Prevention%20of%20Surgical%20Site%20Infections

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Prevention of Surgical Site Infections

• William A. Rutala, Ph.D., M.P.H.
• UNC Health Care System and UNC School of
  Medicine, Chapel Hill, NC

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Disclosure

• This educational activity is brought to you, in
  part, by Advanced Sterilization Products (ASP)
  and Ethicon. The speaker receives an honorarium
  from ASP and Ethicon and must present information
  in compliance with FDA requirements applicable to
  ASP.

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TOPICS

• Epidemiology of healthcare associated infections
  (HAI)
• Review the morbidity, mortality, and economic
  consequences of HAIs
• Discuss the risk factors and etiology of SSIs
• Provide strategies to prevent SSIs
• National initiatives to prevent SSIs

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Healthcare-Associated Infections (HAIs)

• HAIs are those that develop in the hospital that
  were neither incubating nor present at the time
  of admission
• 40 million persons hospitalized annually in US
  5 or 2M will develop a HAI
• Morbidity and mortality (90,000 deaths) 6th
  leading cause of death in the US
• Variable prolongation of hospital stay
• 5-10 billion/year

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Impact of Healthcare-Associated Infections
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Cost Estimates for Specific Healthcare-Associated
Infections
HAI type Weight-Adjusted Cost per HAI Mean SE Range of Published Estimates of Cost per HAI
VAP 25,072 4,132 8,682-31,316
BSI 23,242 5,184 6,908-37,260
SSI 10,443 3,249 2,527-29,367
CA-UTI 758 41 728-810
2005 US dollars Anderson DJ, et al. ICHE
200728767-773
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UNC HospitalsSelected HAIs and Estimated Cost
HAI type UNC Cases, 2006 Estimated Cost,
VAP 85 2,131,120
BSI 297 6,902,874
SSI 266 2,777,838
CA-UTI 311 235,738
Total 959 12,047,570
Total cost estimated by multiplying number of
cases at UNC Hospitals by mean cost derived from
Duke meta-analysis
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Most Prevalent
Weinstein RA. Emerg Infect Dis.
19984(3)416-420. CDC, NNIS Semiannual Report,
Dec 2000.
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Surgical Site Infection
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Surgical Site Infection

• SSIs third most common HAI, accounting for 14-16
  of HAIs
• Among surgical patients, SSIs were most common
  accounting for 40 of healthcare-associated
  infections
• 67 incisional infections (confined to incision)
• 33 organ/space infections
• Increase an average of 7 days to each
  hospitalization
• Increase gt10,000 (2005 ) to each
  hospitalization
• Appropriate preoperative administration of
  antibiotics and other prevention measures are
  effective in preventing infection

Surgical Site Infections. Available at
http//www.ihi.org/IHI/Topics/PatientSafety/Surgic
alSiteInfections/. Odom-Forren J. Nursing2006.
200636(6)58-63.
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Surgical Site Infection

• Advances in infection control practices
• Improved operating room ventilation
• Sterilization methods
• Barriers
• Surgical technique
• Antimicrobial prophylaxis

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Challenges in the Prevention and Management of
Surgical Site Infections

• Changing population of hospital patients
• Increased severity of illness
• Increased numbers of surgical patients who are
  elderly
• Increased numbers of chronic, debilitating or
  immunocompromising underlying diseases
• Shorter duration of hospitalization
• Increased numbers of prosthetic implant and organ
  transplant operations performed
• Public reporting of infection rates/proportions
• Growing frequency of antimicrobial-resistant
  pathogens
• Non-reimbursement for medical errors-CMS
• Lack of compliance with hand hygiene

