Surgical Site Infection Prevention: what’s new?

Barbara DeBaun, RN, MSN, CICAlaska State Hospital and Nursing Home Association Webinar Series

March 20, 2018

Surgery and SSI’s: Current Situation

• 80 million surgeries in US/year• 1.5 million SSI’s• Most common HAI (30%)• 3% mortality rate• 75% of SSI-associated deaths are

directly attributable to the SSI• Cost $5,000-$13,000• 55% are preventable

2020: The Silver Tsunami

Prevention of Surgical Site Infection, 2017

• 1999 guidelines were primarily driven by expert opinion

• 2017 guidelines were driven by an evidence rating system

• Review of >5,000 studies published between 1998 and 2014.

HICPAC Strength of Evidence

Category IA A strong recommendation supported by high- to moderate-quality evidence suggesting net clinical benefits or harms.

Category IB A strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms, or an accepted practice, supported by low- to very low-quality evidence.

Category IC A strong recommendation required by state or federal regulation.

Category II A weak recommendation supported by any quality evidence suggesting a tradeoff between clinical benefits and harms.

No recommendation/unresolved issue An unresolved issue for which there is either low- to very low-quality evidence with uncertain tradeoffs between benefits and harms or no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention.

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SSI Resource – Supplemental Guidance

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Interventions for All Procedures

antimicrobial prophylaxis

(AMP)

glycemic control normothermia oxygenation antiseptic

prophylaxis

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Polling Question

In my facility, we:

a. Give every surgical patient the same dose of prophylactic antibioticsb. Adjust prophylactic antibiotics based on patient’s BMI or weightc. Not sure

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Polling Question

At my facility we:

a. Re-dose prophylactic antibiotics based on the drug half-life and duration of surgeryb. Do not re-dosec. Not sure

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Antimicrobial Prophylaxis

• Only when indicated• Selection• Time• No re-dosing after incision is

closed, even in presence of a drain (clean and clean-contaminated)

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Preoperative Antimicrobial Agents

HICPAC SSI Prevention Guidelines• No recommendation for weight

based dosing

• No recommendation for intra operative redosing

WDPH SSI Prevention Guidance• Follow the 2013 American

Society of Health-System Pharmacists (ASHP) guidelines

• Give based on BMI or weight in kilograms

• Base re-dosing on drug half-life and duration of surgery

Polling Question

In my facility, we:

a. Aim to maintain a hemoglobin A1C of <6.7 for all surgical patientsb. Only focus on patients with known diabetesc. Not on our radard. Not sure

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Glycemic Control

• Maintain perioperative blood glucose levels <200mg/dl in ALL surgical patients (not just diabetics)

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Glycemic Control

HICPAC SSI Prevention Guidelines• No recommendation regarding

the safety and effectiveness of lower or narrower BG target levels and SSI

• No recommendation for hemoglobin A1C target levels and risk of SSI

WDPH SSI Prevention Guidance• Avoid increased risk of

hypoglycemic events and increased mortality associated with tight glycemic control

• Maintain hemoglobin A1C level <6.7

Polling Question

In my facility, we:

a. Keep our surgical patients warm before, during, and after surgeryb. Are not focused on keeping patients warmc. Not sure

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Normothermia

• 35.5 C or more• Mild degrees of hypothermia

can increase SSI risk• Impacts circulation, coagulation,

medication metabolism and wound healing

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Normothermia

HICPAC SSI Prevention Guidelines• No recommendation regarding

safety or efficacy of normothermia strategies, ranges or duration

WDPH SSI Prevention Guidance• Consider use of forced-air

warming to reduce incidence of SSI’s

Polling Question

In my facility, we

a. Provide high oxygen supplementation to patients undergoing colon surgeryb. Do not provide high oxygen supplementation to surgical patientsc. Not sure

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Oxygenation

• Pre/intra/post• Optimizes tissue oxygenation

and reduces SSI risk• Low cost and simple

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Oxygenation

HICPAC SSI Prevention Guidelines• No recommendation for high

oxygen supplementation

WDPH SSI Prevention Guidance• Consider use of high oxygen

supplementation as an SSI risk reduction strategy during colorectal procedures

Skin Antisepsis (Pre and Peri-op)

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Polling Question

In my facility, we

a. Have reliable processes to provide pre-surgical skin antisepsis/bathing for our patientsb. No, we don’t have this in placec. Not sure

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Antiseptic Prophylaxis

HICPAC SSI Prevention Guidelines• Advise patients to shower or

bathe (full body) with either soap (antimicrobial or non-antimicrobial) or an antiseptic agent on at least the night before the operative day

WDPH SSI Prevention Guidance• Ensure that all patients

undergoing elective surgical procedures involving skin incisions undergo a standardized preadmission shower/cleansing with 4% aqueous or 2% (cloth coated) CHG

Patient Instructions

Antiseptic Prophylaxis

HICPAC SSI Prevention Guidelines• No recommendation for optimal

timing of the preoperative shower or bath, # of soap or antiseptic applications or CHG washcloths

WDPH SSI Prevention Guidance• Standardize the preadmission

shower• Specific recommendations for #

of baths

Third Time’s a Charm?

Antiseptic Prophylaxis

HICPAC SSI Prevention Guidelines• Consider use of triclosan-coated

sutures to prevent SSI’s

WDPH SSI Prevention Guidance• Use triclosan-coated

antimicrobial sutures to close surgical wounds

Additional Interventions

• Prosthetic joint• Staphylococcal screening and decolonization• blood transfusion• systemic immunosuppressive therapy, intra-articular corticosteroid injection,

anticoagulation, orthopedic space suits, and biofilms

• Colorectal• Mechanical bowel preparation with antibiotics

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Use of Surgical Care Bundles

What is on the other side of the red line?

Skin Prep

Hair removal

Nasal Decolonization

Glove Changes/New Instruments

Irrigation

Challenges

Surgical Attire: What We Wear Matters

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Head Covers

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Staff hair containment does matter

Traffic Control

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Red Cap

UV light as adjunct to manual cleaning

• Anderson DJ et al. “Decontamination of targeted pathogens from patient rooms using an automated ultraviolet-C-emitting device.” Infect Control Hosp Epidemiol. 2013 May;34(5):466-71.

• Doan L et al. “Clinical and cost effectiveness of eight disinfection methods for terminal disinfection of hospital isolation rooms contaminated with Clostridium difficile 027”. J Hosp Infect. 2012 Oct;82(2):114-21.

Antimicrobial post-op dressing

• Eberlein T et al. “Comparison of PHMB-containing dressing and silver dressings in patients with critically colonised or locally infected wounds”. J Wound Care. 2012 Jan;21(1):12, 14-6, 18-20.

• Martín-Trapero C, et al. “Surgical site infections. Effectiveness of polyhexamethylenebiguanide wound dressings.” Enferm Clin. 2013 Mar 22.

Antimicrobial dressingfor pins and drains

Blechman K, Reavey P. American Association of Plastic Surgeons Conference April 2012. ABSTRACT: “Use of the Biopatch Drain Dressing to Reduce Infection Rates in Expander/Implant-Based Breast Reconstruction.”

SSI Patient Brochure

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SSI Change Package & Top 10 Checklist

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For more SSI resources, visit http://www.hret-hiin.org/topics/surgical-site-infection.shtml

SSI Change Package SSI Top 10 Checklist

Any Questions/Comments in the Chat Box?

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Next Steps