab coats in Environmental Services

Fellows/Residents/PA – provide weekly lab coats

Bacterial contamination of health care workers' white coats American Journal of Infection Control 37:(2) 101-105 (March 2009) 148 cultured: 23% Staph aureus, 18% MRSA

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Peri-operative Environmental Evaluation

▫ Overall preventive maintenance schedule

▫ HVAC – filters and calibration of system, air quality & exchanges

▫ Laminar flow in all operating rooms (although data inconclusive that these

reduce SSI rates)▫ Terminal room cleaning procedures

on night shift – are there sufficient cleaning staff?

▫ Autoclave maintenance, instrument processing and sterilization

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Complicated Orthopedic Instruments• Inspection of Orthopedic Instruments

▫ Lumens, grooves, sorting, hand cleaning, disassembly required – massive kits

▫ Many instruments cannot be disassembled

• Company contracted – disassemble and bead blast the material coagulated and hardened within lumens

• Instituted better pre-soaking and rinsing of tissue and blood from the instruments in the operating room before decontamination

• 2009 built new CSPD – state of the art

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Environmental Upgrades

Upgraded all OR rooms to laminar flow

• (although data inconclusive that these reduce SSI rates)

• Annually - close the OR over the holidays - entire cleaning of the inner core and rooms

• Traffic Control – keep room doors closed and minimize traffic

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Operating Room - 2004

• More frequent environmental safety rounds by team

• Infection control education forOR staff and surgeons

• Implement SCIP core measures: warming patient• surgical prophylaxis• hair clippers• increased oxygen

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• Established a weekly cross-check system of patients identified with resistant organisms (MRSA/VRE)

• Weekly email from Infection Control to:• Pre-surgical Holding Unit• OR Surgical Scheduling• Patient Access (admitting)• Operating Room • Pre-assessment screening Unit (PASU)• PACU

• Master list of MRSA/VRE positive patients accessed on-line as a “live” file

Infection Control - 2005

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FY05 Operating Room• Ultrasonic scrub

• movable carts, tables, poles and equipment

• 1500 pieces cleaned• OR, radiology, nursing

units

• Cost: ~$20,000• Done annually

• APIC 2005 - Poster• M Spencer: The E=MC2 Project: Environment =

Maintaining Cleanliness: A Multidisciplinary Approach To Establish a Routine Cleaning Schedule for Medical Equipment. APIC 2005 Baltimore Conference

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Environmental Disinfection Developed cleaning

schedules for departments in Patient Care Services

Eliminated dirty buckets of water – instituted micro fiber mop per OR room and wash/dry onsite

Daily check sheet for terminal cleaning of OR at night and for all precaution cases

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Environmental DisinfectionSilver Disinfectant Spray

that kills organisms up to 24 hrs on surfaces (Spectrum clene24 - (previously Agion)

Use in high volume areas that are cleaned once a day Radiology, Ambulatory Care Unit PACU and Pre-surgery Unit

Cubicle-curtain change policy –after each precaution discharge and 6 months on nursing unit 3 months - ICU and Ambulatory

Care

APIC 2007 – Poster Presentation: M Spencer: “Microbiologic Evaluation of a Silver Antimicrobial Disinfectant Spray” APIC San Jose, June 2007

Environmental Disinfection Assigning of staff to clean

before each use: Blood pressure cuffs Pulse oximeters Thermometers Leg tourniquets Bar Coding equipment Computers on Wheels

SHEA poster March 2009 – San Diego Conference

Spencer M, et al: Nondisposable Blood Pressure Cuffs as a Potential Source for Cross Contamination.