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Clinical and Economic Impact
Procedure/Device Devices/yr Infections/yr Avg. cost Mortality
CARDIO CARDIO CARDIO CARDIO CARDIO
Heart valves 85,000 3,400 50,000 High
Vascular grafts 450,000 16,000 40,000 Moderate
Pacemaker/ICD 300,000 12,000 35,000 Moderate
LV assist dev. 700 280 50,000 High
NEURO NEURO NEURO NEURO NEURO
CNS shunt 40,000 2400 50,000 Moderate
Adapted from Darouiche RO. N Engl J Med.
20043501422-429. Darouiche RO. Clin Infec Dis.
2001381567-1572.
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Clinical and Economic Impact
Procedure/Device Devices/yr Infections/yr Avg. cost Mortality
ORTHOPEDIC ORTHOPEDIC ORTHOPEDIC ORTHOPEDIC ORTHOPEDIC
Joint prosthesis 600,000 12,000 30,000 Low
Fracture fixator 2,000,000 100,000 15,000 Low
PLASTIC PLASTIC PLASTIC PLASTIC PLASTIC
Breast implant 130,000 2600 20,000 Low
UROLOGICAL
Penile implant 15,000 450 35,000 Low
Adapted from Darouiche RO. N Engl J Med.
20043501422-429. Darouiche RO. Clin Infec Dis.
2001381567-1572.
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SSI Pathogenesis

• Risk of surgical site infections
• Dose of bacterial contamination x virulence
  (toxins)
• Resistance of the host

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SSI Primary Risk Factors

• Endogenous microorganisms
• Skin-dwelling microorganisms
• Most common source
• S aureus most common isolate
• Fecal flora (gnr) when incisions are near the
  perineum or groin
• Exogenous microorganisms
• Surgical personnel (members of surgical team)
• OR environment (including air)
• All tools, instruments, and materials

Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
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SSI Microbiology (NNIS, 1996)
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PATHOGENS ASSOCIATED WITH SSIs NHSN, 2006-2007
Hidron AI, et al. ICHE 200829996-1011
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To Reduce the Risk of Surgical Site Infection

• A simple but realistic approach must be applied
  with the awareness that the risk of SSIs is
  influenced by characteristics of the patient,
  operation, personnel and hospital

Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
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CDC SSI Recommendations, 1999

• Definitions
• IA Strongly recommended for all hospitals and
  strongly supported by experimental or
  epidemiologic studies
• IB Strongly recommended for all hospitals and
  viewed as effective by experts
• II Suggested for implementation in many
  hospitals suggestive clinical or epidemiologic
  studies, strong theoretical rationale

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SSI CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
24
SSI CDC Guidelines
Patient characteristics/risk factor
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
25
Risk and Prevention in SSIs

• Risk Factor-a variable that has a significant
  independent association with the development of
  SSI after a specific operation

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SSI Intrinsic/Patient Risk Factors

• Age-extremes
• Nutritional status-poor
• Diabetes-controversial increased glucose levels
  in post-op period ? risk
• Smoking-nicotine delays wound healing ? risk
• Obesitygt20 ideal body weight

• Remote infections ? risk
• Endogenous mucosal microorganisms
• Preoperative nares S. aureus- CT patients
• Immunosuppressive drugs may ? risk
• Preoperative stay-surrogate for severity of
  illness

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Prevention of SSIs

• Preoperative preparation of the patient
• Minimize preoperative stay (II)
• Identify and treat remote site infections (IA)
• Adequately control glucose in diabetics (IB)
• Encourage discontinuation of tobacco for 30d
  (IB). Consider delaying elective procedures in
  severely malnourished patients (II)
• No recommendations to taper or discontinue
  steroids (Unresolved issue)

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SSI CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
30
SSI Preoperative IssuesModifiable Risks
Glucose control-in diabetic patients
Preoperative CHG shower
Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia-hypo higher risks
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278. 5 Million lives. Institute
for Healthcare Improvement. Available at
http//ihi.org/IHI/Programs/Campaign/Campaign.htm
. Accessed on February 8, 2007.
31
Prevention of SSIs

• Preoperative preparation of the patient
• Preoperative showers with antiseptic agent at
  least the night before (IB)
• Do not remove hair preoperatively unless it will
  interfere with the operation (IA)
• If hair removed, remove just prior to surgery
  with electric clippers (IA)
• Wash and clean at and around incision site prior
  to performing antiseptic skin preparation (IB)

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Preoperative Showers

• Garibaldi R (J Hosp Infect 198811(suppl B)5
• Reduction in bacterial counts Chlorhexidine
  9-fold, povidone-iodine 1.3-fold
• Cruse and Foord (Arch Surg 1973107206)
• Clean surgery
• SSI rate, no shower 2.3
• SSI rate, shower with soap 2.1
• SSI rate, shower with hexachlorophene 1.3

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Chlorhexidine Preoperative Showers

• CDC recommends preoperative showering with
  antiseptic1
• CHG more effective than PI and triclocarban
• Lower rates of intraoperative wound contamination

1. Mangram AJ et al. Infect Control Hosp
Epidemiol. 199920(4)250-278. 2. Garibaldi RA. J
Hosp Infect. 198811(suppl B)5-9.
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Chlorhexidine Preoperative Showers

• Patients who had 2 preoperative showers with CHG
  24 hours before surgery had reduced rates of
  wound infection compared to patients who showered
  with soap.

