presented by: kathleen kohut, rn, ms, cic, cnor system director of infection prevention cone health,...
TRANSCRIPT
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"SSI Prevention: Preparing for the future by going back to the basics"
Presented by:
Kathleen Kohut, RN, MS, CIC, CNORSystem Director of Infection PreventionCone Health, Greensboro, NC
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Speaker Disclosures
3M
AMN Healthcare
The Compass Group
BE Smith Consulting
Johns Hopkins Hospital
NCH Healthcare System
APIC
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Learning Objectives
1. Discuss the five basics of SSI prevention
2. Describe the use of glycemic control, nasal decolonization, and normothermia initiatives for the reduction of SSIs.
3. Name the 2 most common mechanisms for wound contamination
4. Name 3 SCIP Measures
5. Discuss two opportunities for practice improvement
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PREPARING FOR THE FUTURE
Current National SSI Initiatives include:
The Joint Commission National Patient Safety Goal NPSG.07.05.01 included in 2009
CMS Public reporting requirements for SSIs 2012 - Colon Resections and Abd Hysterectomies▪ Nationally
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SCIP Quality Measures
1. Antibiotic Prophylaxis ( Inf- 1,2,3) Drug, Timing, Dosing, Discontinuation
2. Hair Removal (Inf- 6)
3. Glycemic Control (Inf – 4)
4. Foley Catheter removal POD1 or POD2 (Inf- 9)
5. “Normothermia” (Inf 10) Expanded in June 2011 All surgical patients
http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx
http://www.jointcommission.org/assets/1/6/Surgical%20Care%20Improvement%20Project.pdf
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Barriers to Progress in SSI Prevention
SSI is an unfortunate possibility (it says so right on the consent form)
Challenge-change the culture of tolerance to one of intolerance to SSI
The Business Case- maximization of OR volume to increase revenueChallenge- improve efficiencies without compromising infection prevention
TraditionChallenge- re-examine practices from a fresh perspective to find new
opportunities
Lack of researchChallenge- conduct research and publish to create a solid body of evidence
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Going Back to the Basics
Five Focus Areas:
1. Patient Preparation2. Aseptic Technique3. ABX Prophylaxis4. Hair Removal5. Skin Antisepsis
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1. Optimal Patient Preparation Includes:
Losing weight, quitting smoking
Glucose Management
Nasal Decolonization
Normothermia – pre-warming
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Diabetes
The stress response induced by surgical procedures increases blood glucose levels
Non-diabetics may also experience hyperglycemia during this critical perioperative period
CDC(2011). http://www.cdc.gov/diabetes/pubs/factsheet11.htm; accessed on May 10, 2013.
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Glycemic Control
>25 million Americans diagnosed with diabetes
> 7 million are undiagnosed
79 million considered pre-diabetic 30-35% of cardiac patients are
diabetics
http://www.cdc.gov/diabetes/pubs/factsheet11.htm
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Glycemic Control
SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.
All Patients should be managed with a target of <200
The first 24 hours is critical
The OR cannot be a black hole
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S. aureus Nasal Carriage
Between 25-30% of all patients are colonized at any given time and another 60% carry it intermittently.
Carriers are at higher risk S. aureus causes 25-35% of all HAIs 20% of all surgical pts acquire some type of
HAI during their postoperative course
Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24): 1871-7.
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Nasal Decolonization
85% of S. aureus infections were endogenous in SSI study populations Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61:254-261.
MRSA SSI rates decreased from .23% to .09% (5,094 pts) with MRSA eradication program
Pofahl, WE, et al. Active Surveillance Screening of MRSA and Eradication of the Carrier State Decreases Surgical-Site Infections Caused by MRSA. J Am Coll Surg 2009;208:981-988.
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Normothermia
SCIP Measure Inf-10
Includes all SCIP surgical patients (June 2011)
▪ Total Knee, Hip, Vascular, Cardiac, ABD Hyst, Colon Resect
Requires one temperature > 96.8º F(36º C) 30 min. before or 15 min after anesthesia end time.
Start with pre-warming
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2. Aseptic Technique
Principles were developed to reduce the risk of wound contamination.
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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
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Causes of Wound Contamination
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
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The Number One Source
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
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Traffic Control
Requires the control of the amount of traffic and the traffic patterns themselves
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 care Utilize alternative methods of communication
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.