Patient Risk Factors

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Prosthetic Joint InfectionRisk Factors

• Obesity • Diabetics and pre-diabetics• Poor patient hygiene • Revision surgery• Malignancy• Steroid Use• Rheumatoid Arthritis• Chronic Renal Insufficiency• Malnutrition• Blood Transfusion• Prior Infection in joint

• Berbari E. et al: Clinical Infectious Diseases 1998;27:1247–54

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MRSA and Staph aureus Eradication Program

Prescreening ProcessTopical Decolonization ProtocolVancomycin for MRSA

Kim D, Spencer M, Davidson S, et al. J Bone Joint Surg Am. 2010;92:1820-6

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February 2006 Obtained Anonymous Nares Cultures To Prove to Administration They Come In With Staph aureus

and MRSA

N = 133 patients

Purpose: to determine pre-opMRSA and Staph aureusColonization rates

Results:38 – Staph aureus (29%)

*5 - MRSA ( 4%)*all undiagnosed, no precautions used in OR or postop nursing unit, all MRSA cases received Cefazolin for prophylaxis

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Implemented Decolonization Protocol

•5-day application of intranasal 2% mupirocin - applied twice daily - for MRSA and Staph aureus positive patients

•Prescription called in by Nurse Practitioner in prescreening unit

•Daily body wash with chlorhexidine (purchased by patient)

•MRSA Patients – Unique sticker system to notify Pre-surgery Unit of Vancomycin surgical prophylaxis

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AORN Journal –Nov 2008 Vol 88, Nov. pages 818-820

“Dealing with Antibiotic Resistant Organisms”

AORN

Contact Precautions in Pre-op area, OR & PACU Gowns and gloves throughout procedure (in addition to

Mask already worn) by Circulator ad Anesthesia Circulator removes gown and gloves before leaving OR

to retrieve supplies/equipment Enhanced environmental cleaning after precaution cases

– therefore last case in room or scheduled last case of day

Use outside runner or circulator if possible to prevent contamination of perioperative environment MRSA – survives from 22-90 days on polyethylene Enterococci – 11 days Clostridium difficile – five months

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MRSA/MSSA Eradication Results

From July 17, 2006 through July 2010

25,025 patients screened 5770 (23%) positive for Staph aureus 1027 ( 4%) positive for MRSA

Repeat nasal screens on MRSA patients revealed 78% eradication

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Time Period Inpatient surgeries # Surgical Infections % MRSA/MSSA

FY06 10/01/05-07/16/06* 5293* 24* 0.45%*

FY0707/17/06-09/30/07 7019 6 0.08%

FY08 10/01/07-09/30/08 6323 7 0.11%

FY09 10/01/08-09/30/09 6364 11 0.17%

FY10 10/01/10-07/31/10 5397 5 0.09%

*historical controls

% MRSA and Staph aureus SSI

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Time Period Inpatient surgeries # MRSA SSI MRSA % #Infections/#MRSA+

FY06 10/01/05-07/16/06 5293* 10 (NA) 0.19% NA

FY0707/17/06-09/30/07 7019 3 (3+) 0.04% 3/ 309 (0.97%)

FY08 10/01/07-09/30/08 6245 4 (2+) 0.06% 2/242 (0.83%)

FY09 10/01/08-09/30/09 6366 6* (2+) 0.09% 2/234 (0.85%)

FY10 10/01/10-07/31/10 5397 0 0.00% 0/208 (0%)

*isolates have been sent for pulse field gel electrophoresis

5 of the 6 isolates were available for PFGE and were not related genetically

% MRSA SSI in

MRSA + Screened Patients

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Time Period Inpatient surgeries # MSSA SSI MSSA % #MSSA Infections/# MSSA +

Historical controlsFY06

10/01/05-07/16/06 5293* 14 (NA) 0.26% NA

Screened PatientsFY0707/17/06-09/30/07 7019 3 (3+) 0.04% 3/1588 (0.19%)

FY08 10/01/07-09/30/08 6245 3 (1+) 0.05% 1/ 1422 (0.07%)

FY09 10/01/08-08/31/09 6364 5 (3+) 0.08% 3/1403 (0.21%)

FY10 10/01/10-07/31/10 5397 5 (4+) 0.07% 4/1232 (0.32%)

% Staph aureus (MSSA) SSI in

Screen + Patients

FDA Cleared “Innovative Technologies"