Hayek LJ, et al. J Hosp Infect.
198710(2)165-172.
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4 Chlorhexidine Gluconate (CHG) Shower - Mean
Skin Surface Concentration (N60)
CHG Shower
Group 1A Evening (PM)
Group 2A Morning (AM)
Group 3A Both (AM and PM)
CHG Concentration (PPM)
p lt0.05 NS Plt0.001
MIC90 4.8 ppm
Left Elbow
Right Elbow
Abdominal
Left Knee
Right Knee
Skin Sites
Edmiston et al, J Am Coll Surg 2008207233-239
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Preoperative Hair Removal

• Seropian and Reynolds (Am J Surg 1971121251)
• SSI rate, razor-shave (microabrasions) 5.6
• SSI rate, razor-shave gt24 hours 20
• SSI rate, razor-shave within 24 hours 7.1
• SSI, razor-shave immediately preop 3.1
• SSI rate, no removal or depilatory 0.6

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Preoperative Hair Removal

• Cruse and Foord (Arch Surg 1973107206)
• SSI rate, razor-shave 2.5
• Manual hair clipped 1.7
• Electric hair clipper 1.4
• No shave or clip 0.9

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SSI Preoperative IssuesModifiable Risks
Glucose control-in diabetic patients
Preoperative CHG shower
Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia-hypo higher risks
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278. 5 Million lives. Institute
for Healthcare Improvement. Available at
http//ihi.org/IHI/Programs/Campaign/Campaign.htm
. Accessed on February 8, 2007.
39
Prevention of SSIs

• Preoperative preparation of the surgical team
• Keep nails short and no artificial nails (IB)
• Perform preoperative surgical scrub for 2-5
  minutes with antiseptic-alcohol, chlorhexidine,
  iodophors (IB) new waterless, surgical hand
  antisepsis with alcohol
• Perform preoperative scrub including forearms
  (IB)
• Do not wear hand/arm jewelry (II)
• Prohibiting nail polish (No recommendation)

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Importance of Our Skin

• Largest organ of the body
• Epidermis
• Dermis
• Subcutaneous tissue (hypodermis)

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Importance of Our Skin
1 Function Protective Barrier

• Microorganisms
• 80 in first 5 cell layers of epidermis
• When skin is perforated
• Integrity is compromised
• ? infection risk

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Normal Skin Micro-Flora
Numbers of bacteria that colonize different parts
of the body

• Numbers per square centimeter of skin surface
  (cfu/cm2). Counts on hands range from 3.9x104 to
  4.6x106.

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Surgical Hand Antisepsis
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Alcohols
Advantages Disadvantages
Broad spectrum Effective against Most gram-positive Most gram-negative Fungi Viruses Rapid acting Short persistence Potentially drying to skin Potentially flammable Spores may be resistant Not applicable for mucosal membranes
Larson EL.. Am J Infect Control.
199523(4)251-269. Boyce JM, et al. MMWR Recomm
Rep. 2002 Oct 2551(RR-16)1-45. Crosby CT,
Mares AK. JVAD. 20011-6.
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Iodine/Iodophors
Advantages Disadvantages
Broad spectrum Effective against Most gram-positive Most gram-negative Fungi Viruses Some activity against spores Diminished efficacy by organic material (e.g., blood) Variable persistence Irritates skin
Larson EL.. Am J Infect Control.
199523(4)251-269. Boyce JM, et al. MMWR Recomm
Rep. 2002 Oct 2551(RR-16)1-45. Crosby CT,
Mares AK.. JVAD. 20011-6.
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Chlorhexidine
Advantages Disadvantages
Broad spectrum Effective against Most gram-positive Most gram-negative Fungi Viruses Yeast Highly persistent Effective in the presence of organic material (e.g., blood) Minimally absorbed Direct instillation can damage ears or eyes Direct contact with nerve tissue can be damaging Minimal activity against spores
Larson EL. Am J Infect Control.
199523(4)251-269. Hidalgo E, Dominguez C.
Toxicol In Vitro. 200115(4-5)271-276. Maki DG,
et al. Lancet. 1991338339-343. Larson E, Bobo
L.. J Emerg Med. 199210(1)7-11.
Boyce JM, et al. MMWR Recomm Rep. 2002 Oct
2551(RR-16)1-45. Anders N, Wollensak J. J
Cataract Refract Surg. 199723(6)959-962. Perez
R, et al. Laryngoscope. 2000110(9)1522-1527.
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Surgical Hand Antisepsis