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Kohut SSI Equation
People + Wind + (-) Aseptic Technique > ABX + Skin Prep =
Wound Contamination = SSI
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Containment is the key
Patient Opportunities
Pre-op showering program-At least 2 showers with CHG
Hat and clean gown/linen for patient transport Hair removal only when necessary
Clippers, not in the OR
Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.
Chlebicki MP, et al. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: A meta-analysis. Am J Infect Control 2013;41:167-73.Newsmanager.commpartners.com/shea/issues/2013-04-02/1.html. Accessed 4/3/13.
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Containment is the key
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)
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Ban Skull Caps
If it takes 17 years to adopt new technology, our time is up!
Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov) 1157-59.
Institute of Medicine (IOM). (2001). Crossing the quality chasm. Crossing the quality chasm: A newhealth system for the 21st century. Washington: National Academy Press.
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Other Industries
THE JACKSON LABORATORYBIOTECHNOLOGY COMPANY
COSTCO
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Environment
Room Requirements• Ventilation System ▪ (min 15- recommended- 20-25/hr, 3 fresh)▪ Positive pressure
• Temperature (68-73° F)• Humidity (20-60%)
Room Cleaning• Between cases• Terminal cleaning• Types of construction materials• Clutter
AORN, Recommended Practices for Perioperative Nursing: Patient & Worker Safety. (2011 ed., p 219-221)
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3. Antibiotic Prophylaxis
SCIP Measures - INF 1,2,3 and NPSG.07.05.01 (#7)
Goal >95%▪ Challenge the organization to 100%
Proper dosage for obese population (BMI>30)(Surg 1989;106:750)
Redosing q 3 hours (Ann Surg 2009; 250:10)
• RCA or Med Error if missed
Bratzler, DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst. Pharm. 2013;70:195-283.
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4. Hair Removal
1. SCIP measure (Inf-10)
2. NPSG.07.05.01 (#8)Goal
Minimize as much as possibleClippers only
3. Not addressed: Location of hair removal
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5. Skin AntisepsisThe attributes of an appropriate surgical skin antiseptic
require: The ability to significantly reduce microorganisms (2 log-dry sites, 3 log-wet sites) Provide broad spectrum activity Be fast acting Have a persistent effect
All products with FDA approval meet this criteria
Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.
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Other Skin Antisepsis Considerations
1. Procedure (location and type of incision site) May challenge the prep area with the presence of blood,
saline, friction from retractors, etc.2. Patient Safety
Consider not using alcohol based preps for head and neck surgeries due to the highest risk of fire.
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There are no specific recommendations…
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
NQF 2011 recommendation: “use solutions that contain isopropyl alcohol as skin antiseptic preparation until other alternatives have been proven as safe and effective, and allow appropriate drying time per product guidelines.”
National Quality Forum: http://www.qualityforum.org/News_And_Resources/Press_Releases/2011/NQF_Maintains_Endorsement_of_Safe_Practice_to_Prevent_Surgical_Site_Infection.aspx
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Surgical Skin Antisepsis Research
Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes
The majority of the literature compares microbial counts
Much more work must be done to create a body of evidence to guide practice
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Current Research
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 patients comparing 3 methods (Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™)
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 3209 pts comparing 3 methods (Iodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™
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 patients comparing 2 methods (Iodophor Scrub/Paint vs. Chlorhexidine-alcohol)
Savage, JW et al. Efficacy of Surgical Preparation Solutions in Lumbar Spine Surgery. J Bone Joint Surg Am. 2012;94:490-4
Efficacy study comparing ChloraPrep® to DuraPrep™ preop, post prep, and post-op
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Clear as Mud……..
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Isopropyl Alcohol
Mechanism of actions: Denatures (kills) proteins
Bactericidal Fungicidal Virucidal Does not kill spores
Has no persistent effect
Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.
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Product Application Methodology
Follow manufacturer’s directions Read the labels!
Utilize proper aseptic technique during application & gloves to contain shedding
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Facilitating Process Improvements
Create relationships between IP, OR, SPD, Pre-op, Surgeons (and their offices):
Learn how they do their work Learn how you can help each other Choose process measures together Its about partnering not policing
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Process Improvements
Provide process data on an ongoing basis
Maintains focus▪ IUS rates▪ Compliance with surgical attire
Review outcome data regularly SSI Rates
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Summary
SSIs are preventable and there is much work to be done
The tools for success include SCIP measures, NPSG.07.05.01, process and outcome data and the operating room basics to:
1. Educate
2. Measure
3. Communicate