Antiseptic cloth 2% chlorhexidine gluconate (CHG) impregnated

Urologic devices - Foley catheters-hydrogel/silver, Ureteral stents-triclosan eluting, Implantable prostheses—antibiotic

Central venous catheters - CHG-impregnated disk (dressing), Silver alone, Silver sulfanilamide (SS), SS/CHG, Minocycline/rifampin

Peritoneal catheters Silver-coated Vascular catheters Silver/antibiotic-coated Orthopedic devices external fixation pins- Silver Antibiotic-

impregnated polymethylmethacrylate (PMM) Surgical sutures - Braided and monofilament with triclosan Topical Skin Adhesives - proven microbial barriers

Product Format CHG Concentration Healthcare Uses

Topical solution SpongeapplicatorsSwab sticksAmpules

2% or 3.15% With 70% isopropyl alcohol

Skin preparation for surgery, invasive procedures, central lines to prevent SSI and BSI

Scrub solution Liquid detergent (sudsing base)

2% or 4% aqueous Preoperative showering/bathing General skin cleansing

Washcloth Impregnated single-use washcloth/wipe

2% aqueous Daily bathing in ICU patients

Dental solution Oral rinse 0.12% Decontaminate oral cavity (ventilator-associated pneumonia prevention protocols)

Gauze dressing Cotton-weave gauze dressing

0.5% with paraffin Wounds or burns

Catheter dressing CHG pad or integrated with semi-permeable transparent dressing

2% gel pad or foam disk Peripherally inserted central catheters Central line dressings

Hand rub Waterless antiseptic hand gel

1% alcohol based with emollients

Hand sanitizer for healthcare personnel (nonsoiled hands)

Sample of Chlorhexidine Products for Healthcare Use

BSI = bloodstream infection; CHG = chlorhexidine gluconate; ICU = intensive care unit; SSI = surgical site infection

New CHG Irrigation Solution

Wound Debridement and Cleansing system ▫ CHG concentration is 0.05%, lowest FDA-

cleared concentration of this antiseptic▫ Testing shows that this concentration kills and

inhibits Staphylococcus, CA-MRSA, HA-MRSA, Coagulase negative Staphylococcus, Pseudomonas aeruginosa, E. Coli and Aspergillus niger

▫ IrriSept passed the FDA-required safety testing for irritation, immune response and cytoxicity.

▫ There are only three limitations to use: (1) it should not be used on the eyes; (2) near the ear canal; or (3) on individuals sensitive to CHG.

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Antisepsis with Chlorhexidine

2% CHG/70% alcohol skin preparation (tinted orange) Has a lasting effect on the skin

~ 2 days postop Iodophors are fast kill but no long

term effect CHG dry time is 3 minutes (to

prevent fires)

• Evidence that chlorhexidine/ alcohol achieves better skin antisepsis than iodophor

Darouiche et al NEJM 2010 Ostrander et al JBJS Am 2005 Saltzman et al JBJS Am 2009

OR Air Current Contamination

In teaching hospitals:

Surgeon leaves roomResident, Physician Assistant or Nurse Practitioner work on incisionCirculating Nurse counts sponges and starts room breakdownScrub Technician starts breaking down tables and preparing instruments for Central ProcessingAnesthesia move in and out of roomInstrument representative might leave roomVisitors may leave room

Suture with Staphylococcus colonies

Air settling plates in the operating room at the last hour of a total joint case

Potential for Contamination of Sutures at End of Case

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NEBH

Antibacterial Suture Staph aureus Culture Plate Study

• A pure culture - 0.5 MacFarland Broth - of Staph aureus was prepared on a plate

• A coated antibacterial suture was aseptically cut and planted and incubated for 24 hrs

• Photo #1 shows zone of inhibition at day 5

• Photo # 2 shows zone of inhibition at day 10

• Plate on right is a non-coated suture. Staph aureus growth right over it

5 day zone of inhibition

10 day zone of inhibition

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2005 – New England Baptist HospitalOne Year Prospective Study of