• Surgical hand scrubs should
• Significantly reduce microorganisms on intact
  skin
• Contain a non-irritating antimicrobial
  preparation
• Have broad-spectrum activity
• Be fast-acting and persistent

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Combined Agents
Active Agents Tincture of Iodine Traditional Iodophors CHG/ Alcohol
Broad Spectrum X X X
Rapid Activity X X X
Residual Activity X
Activity in Blood/Organic X
Non-Irritating X
Minimal Absorption X
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Surgical Hand Antisepsis

• Formulations containing 60-90 alcohol alone, or
  50-95 when combined with small amounts of a
  QUAT, or CHG lower bacterial counts on skin
  post-scrub more effectively than other agents
• Next most active agents (in order of decreasing
  activity) are CHG, iodophors, triclosan, and
  plain soap
• Alcohol-based preparations containing 0.5-1 CHG
  have persistent activity but alcohol alone may
  not

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Surgical Hand Antisepsis

• Studies suggest that neither a brush nor a sponge
  is necessary to reduce bacterial counts on the
  hands of surgical personnel to acceptable levels,
  especially when alcohol-based products are used
• One study (AORN J 200173412) found a brushless
  application of a preparation of 1 CHG plus 61
  ethanol yielded lower bacterial counts on the
  hands of participants than using a sponge/brush
  to apply 4 CHG

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Prevention of SSI

• Preoperative preparation of the patient
• Use appropriate antiseptic for skin preparation
  (IB)
• Alcohol (70-92)
• Chlorhexidine 4, 2 or 0.5 in alcohol base
• Iodine/iodophors
• Apply in concentric circles moving to periphery
• Prep area to include incision and any drain sites

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Chlorhexidine

• Highly effective in studies of
• hand washing
• preoperative showering
• IV catheter care
• CHG has a broad spectrum of activity
• Rapid
• Persistent
• Active w/ organic material
• Non-irritating
• Recommended in 15 evidence-based guidelines (hand
  hygiene, catheter-related bloodstream infection)

Larson E.. Am J Infect Control.
199523(4)251-269. Maki DG, et al. Lancet.
1991338339-343.
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2 CHG/70 IPA vs. 10 PVP-I

• Randomized, parallel group, open label, healthy
  human volunteers
• 55 subjects
• Microbial samples right and left abdominal and
  inguinal sites
• Efficacy defined as
• 2.0 log10 reduction from baseline CFUs/cm2 on
  abdominal sites
• 3.0 log10 mean reduction from baseline CFUs/cm2
  on inguinal sites

Hibbard JS. J Infus Nursing. 200528(3)194-207.
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2 CHG/70 IPA vs. 10 PVP-I
Abdominal
Inguinal
P0.0001 compared to baseline for all results
Hibbard JS. J Infus Nursing. 200528(3)194-207
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2 CHG/70 IPA for Foot and Ankle Surgery

• Prospective, randomized trial
• 125 evaluable patients
• 40 subjects/group
• 5 pre-prep baseline
• Products
• ChloraPrep (2 CHG/70 IPA)
• DuraPrep (0.7 Iodine/74 IPA)
• Techni-Care (3 Chloroxylenol-PCMX)
• Cultures hallux, web spaces between toes, and
  control site

Ostrander RV, et al. Bone Joint Surg Am.
200587(5)980-985.
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2 CHG/70 IPA for Foot and Ankle Surgery
Control anterior tibia, 12 cm proximal to the
ankle joint.
Ostrander RV, et al. J Bone Joint Surg Am.
200587-A980-985.
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2 CHG/70 IPA for Foot and Ankle Surgery
Ostrander RV, et al. J Bone Joint Surg Am.
200587-A980-985.
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Prevention of SSIs

