the application of evidence based bundle approach to

The Application of Evidence Based Bundle Approach to Reduce Surgical Site Infection in Geriatric Hip Fracture Patients – A Single Centre Experience Chan PHA1, Chu WSV 1, Hung KYR 2, Chow CYV 3, Yuen FYF 4, Kwok KBC 1, Hung YW 1, Fan CHJ 1 , Ho PC 1 1 Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital 2 Infection Control Nurse, Alice Ho Miu Ling Nethersole Hospital 3 Department of Microbiology, Prince of Wales Hospital 4 Department of Anaesthesiology and Operating Services, Alice Ho Miu Ling Nethersole Hospital, Hong Kong

Geriatric Hip Fracture Hemiarthroplasty

ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC

• Common Orthopaedic Procedure

• At least 1 Surgeon + At least 1 Assistant

• Done by Trainee or Specialist

Background • The Surgical Site Improvement Program and Audit

for Orthopedic surgeries has been developed in 2009 in AHNH

• 10.3% Surgical Site Infection (SSI) in Geriatric Hip Hemiarthroplasties in 2010

• 8% SSI in Geriatric Hip Hemiarthroplasties in 2012


Morbidities Quality of Life Hospital length of stay by 7 -14 days Likelihood of ICU admission by 60%

Median total direct Costs by 300%

Risks of Rehospitalization & Death


Surgical Site Infection (SSI)= Dreadful Complication (Mangram A, Horan T, Pearson M, et al. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247–78. Katarincic JA et al. Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review. J Am Acad Orthop Surg 2018 Jan.)

What to Do?


Pre-operative Preparation

Post-operative

Preparation

Intra-operative

Preparation

Multidisciplinary Teamwork Orthopaedic Surgeons +

Nurses

Operation Theatre

Infection Control Team

Infection Control Nurse

(ICN)

Microbiologist


Methodology • Objective:

◦ To reduce surgical site infection (SSI) in hemiarthroplasty operation in

geriatric hip fracture patient

• Target group:

◦ > 65 years old

◦ Fracture neck of femur

◦ Hemiarthroplasty operation



• MRSA screening

◦ Performed for all potential hemiarthroplasty cases for Hip fractures

◦ For positive cases:

◦ Vancomycin is used as prophylactic antibiotics.

◦ Decolonization is carried out

A. Pre-operative Preparation


Preoperative Skin Preparation by Chlorhexidine Bathing

1 day before operation / on operation day

B. Intra-operative Preparation


Strict Observation of Hand Washing Guideline

Limitation of Traffic


Step I. Povidine iodine disinfection before draping

Step II. Double-sponge disinfection with povidine iodine upon water-tight draping


Step III. Coverage of the knee to distal region with a sterile plastic sheet wrapped by crepe bandage

Step IV. ChloraPrep with tint (Chlorhexidine gluconate and isopropyl alcohol) with time allowed for alcohol evaporation


Step V. Circumferential iodophor impregnated plastic adhesive drape ('Ioban') covering the hip and thigh region


VI. Surgical wound dressed with Aquacel Adhesive tape after wound closure

C. Post-operative Care

• Dressing care:

◦ Change dressing immediately after soaked or contaminated

• Wound Inspection Precautions:

◦ Surgical wound should NOT be left unattended for inspection.

◦ Unnecessary wound inspection in early post-operative period should be

avoided.


Total of 496 Hemiarthroplasties (2008-2017Q3)

Chi-square test p=0.082


Operative Statistics



IHD 5%

AF/ warfarin 3% Lipid

3%

DM 15%

HT 15% CVA/

Parkinon's disease

11% ESRF/RF

5% RA/SLE

1%

GIB 2%

Liver failure 5%

steroid 0%

Dementia 8%

Psy problem 3%

Coagulopathy 2%

CHF 2%

others 18%

Medical Comorbidities 2008-2017

No. of comorbidities /

patient 2008-

17Q3 2008-2012

2013-17 Q3

1 2 1 1 2 12 7 5 3 2 2 0 4 7 5 2 5 3 1 2 6 2 1 1

One 7%

Two 43%

3 7%

Four 25%

Five 11%

Six 7%

No. of comorbidities / patients 2008-2017


3.31

1.95

3.95

1.6

7.25

3.55

0

1

2

3

4

5

6

7

8

2008-2012 2013-17 Q3

Superficial Infection

Deep Infection

Overall Infection rate

Average Yearly Infection Rate (%)


14.28571429

3.636363636

10.34482759

0

8

4

6

2.702702703 3.174603175

1.851851852

AHNH overall mean=5.24

HA overall =1.598 0

2

4

6

8

10

12

14

16

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Q1-Q3

SSI r

ate

(%)

AHNH Surgical Site Infection Surveillance (AMA & Unipolar Hip Arthroplasty) 2008 - 2017 Q3

Infection rate of AMA/Unipolar hip arthroplasty (%) AHNH Overall mean of AMA & UHA

HA overall mean for HPRO 2016


Yearly SSI for Hip fracture Hemiarthroplasty/ AMA


79%

21%

Antibiotic Alone

SurgicalDebridement

Treatment of Superficial Wound Infections

100%

Removal of Implant and Surgical Debridements

Treatment of Deep Wound Infections


Bacteriology of AMA/ Unipolar Hip Arthroplasty

2008-2017

2008-2012

2013-2017 Q3

Acinetobacter species 2 2

Enterococcus species 1 1

Klebsiella species 1 1

Pseudomonas Species 3 2 1

Staphylococcus aureus 3 2 1

MRSA 6 3 3

Staphylococcus CNS 4 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008-2017 2008-2012 2013-2017 Q3

2

2 1

1

1

1

3

2

1 3

2

1

6

3

3

4

4

Bacteriology of AMA / Uniploar Hip Arthroplasty

Staphylococcus CNS

MRSA

Staphylococcus aureus

Pseudomonas Species

Klebsiella species

Enterococcus species

Acinetobacter species

Discussion • The Bundle Approach cannot 100% eliminate

SSI, BUT….

• Decreasing trend of Overall SSI

• Decreasing trend in Deep wound infection in consecutive 2 years since 2015


Conclusions • The bundle approach has shown to achieve an effective

and sustained decrease in SSIs in Hemiarthroplasty operations for geriatric hip fracture patients

• The result needs shared efforts, mutual communications, support and understandings of multidisciplinary teams

Reference:

1.Acklin YP, Widmer AF, Renner RM, Frei R, Gross T. Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach. Injury. 2011 Feb;42(2):209-16.

2.Fairclough JA, Johnson D, Mackie I. The prevention of wound contamination by skin organisms by the pre-operative application of an iodophor impregnated plastic adhesive drape. J Int Med Res. 1986;14(2):105-9.

3.Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden. Patient Saf Surg. 2012 Jun 14;6(1):11.

4.Katarincic JA, Fantry A, DePasse JM, Feller R. Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review. J Am Acad Orthop Surg. 2018 Jan 1;26(1):14-25.


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