Annie Laberge, R'N', M'Sc' c

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PRACTICE GUIDELINESSURGICAL SITE INFECTIONS
(SSI) RELATED TO ORTHOPEDIC IMPLANTS KNOWING HOW
TO RECOGNIZE AND PREVENT THEM

• Annie Laberge, R.N., M.Sc. (c)
• Marie-Claude Roy , M.D.
• Centre hospitalier affilié universitaire de
  Québec
• (CHA de Québec)
• Françoise Côté, R.N., Ph.D.
• Johanne Gagnon, inf., Ph.D. Sc. Inf.
• Université Laval
• CHICA-AIPI, June 3, 2008

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Agenda

• Introduction
• Physiopathology and microbiology of
  implant-related surgical site infections (SSI)
• Impact
• Why develop these guidelines?
• Literature retrieval method
• Results
• Practice guidelines
• Key documented recommendations
• Conclusion

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Physiopathology and Microbiology of
Implant-related SSIs

• Surgery or the placement of implants is conducive
  to the development of infections
• A limited amount of bacteria inoculum(102
  microorganisms/g rather than 105) is needed for
  development of a SSI.
• A larger spectrum of microorganisms can cause
  SSIs (minimally pathogenic bacteria such
  asStaphylococcus albus).
• The hosts immune response encourages the
  development and persistence of infections.

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Impact of a SSI Following Implant Orthopedic
Surgery

• Prolongs hospital stay by 14 days on average
• US24 344/infection in related costs
• Decreases patients quality of life pain,
  reduced physical abilities
• Difficult to treat
• Risk of death doubles with a SSIs following total
  hip replacement (THR) surgery
• Results in another visit to the operating room
• Whitehouse et al. Infect Control Hosp Epidemiol
  200223183-89,
• Jodra et al. Infect Control Hosp Epidemiol 2006,
  27(12), 1299-1303.

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Why develop these guidelines?

• High post-surgical SSI rates at the CHA de
  Québec intervention to reduce these rates
• CHA de Québecs practice guidelines date back to
  1999. Have there been any advancements?
• Evidence-based data references for staff and
  students

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Literature Retrieval Method BTEC

• This guide was created at the Bureau de transfert
  et déchange des connaissances (BTEC) of
  Université Lavals Faculty of Nursing Sciences.
• BTEC provides nurses with a way to integrate
  scientific evidence into their professional
  practice
• As part of their graduate studies, the BTEC
  allows students to turn their ideas into
  literature review questions and conduct
  exhaustive literature reviews
• Literal translation Knowledge Transfer and
  Exchange Bureau

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Method Research Questions

• In order to prevent post-surgical infections in
  patients undergoing orthopedic surgery or initial
  placement of an implant, it is important to know
  the following
• What are the risk factors of a surgical site
  infection in orthopedics?
• What preventative practices have demonstrated to
  be effective in preventing this type of
  infection?

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Method Inclusion Criteria

• Our inclusion criteria for obtaining
  evidence-based data
• Experimental or quasi-experimental studies,
  descriptive studies, systematic reviews,
  meta-analyses or evidence-based practice
  guidelines
• Articles on risk factors, preventative
  interventions and impact of SSIs, particularly in
  orthopedic surgery, including implant surgery
• Studies based on the NNIS method or the equivalent

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Results Practice Guidelines

• 101 references were chosen based on our criteria
• A 21-page practice guideline was designed and
  validated, consisting of
• Key documented recommendations
• Theory about SSIs and implant-related SSIs
  classifications and definitions, microbiology,
  physiopathology and risk factors
• Tables suggesting ways to control risk factors as
  well as other interventions that may be effective
  in preventing SSIs.

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Key RecommendationsBefore surgery, by the
nursing staff
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Key RecommendationsBefore surgery, by the
medical team
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Key RecommendationsBefore and during surgery,
by all staff in the room
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Key RecommendationsDuring surgery, by the
medical team
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Key RecommendationsAfter surgery, for the
medical staff
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Key RecommendationsAfter surgery, by the
infection prevention team
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Conclusion

• These practice guidelines prove to be a reference
  for staff involved in the prevention of SSIs.
• Most of the recommended interventions in these
  guidelines have been applied in the operating
  room of Hôpital de lEnfant-Jésus.
• The interventions performed have lead to
  decreased SSI rates in total hip replacement
  (THR), total knee replacement (TKR) and total
  shoulder replacement (TSR) surgery.

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Post-surgical Orthopedic Implant Infections
English Legend ORIFTSRTHRTKR
2005 2006 2007
2008
Open reduction internal fixation (ORIF)
infections currently being validated for 2007-2008
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Acknowledgments

• Infection Control Department (ICD) nurses from
  theCentre hospitalier affilié universitaire
  (CHA) de Québec particularly Valérie Dancause,
  who started ORIF infection monitoring in 2005
• The various experts who have taken part in
  reviewing the guidelines include
• Dr. Luc Bédard, Orthopedist, CHA de Québec
• Claire Bégin, ICD Coordinator, Hôtel-Dieu de
  Lévis
• Valérie Dancause, ICP, CHA de Québec
• Nathalie Goulet, Operating Room Monitor, Hôpital
  de lEnfant-Jésus
• Dr. Alain Paradis, Microbiologist/Infectious
  Disease Specialist, CHA de Québec
• Michèle Ricard, Risk Management Adviser, CHA de
  Québec

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Questions