3800 Total Joints and Antimicrobial Sutures

• In July, 2005 – implemented use of antibacterial sutures for a full year evaluation – changed product over July 4th holiday and did not tell all surgeons (only those involved with study)

At the end of the year long trial period:▫ 45% reduction in surgical site

infections caused by Staph aureusand MRSA

▫ Reduction in total joint infections rate during trial period 0.44% - 0.33%

NAON Poster Presentation - 2010 • Spencer M, et al: Reducing the Risk of Orthopedic Infections: The Role of

Innovative Suture Technology

IRGACARE® MP (triclosan) Properties

IRGACARE MP 2,4,4′-tri-chloro-2′-

hydroxydiphenyl ether High-purity material that

meets USP specifications for triclosan, with minimal residue content

IRGACARE MP is safe Biocompatible, nontoxic Consumer products

Mouthwash, toothpaste, soaps, cosmetics

IRGACARE MP is effective Active against methicillin-

sensitive and methicillin-resistant S aureus and S epidermidis (most common for device infections)

Active against Escherichia coli and Klebsiella pneumoniae

IRGACARE MP is compatible with suture processing Maintains excellent suture

properties

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USP=United States Pharmacopeia.

Zurita R et al. Macromol Biosci. 2006;6:58-69.

Ming Xet al. Surg Infect (Larchmt). 2007;8:201-207.

Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.

Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53.

Compared with controls, IRGACARE MP-coated polyglactin 910 sutures produced

• Substantial zones of inhibition (all sizes; P<.05)1

• Zones of inhibition against methicillin-sensitive and methicillin-resistant S aureus and S epidermidis1

• Microbial recovery of gram-positive and gram-negative organisms was significantly lower with IRGACARE MP-coated sutures vs non-coated sutures (P<.01)2

• Effective antiseptic activity of IRGACARE MP was present for at least 96 hours2

IRGACARE MP-Coated Sutures: In Vitro Activity

1Rothenburger S, et al. Surg Infect (Larchmt). 2002;3(suppl 1):S79-S87.2Edmiston CE, et al. J Am Coll Surg. 2006;203:481-489.

Suture without IRGACARE MP

Suture with IRGACARE MP

IRGACARE® MP (triclosan): Mode of Action

Chlorinated phenolic biocide—a “phenol” with multi-targeted biocidal mechanisms Nonspecific effects on cell

membrane activities and cell membrane integrity

Blocks active site of the enoyl-acyl carrier protein reductase—an essential enzyme in fatty acid synthesis—building cellular components and reproduction

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Why IRGACARE® MP (triclosan)?

Able to withstand the manufacturing process

Cost-effective Safe in tissues Performance/function

properties Handling Absorption profile, breaking-

strength retention

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IRGACARE® MP (triclosan): Pharmacokinetics

Well absorbed Well distributed in the body Rapidly metabolized in liver to the

glucuronide/sulfate conjugate T½=10 to 13 hours

Excreted through kidneys

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IRGACARE® MP (triclosan) and Microbial Resistance

IRGACARE MP is very effective against S aureus, S epidermidis and E coli, which are the 3 most important bacteria related to SSIs

There is no connection between the use of IRGACARE MP and significant antibiotic resistance

The use of IRGACARE MP may lead to the overall reduction of the antibiotic burden Decreases the risk of SSIs and the resulting

application of stronger antibiotics against SSIs The use of IRGACARE MP is not associated with

increased bacterial virulence that raises the antibiotic burden

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Ming X et al. Surg Infect (Larchmt). 2007;8:209-213.

Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53.

Ford HR et al. Surg Infect (Larchmt). 2005;6:313-321.

Articles Related To Antibacterial Sutures

*Justinger, C, et al. Antibiotic coating of abdominal closure sutures and wound infection. Surgery 2009;145:330-4. (*RCT)

Rothenburger S, et al. In vitro antimicrobial evaluation of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect 2002;3 Suppl 1:S79-87

Ford HR, et al. Intraoperative handling and wound healing: controlled clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture). Surgical Infections. 6(3):313-21, 2005.