• Preoperative preparation of the surgical team
• Clean underneath each fingernail prior to first
  surgical scrub (IB)
• After performing surgical scrub keep hands up and
  away from body allow water to run from hands to
  elbows dry with sterile towel (1B)

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Prevention of SSIs

• Management of infected or colonized surgical
  personnel
• Exclude from duty, surgical personnel who have
  draining skin lesions until infection eliminated
  or personnel have received adequate therapy (IB)
• Do not routinely exclude personnel colonized with
  S. aureus or group A strep unless personnel
  linked epidemiologically to outbreak (IB)
• Educate personnel regarding symptoms and signs of
  infection-have them report to OHS (IB)

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Prophylactic Antibiotics

• Antibiotics given for the purpose of preventing
  infection when infection is not present but the
  risk of postoperative infection is present.
  Cefazolin is widely used for clean operations.

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Surgical Infection PreventionArch Surg
2005140174
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Prevent Surgical Site InfectionsInstitute for
Healthcare Improvement

• Components if implemented reliably can eliminate
  SSIs
• Appropriate use of antibiotics one hour before
  incision appropriate antibiotics discontinue
  with 24 h after surgery (Surgical Care
  Improvement Project-CMS Quality Indicator)
• Appropriate hair removal
• Maintenance of postoperative glucose control
  (lt200mg/dl) for major cardiac surgery patients
• Establishment of postoperative normothermia for
  colorectal surgery patients

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SSI CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
71
SSI Primary Risk Factors

• Endogenous microorganisms
• Skin-dwelling microorganisms
• Most common source
• S aureus most common isolate
• Fecal flora (gnr) when incisions are near the
  perineum or groin
• Exogenous microorganisms
• Surgical personnel (members of surgical team)
• OR environment (including air)
• All tools, instruments, and materials

Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
72
OR Environment

• Air
• Largest source of airborne microbial
  contamination is the OR staff
• Organisms become airborne as a result of
  conversation or shedding from the hair or exposed
  skin
• Microbial level directly proportional to the
  number of people moving about in the room
• Improved ventilation associated with decreased SSI

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Prevention of SSIs

• Intraoperative (Ventilation)
• Maintain 15 AC/hr (gt3 fresh), positive pressure
  (IB)
• Filter all air through appropriate filters (IB)
• Introduce air at ceiling and exhaust near floor
  (IB)
• Keep OR doors closed as needed for passage of
  equipment, personnel, and patients (IB)
• Limit the number of OR personnel (IB)
• Consider ultraclean air for orthopedic implants
  (II)

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OR Environment

• Ventilation
• Three primary design components act to purify the
  OR air
• High-flow ventilation - 15 air changes per hour
  (3 outside air)
• High-efficiency filtration 90-99.97
• Positive pressure relative to adjacent areas
  (prevents contamination from less clean areas)
• Maintain the temperature (680-730F 20-230C) and
  relative humidity (30-60)

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OR Environment

• Environment as an Exogenous Source of Pathogens
• Clean environment minimizes the risk of OR
  environmental surfaces and floors as a source of
  infection
• Microorganisms isolated from the OR are usually
  non-pathogens rarely associated with infection
• When inanimate sources implicated, the sources
  have been contaminated solutions, antiseptics, or
  dressings (not floors, walls or environmental
  surfaces)

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Prevention of SSIs

• Intraoperative (Cleaning/disinfection
  environmental surfaces)
• Clean when visibly soiled/contaminated with EPA
  approved disinfectant before the next operation
  (IB)
• Do not perform special cleaning after
  contaminated or dirty surgery (IB)
• Do not use tacky mats (IB)
• Cleaning between surgery if no visible
  contamination (No recommendation)

77
OR Environment

• Disinfection
• OR environment (furniture, lights, equipment)
  should be damp-dusted with a germicide on a
  scheduled basis
• Exogenous microorganisms can contaminate surgical
  practice setting
• Disinfection is essential to reduce the risk of
  cross-infection
• Disinfection of these surfaces will control
  airborne microorganisms that might travel on dust
  and lint

