Preventing Surgical Site Infections: Back to Basics

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Preventing Surgical Site InfectionsBack to
Basics

• Kathleen Kohut, RN, MS, CIC, CNOR
• Klkohut_at_gmail.com

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Speaker Disclosures

• 3M
• AMN Healthcare
• BESmith
• The Compass Group

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Objectives

1. Name the 2 most common mechanisms for wound
   contamination
2. Discuss 7 areas of opportunity for improvement
3. Describe the use of glycemic control and nasal
   decolonization initiatives for the reduction of
   SSIs.
4. List 3 ways to facilitate process improvements in
   the Operating Room

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Invaluable Resources

• National Healthcare Safety Network (NHSN)
• 1999 HICPAC SSI Guidelines
• AORN Guidelines
• Surgical Care Improvement Project (SCIP) Measures

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SCIP Quality Measures

• Antibiotic Prophylaxis
• Drug, Timing, Dosing
• Hair Removal
• Glycemic Control
• Normothermia
• Expanded in June
• All surgical patients
• Qualitynet.org

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Back to the Basics

• Aseptic Technique
• Traffic
• Aseptic Technique
• Sterilization
• Aseptic Technique
• ABX Prophylaxis
• Aseptic Technique
• Hair Removal
• Aseptic Technique
• Skin Antisepsis
• Aseptic Technique
• Dressings

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1. 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 Virulence
• Resistance of Host (patient)
• Berry Kohns, Operating Room Technique, 11th
  ed., p. 254

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Causes of Wound Contamination

• Exogenous sources
• Cleanliness of environment, lack of proper
  airflow, shedding by the Surgical Team
• Endogenous sources
• Patients own skin/hair
• Infection at a remote site

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The Number One Source

• People Shedding
• 4000-10,000 particles per minute
• (Berry Kohns, Operating Room Technique, 11th
  ed., p. 252)
• Carried by wind currents to the sterile field
  which results in wound contamination.
• Patient
• Surgical Team
• Ancillary Personnel
• Sales Reps
• Students
• Passersby

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Shedding plus Wind Currents

• Requires the control of
• Amount of Traffic
• Traffic Patterns
• Sherertz, et al. Cloud HCWs. Emerging Infect
  Dis. 20017(2) 241-44.
• Edmiston, et al. Airborne Particulates in the OR
  Environment. AORN 1999 69(6) 1169-1183.

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2. Traffic Control

• 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
• DeKastle, R.  Telesurgery Providing Remote
  Surgical Observations for Students.  AORN 2009
  90 (1) 93-101.
• Utilize alternative methods of communication

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Kohut SSI Equation

• People Wind (-) Aseptic Technique
• gt ABX Skin Prep
• Wound Contamination
• SSI

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Containment is the key

• 1. Patient
• Pre-op Showers
• Hat and clean gown/linen for patient
• 2. 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

• Dineen, P, Drusin, L. Epidemics of Postoperative
  Wound Infections Associated with Hair Carriers.
  Lancet 1973 (Nov) 1157-59.

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Lack of Containment

• BAD

• VERY BAD

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Standards of Excellence

• PETA APPROVED

• GOLD STANDARD

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Environment

• Room Requirements
• Ventilation System (15/hr 3 fresh)
• Positive pressure
• Temperature (68-73 F)
• Humidity (30-60)
• Room Cleaning
• Between cases
• Terminal cleaning
• Types of construction materials
• Clutter
• AORN, Recommended Practices for Perioperative
  Nursing Safe Environment of Care. (2008 ed., p
  357)

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Surgical Conscience

• Requires strict adherence to the principles of
  aseptic technique by all team members for every
  patient on every case.
• ORs that value these principles create a patient
  centered culture.
• Girard, NJ. Surgical Conscience Still
  Pertinent. AORN (2007)86 (1) 13-14.

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3. Sterilization

• Proper Management of Sterile Processing
  Departments
• Technology
• Workflow
• Staff certification
• Proper Sterilization Processes
• Focus area for The Joint Commission
• Cleaning, sterilization, and storage
• www.jointcommission.org/Library/WhatsNew/steam_ste
  rilization.htm

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Flash Sterilization

• Utilized for
• Dropped instruments
• Poorly designed work processes
• Lack of instrumentation
• Surgeon scheduling
• Results in contamination due to
• Poor cleaning due to lack of time
• Methods of delivery to the sterile field
• Closed containers are best practice
• TJC will be looking for them
• Carlo, A. The New Era of Flash Sterilization.
  AORN 2007 86(1) p 58-70.

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Flash Data

• Calculation of flash events rate x
  100 of cases/month

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4. Antibiotic Prophylaxis

• SCIP Measures
• INF 1,2,3
• Goal gt90
• Best Practice- Anesthesiologists
• Proper dosage for obese population (BMIgt30)
• Dont forget redosing q 3 hours

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5. Hair Removal

• SCIP INF 6 Surgery patients with appropriate
  hair removal.
• Minimize as much as possible
• Clippers only
• Not in the OR!