Edmiston CE, et al. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? Journal of the American College of Surgeons. 203(4):481-9, 2006 Oct .

Protect OR Staff: ETHIGUARD* Blunt Point Needles

ETHIGUARD Blunt Point Needles provide blunt point geometry that allows soft tissue penetration with minimum force, designed to decrease the incidence of needlestick injuries.

ETHICON offers 97 codes on ETHIGUARD Blunt Point needles, combined with braided and monofilament suture materials including Coated VICRYL* Plus Antibacterial Suture, MONOCRYL* Plus Antibacterial Suture, and PDS* Plus Antibacterial Suture, etc.

ETHIGUARD Needles are available on the most frequent use needles for fascia closure.

The sutures combined with ETHIGUARD needle have size from 1 to 3-0.

ETHIGUARD needle with a ribbed and flattened body affords greater stability in the needle holder, for improved protection against slipping and for precise control.

ETHIGUARD Blunt Point Needles require no changes to surgical technique.

ETHIGUARD Blunt Point Needles are supplied in secured needle packaging.

TPB-1: 65 mm

SHB: 26 mm

CTB-1: 36 mm

CTXB: 48 mm

CTB-2: 26 mm

CTB: 40 mm

* Trademark

INCISIONAL SKIN ADHESIVE TO PREVENT EXOGENOUS CONTAMINATION TO INCISION

DURIN G POST-OP PERIOD

Skin Issues in Orthopedics

Anterior fusion with tape burns

Posterior fusion with contaminated steri-strips

Contaminated steri-strips

We Do Not Recommend Incisions opened to air with contaminated steristrips

Bacteria feed off blood (and sugar)

Incisions are in exudative stage of wound healing first few post-op days

Sent home on day 3- 4 with incision and underlying tissues starting proliferative stage of wound healing

Wounds are susceptible to dehiscence

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Obesity and Surgical Incision Incision collects fluid –

serum, blood - growth medium for organisms

Spine fusions -incisions close to the buttocks or neck

Heavy perspiration common

Body fluid contamination from bedpans/commodes

Friction and sliding - skin tears and blisters

Itchy skin - due to pain medications - skin breakdown

Octyl-Cyanoacrylate Topical Skin AdhesiveCyanoacrylates were developed in 1949

1970s - n-butyl-2-cyanoacrylate

1999 - 2-Octyl-Cyanoacrylate (DERMABOND) 1st FDA approved Topical Skin Adhesive

Today – over 5 million patients a year are treated with Incisional Adhesive

• 2 Octyl cyanoacrylate has the longest carbon side chain for increased flexibility and, increased breaking strength versus butyl cyanoacrylate1

• In vivo and In vitro studies demonstrate a proven microbial barrier against bacteria which may cause infection.

• 24 months shelf life, stores at room temperature

• a violet, non tattooing dye for easy observation

1. Quinn, JV Tissue Adhesives in Wound Care, BC Decker 1998. Attached are chapters from the book.

Mechanism of action

Combination of monomer and

plasticizers, that polymerizes to form a

flexible/pliable adhesive film

Sets or cures within 45-90 seconds

following final layer and reaches full

mechanical strength in 2.5 minutes

If needed, can be wiped from skin within

10 seconds after application or with a

petroleum based product after setting

Adhesive film sloughs or falls off wound

within 7-10 days as skin re-epithelializes

Equivalent to 7 days wound healing

strength in 3 minutes1

OCA: 300-500 microns thick compared to other N- Butyls at :

<50 microns thick

1. Singer and Hollander, Lacerations in Acute Wounds: An evidence-based guide, p.85

Benefits for surgeons, nurses, patients, and hospitalsPhysician, Hospital -centered Benefits

Proven microbial barrier for lasting protection

7 days of wound healing strength in 3 minutes for strong closure and peace of mind