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OR Environment

• Disinfection
• Floors should be cleaned with a low-level
  disinfectant
• For end-of-use cleaning, necessary to clean a
  3-to-4 ft perimeter around the operative site
  (extended as necessary by contamination)
• Important to reestablish a clean environment
  after each operation
• For terminal daily cleaning, entire floor is
  cleaned
• Same cleaning procedures performed whether clean
  or contaminated case

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OR Environment

• Disinfectants
• Low-level disinfectants are used for non-critical
  (skin contact) surfaces/furniture/lights
• Phenolics
• Quaternary ammonia compounds
• Chlorine (110 dilution of 5.25 sodium
  hypochlorite- blood spills)

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OR Environment

• Reusable Items
• Clean (in accordance to manufacturers
  recommendation)
• Lower the microbial load (mechanical or manual)
• Reduces organic and inorganic residual
• Disinfect or sterilize based on the risk of
  infection associated with the use of the item
• Critical items (sterile tissue, vascular system)
  must be sterile
• Semicritical (endoscopes) must be high-level
  disinfected

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OR Environment

• Sterilization
• Inadequate sterilization of surgical instruments
  has resulted in SSI
• Surgical instruments can be sterilized by steam,
  ethylene oxide, hydrogen peroxide plasma, dry
  heat or other approved methods
• Microbial monitoring of sterilization performance
  is necessary and can be accomplished by
  biological indicators

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Prevention of SSIs

• Intraoperative (Sterilization of surgical
  instruments)
• Perform flash sterilization only for patient care
  items that will be used immediately. Do not use
  for reasons of convenience, as an alternative to
  purchasing additional instrument sets, or to save
  time (IB)
• Sterilize all surgical instruments according to
  published guidelines (IB)

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OR Environment

• Microbiologic Sampling
• No standardized parameters by which to compare
  microbial levels obtained from cultures of
  ambient air or environmental surface
• Routine microbiologic sampling cannot be
  justified
• Environmental sampling should only be performed
  as part of an epidemiologic investigation

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Prevention of SSIs

• Intraoperative (Surgical attire and
  drapes-minimize patients exposure to skin, mm,
  or hair of surgical team and protect team from
  exposure to blood and OPIM)
• Wear a mask to fully cover the mouth and nose,
  and a cap or hood to fully cover hair on head and
  face (IB)
• Wear sterile gloves (IB)
• Do not wear shoe covers to prevent SSIs (IB)

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Prevention of SSIs

• Intraoperative
• Use materials for surgical gowns and drapes that
  are effective barriers when wet (IB)
• Change surgical scrubs when visibly soiled,
  contaminated and/or penetrated by blood (IB)

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Prevention of SSIs

• Asepsis and surgical technique
• Adhere to the principles of asepsis when placing
  intravascular devices, spinal or epidural
  anesthesia catheters, or when dispensing and
  administering IV drugs (IB)
• Handle tissue gently, maintain effective
  hemostasis, minimize devitalized tissue and
  foreign bodies, and eradicate dead space at the
  surgical site (IB)

87
Prevention of SSIs

• Asepsis and surgical technique
• Use delayed primary skin closure or leave an
  incision open to heal by second intention if the
  surgeon considers the surgical site to be heavily
  contaminated (IB)
• If drainage is necessary, use a closed suction
  drain. Place a drain through a separate incision
  distant from the operative incision. Remove the
  drain as soon as possible. (IB)

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SSI CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
90
Prevention of SSIs

• Postoperative Incision Care
• Protect with a sterile dressing for 24-48 hours
  postoperatively an incision that has been closed
  primarily (IB)
• Wash hands before and after dressing changes and
  any contact with the surgical site (IB)

91
Prevention of SSIs

• Surveillance
• Use CDC definitions of SSI (IB)
• When postdischarge surveillance is performed, use
  a method that accommodates available resources
  and data needs (II)
• Assign surgical wound classification upon
  completion of an operation (II)
• Record key variables shown to be associated with
  SSI (wound classification, ASA class, duration of
  operation)(IB)

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Surveillance at UNC Hospitals

• Follow certain operations for SSIs and benchmark
• Vaginal hysterectomy
• CABG
• Cholecystectomy
• Knee replacement
• Mastectomy
• Ventricular shunt
• Laminectomy