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6. Skin Antisepsis

• The attributes of an appropriate surgical skin
  antiseptic require
• The ability to significantly reduce
  microorganisms (2 log, 3 log)
• Provide broad spectrum activity
• Be fast acting
• Have a persistent effect
• All products with FDA approval meet this criteria
• AORN, Recommended Practices for Perioperative
  Nursing Skin Antisepsis. (2008 ed., pp537-555)

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Other Skin Antisepsis Considerations

• Procedure
• Prep area
• Application Methodology
• Scrubbing vs. Painting
• Length of the procedure
• Challenges to the prep area
• -blood, saline, friction
• Patient Safety

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Critical Thinking is Required

• Ultimately, the OR nurse decides at the point of
  care by assessing the patient to insure that the
  skin antisepsis planned for will be appropriate
  for that patient based on allergy status, body
  site, and skin integrity.

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Current 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

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Current Research

• Limited research is available that compares
  commonly used skin antiseptic agents with SSI
  outcomes
• The majority of the literature compares microbial
  counts
• The correlation between microbial counts and SSI
  outcomes is unclear

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Current Research

• Saltzman, MD, et al. Efficacy of Surgical
  Preparation Solutions in Shoulder Surgery. J
  Bone Joint Surg AM 2009911949053
• Microbial culture study of 150 patients
• Compared 3 methods
• Iodophor Scrub/Paint vs. ChloraPrep vs.
  Duraprep
• Result
• Microbial counts were less using ChloraPrep
• SSI Outcome was no SSIs in any of the groups

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Current Research

• Swenson, et al. Preoperative skin preparation on
  postoperative wound infection a prospective
  study of three skin preparation protocols.
  Infect Control Hosp Epidemiol 2009 30964-971
• SSI Outcome study of 3209
• general surgery patients
• Compared 3 methods
• Iodophor Scrub/ETOH/Paint vs. ChloraPrep vs.
  DuraPrep
• Result
• SSI Outcomes- A statistical difference with lower
  SSI rates using iodine based products.

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Current Research

• 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
• Compared 2 methods
• Iodophor Scrub/Paint vs. Chlorhexidine-alcohol
• Result
• Significantly lower SSI rates with
  Chlorhexidine-alcohol prep for surperficial and
  deep incisional wounds

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Clear as Mud..
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Product Application

• Prewash prior to application
• Follow manufacturers directions
• Utilize proper aseptic technique during
  application gloves to contain shedding

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7. Dressings

• Optimal dressings are
• Permeable to gas exchange
• Impermeable to microbes/contamination
• Create a moist healing environment (37C)

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Dressings

• Stay in place
• Good adherence properties
• Change on day 2-3 unless drainage, dirty, or
  damaged
• Use proper aseptic technique when applying the
  dressings before the drapes are removed
• Partner with Wound Care Specialists
• Sussman, C, Bates-Jensen, B. Wound Care A
  Collaborative Practice Manual for Health
  Professionals 2006 (Chap11)

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The New Basics

• Glycemic Control
• Nasal Decolonization

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Glycemic Control

• 30-35 of cardiac patients are diabetics
• SCIP INF 4 Cardiac surgery patients with
  controlled 6 a.m. postoperative serum glucose.
• The OR cannot be a black hole

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S. aureus Nasal Carriage

• Between 25-30 of all patients are colonized
• Another 60 carry it intermittently
• 85 of S. aureus infections were endogenous in
  SSI study populations
• Nasal decolonization should be considered due to
  the risk of S. aureus SSIs
• Van Rijen, et al. Intranasal Mupirocin for
  reduction of S. aureus in surgical patients with
  nasal carriage. J Anti Chemotherapy 2008
  61254-261.
• 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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Speciality Specific Opportunities

• Cardiac
• Spinal Fusions
• Labor and Delivery
• Cath Lab

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Cardiac Surgery

• 2 concurrent surgeries
• Skin antisepsis
• Bone wax
• Traffic and of people
• Hypothermia

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Spinal Surgery

• Equipment
• Amount, position, cleanliness
• Weiner, BK, Kilgore, WB. Bacterial shedding in
  common spine procedures headlamp/loupes and the
  operative microscope. Spine 200732(8)918-20.
• Biswas, D, et al. Sterility of C-arm fluroscopy
  during spinal surgery. Spine 2008
  33(17)1913-17.
• Antibiotics
• Redosing
• Time
• Longer surgeries, waiting for X-ray
• Dressings
• Posterior incisions (higher risk)

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LD and Cath Lab

• Aseptic technique
• Skin antisepsis

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Facilitating Process Improvements

• Provide the data
• Trend and report ABX and flash data monthly
• SSI Outcome data Quarterly
• Utilize data to implement change
• NPSGs
• Multidisciplinary- IP, Quality, nurses, techs,
  surgeons, anesthesia, schedulers, housekeeping

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Process Improvements

• Make regular observations of aseptic technique
• Standardize
• Use forms to quantify when possible
• Simplify- pick one thing to get started

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Process Improvements

• Implement Changes
• Seek out champions
• Communication is essential
• Get feedback from staff and re-evaluate prn
• Insure that new outcome data is communicated to
  staff
• Celebrate Success!

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Results After Process Improvements
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Questions?

• KLKohut_at_gmail.com