No time spent removing staples or sutures

Reduces needle stick exposure

Increases patient satisfaction

Reduced Hospitalization Costs

Nurse, Patient -centered Benefits

• Reduces number of suture set ups

• Ease of Post Op wound checks

• Reduces number of wound dressings

• Shower immediately

• Excellent Cosmesis

Incisional Adhesive on Total Knee Incision

Incisionial Adhesive and AMD Dressing

Knee: Sealed with Dermabond, covered with antimicrobial Telfa and a transparent dressing

Hip: Sealed with Dermabond, covered with antimicrobial gauze and transparent dressing

Healed incision

If Incisional Adhesive is Not used: Antimicrobial Post-op Dressings

Antimicrobial (AMD) gauze forall post-op incisions that are not sealed with adhesive

Impregnated with a 0.2% PHMB(Polyhexamethylene Biguanides)

Initial dressing and subsequent dressings done by nursing staff

At day of discharge – dressingleft in place for an additional 48 hrs postop

No More Flimsy Post-op Dressings ABD with Paper or Gauze Tape

Check your residents and physician assistants sterile technique

•ABD pads may be stuffed in lab coat pockets during rounds

•Gloves may not be worn for dressing changes.

•Lack of hand hygiene

•Bandage scissors often used between patients with no disinfection between use

•Often discard bloody dressings in regular waste rather than get red bag and bring to dirty utility room – they rush early AM rounds to get into OR

2008 Standardization: Antimicrobial Dressing

(AMD) By Nursing Staff

AMD secured with MeFix tape for protection from exogenous contamination and prevention of tape burn

Allow skin/incision to create proper temperature beneath dressing to enhance wound healing

Protect the incision from exogenous contamination until discharge

Protect the incision from trauma

Incision protected until discharge and then 48 hrs post-op

Knee Dressings with Ace

Ace bandage one day post-op with blood strikethrough after drain removed – nurses told to “reinforce” – another reason to have antimicrobial gauze beneath the ace bandage.

Initial post-op dressing is usually an ace wrap for compression.

AMD gauze are in post-op dressing kits to offer protection to the incision in first two days

Spine Service and Shoulders

AMD sealed with Tegaderm left on until discharge

AMD Island dressing – left on until discharge

Rotator cuff (and total shoulders) – Dermabond is being used or an AMD gauze covered by tegaderm – left on until discharge

Practices with LimitedSupporting Data

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Surgical Incise Drapes

Iodophor impregnated incise barrier drape (“sacred cow”)

Cost: >~ $60,000/year Surgeon preference based on adhesion to skin

and theoretical reduction in skin organisms

beneath the drape during surgery

A search on MEDLINE http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

brought up 10 studies on antimicrobial drapes for human use. All but two were published in the 1980’s.

Of the 10 studies concerning drapes impregnated with a disinfectant, results were mixed. Other studies pointed out that, even though the survival rate of bacteria may have been reduced by using antimicrobial drapes, it represented little or no difference in wound infection rates when compared to conventional preparations

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Bacitracin/Polymixin Irrigation

Feb 2007 - stopped routine use of Bacitracin/Polymixin Irrigation

Cost: > $110,000/year No evidence reduces SSI Cases of anaphylactic shock associated

with Bacitracin Approved limited use for revisions, long

spine cases, allografts and infected cases (irrigation and debridements)

1. Topical irrigation with polymyxin and bacitracin for spinal surgery. Surgical Neurology [Surg Neurol] 1998 Sep; Vol. 50 (3), pp. 208-12.

2. Intraoperative anaphylactic shock after bacitracin irrigation. Anesthesia And Analgesia [Anesth Analg] 1990 Oct; Vol. 71 (4), pp. 430-3.