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Prevention of SSIs

• Surveillance
• Periodically calculate operation-specific SSI
  rates (IB)
• Report stratified, operation-specific SSI rates
  to surgical team members (IB)
• Provide infection control committee with coded
  surgeon specific data (No recommendation)

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CDC Surgical Site Infection Prevention
Guidelines - 1999

• Category IA and IB
• No prior infections 15 air changes/hr in ORDo
  not shave in advance Keep OR doors closed
  Control glucose in D.M. pts Use sterile
  instrumentsStop tobacco use Wear a maskShower
  with antiseptic soap Cover hairPrep skin with
  approp. agent Wear sterile glovesSurgical team
  nails short Gentle tissue handlingSurgical team
  scrub hands DPC for heavily contaminated
• Exclude I/C surgical team wounds Give
  prophylactic antibiotics Closed suction drains
  (when used)Pos pressure ventilation in
  OR Sterile dressing x 24-48 hr SSI surveillance
  with feedback to surgeons

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PLUS Antibacterial Sutures

• Antibacterial agent (triclosan) kills bacteria
  and inhibits colonization of the suture
• Proven in vitro to create a zone of inhibition
  around the suture against common SS pathogens S.
  aureus, MRSA, CONS
• Triclosan-coated sutures may be valuable in
  reducing SSIs. Ann Thorac Surg 200787232
• Hospitals challenged with the question whether to
  invest in this technology for routine surgical
  wound closure-must review data on SSI reduction,
  cost of surgical wounds, wound care, prolonged
  hospitalization, suture cost, etc

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National Organizations Targeting Infection
Prevention as a Measure of Quality

• Centers for Medicare and Medicaid Services (CMS)
• Institute for Healthcare Improvement (IHI)
• National Quality Forum
• The Joint Commission
• Consumers Union-report HAIs

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Center for Medicare and Medicaid Services FY2008

• Rule adopts eight conditions for which CMS will
  not provide higher payments if the event occurs
  while a patient is under the care of the
  hospital, effective FY09
• Object left in surgery
• Air embolism
• Blood incompatibility

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Center for Medicare and Medicaid Services FY2008

• CMS will not provide higher payments
• Catheter-associated urinary tract infections
• Pressure ulcers
• Vascular catheter associated infections
• Mediastinitis after coronary artery bypass graft
• Falls
• Agency intends to consider other HAIs and medical
  errors for non-payment in future years
• Hospitals cannot bill patients for the amount CMS
  refuses to pay

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Center for Medicare and Medicaid Services FY2008

• Intent
• Mobilize hospitals to improve care and keep
  patients safe
• Consensus among public health experts that
  HAI/errors are preventable
• Encourage stricter adherence to proven infection
  prevention practices

• Unintended Consequences
• Avoidance of patients perceived to be at risk for
  infections
• Hospitals may game the system by falsifying codes
  to avoid non-payment

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Public Reporting of HAIs

• Advisory Commission on Hospital Infection Control
  
• Purpose prepare hospitals for the public
  disclosure of HAIs as may be required by law for
  specific clinical procedures
• Class I surgical site infections
• Ventilator-associated pneumonia
• Central-line related bloodstream infections
• Must ensure quality and accuracy of information
• Commission will submit an interim report May 2008
  and final report 2009 General Assembly

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Prevent Surgical Site InfectionsInstitute for
Healthcare Improvement

• Components if implemented reliably can eliminate
  SSIs
• Appropriate use of antibiotics
• Appropriate hair removal
• Maintenance of postoperative glucose control for
  major cardiac surgery patients
• Establishment of postoperative normothermia for
  colorectal surgery patients

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Conclusions

• Surgical site infections result in significant
  patient morbidity and mortality, and increased
  hospital cost
• Reduction in surgical site infections can be
  achieved by strict adherence to standard surgical
  guidelines
• Observations have revealed failure to follow
  standard guidelines
• Strict adherence to standard guidelines crucial
  to reduce SSIs

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TOPICS

• Epidemiology of healthcare associated infections
  (HAI)
• Review the morbidity, mortality, and economic
  consequences of HAIs
• Discuss the risk factors and etiology of SSIs
• Provide strategies to prevent SSIs
• National initiatives to prevent SSIs

104
Thank you
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