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UTI PreventionGoal: Prevent bladder infection that would lead to seeding of prosthetic device upon catheter removal

Closed catheter systems Silver-coated latex /silicone Prevent UTIs postoperatively Ideally in for no more than 48 hrs Some old literature that supports silver catheters

We use silver latex catheters - no longer use Bactrim prophylaxis post-op (unless re-catheterized for urinary retention)

New SCIP core measure – catheters removed within 48 hrs

Our Experience and Evidence

OR Cleanup

Bundle Approach to Reducing SSI

NEBH SSI Rates 2003 – 2010(outpatient and inpatient infections)

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GENERAL SSI FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10(Oct-Jul)

# Infections 6 1 3 4 2 2 1 0# Procedures 1073 920 780 692 567 467 369Infection Rate 0.6 0.1 0.4 0.5 0.3 0.3 0.2 0

ORTHOPEDIC SSI# Infections 63 60 49 46 39 37 28 27# Procedures 8837 9669 9216 8986 9027 8884 8890 8256Overall Infection Rate 0.7 0.6 0.5 0.5 0.4 0.4 0.3 0.3#Hip Infections 14 5 4 7 5 5 10 8 Hip Prosthesis Rate 1.0 0.3 0.2 0.4 0.3 0.3 0.5 0.4#Knee Infections 21 14 11 7 7 11 9 7 Knee Prosthesis Rate 1.6 1.0 0.7 0.4 0.3 0.5 0.4 0.3#Laminectomy Infec. 6 9 7 7 12 4 0 3 Laminectomy Rate 0.7 0.9 0.6 0.8 1.3 0.5 0.0 0.6#Spinal Fusions Infec. 5 15 12 12 5 5 3 3 Spinal Fusion Rate 0.8 2.0 1.4 1.1 0.4 0.4 0.3 0.4

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Creative and Fun Hand Hygiene Educational Programs

Infection Control - $7000.00/year budget

Most Important Control Measure

HAND HYGIENE – wash off the dirt!

Wash hands several times a day – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes and communicate efficiently with one another to transfer antibiotic resistance factors

Alcohol Foam, Liquid and Hand Wipes

All patients receive package of alcohol wipes in admission kit – encourage them to sanitize hands

Foam or liquid sanitizer In each patient room, outside rooms, cafeteria and other areas

Wash hands often – before eating, before leaving work, after contamination

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Got Soap? - Engage Your Staff!!

Engaged the OR staff in a Got Soap? Campaign OR Nurses Surgeons Administration Infection

Control

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November 2005 “Partners in Hand Hygiene”

January 2006“Let it S.N.O.W.”Stop Nosocomial Organisms by Washing

April 2006“Do the H.O.P.”Hand washing Offers Protection

Patient and Visitor Empowerment

Routine Cafeteria Displays

75

LUAU

Let Us Always Use

Good Hand Hygiene Cafeteria Cruise Ship Alcohol hand rub to

enter cafeteria Posters – Engage

the Staff Hawaiian music and

food Raffle table and

candy distributed

Be Creative – Make it Fun

76

Creative and Interactive

Glo-Germ “Bug Beat” Fair Contact

Plates

77

16 poster displays: Admitting Surgical Services Micro Lab EVS, Transport Nursing Units

M.R.S.A . Fair – Program

Make Resistance Stay Away

78

2007

79

2007

80

2008

82

Hand Hygiene Observations

0

10

20

30

40

50

60

70

80

90

100

2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Overall Direct Care Providers Hand Hygiene Compliance FY08-09

Before After`

0

10

20

30

40

50

60

70

80

90

2nd Qtr FY08 3rd Qtr 4th Qtr 1st Qtr FY09 2nd Qtr 3rd Qtr 4th Qtr

Physician and Hospitalist Hand Hygiene Compliance FY08-09

Before After

0

10

20

30

40

50

60

70

80

90

100

2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

RN Hand Hygiene Compliance FY08-09

Before After`

83

Tools for Success

• Senior leadership and Board of Trustees involvement – “lead the effort” from top down

• Structured program with clearly defined goal of zero tolerance for HAIs

• Communication – effective and consistent

• Ongoing and creative education

• Financial support to Infection Control program

Thank YouThank You