Maureen Spencer, RN, M.Ed, CIC

Infection Preventionist Consultant

Establish a Culture of Safety:Working Toward Zero

Surgical Site Infections

Email: maureen_spncr@yahoo.comwww.workingtowardzero.com

www.creativehandhygiene.com

Despite current preventive measures, Despite current preventive measures, SSIs remain a significant problemSSIs remain a significant problem

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In the US, at least 780,000 SSIs occur each year1

SSIs account for about 37% of all hospital-acquired infections for surgical patients1

SSIs occur in up to 5% of surgical patients2

1. WHO Guidelines for Safe Surgery 2009.2. Cheadle WG. Risk factors for surgical site infection. Surg Infect. 2006;7: s7-s11.

Mortality risk is high among patients Mortality risk is high among patients with SSIswith SSIs

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A patient with an SSI is:5x more likely to be readmitted after

discharge1

2x more likely to spend time in intensive care1

2x more likely to die after surgery1

The mortality risk is higher when SSI is due to MRSAA patient with MRSA is 12x more likely to die

after surgery2

1. WHO Guidelines for Safe Surgery 2009.2. Engemann JJ et al. Clin Infect Dis. 2003;36:592-598.

SSIs are costly and are a financialSSIs are costly and are a financialburden on the healthcare systemburden on the healthcare system

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The average cost of treating one SSI is between $11,000 and $35,0001

The average cost of treating one MRSA-related SSI is more than $60,0002

In total, SSIs have been estimated to cost the US healthcare system up to $10 billion/yr1

1. Scott RD. Centers for Disease Control and Prevention. March 2009. 2. Anderson DJ et al. PLoS One. 2009 Dec 15;4(12):e8305.

Changing demographics are increasing Changing demographics are increasing patients’ risk for SSIspatients’ risk for SSIs

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A patient with even ONE of these risk factors is at greater risk of developing an SSI.1-4

Older (>70 yrs old) Obese (BMI > 25) Smoker Diabetes or poor glucose control Undergoing abdominal surgery Prolonged surgery required (>2 hrs) Longer hospital stay ≥3 discharge diagnoses

1. Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134.2. SHEA, APIC, CDC, SIS Consensus paper. Infect Control Hosp Epidemiol 1992;13:599-605.3. Cheadle WG. Surg Infect. 2006;7: s7-s11.4. Konishi T, Watanabe T, Kishimoto J, Nagawa H. Ann Surg. 2006 Nov;244(5):758-63.

SSI Risk Factors – SSI Risk Factors – Procedures/TechniquesProcedures/Techniques

Duration of operation Duration of surgical scrub Preoperative shaving,

skin preparation Inadequate OR ventilation Inadequate sterilization of

instruments Surgical technique

Poor hemostasis Failure to obliterate dead

space Tissue trauma Skin antisepsis Antimicrobial prophylaxis Surgical drains

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Mangram AJ et al. Am J Infect Control. 1999;27:97-134

Tissue kept moist with saline Tissue allowed to air dry heals better do not heal as well

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Orthopedic Surgical Site InfectionOrthopedic Surgical Site Infection

Orthopedic Total Joint Infections:Hip or Knee aspiration If positive – irrigation and

debridementRemoval of hardware may

be necessary Insertion of antibiotic

spacersRevisions at future dateLong term IV antibiotics in

community or rehabFuture worry about the joint In other words –DEVASTATING FOR THE

PATIENT AND THE SURGEON

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Relative Economic Burden Associated with Relative Economic Burden Associated with HAIsHAIs

• SSISurgical Site Infections

• CLA-BSICentral-Line Associated Blood Stream Infections

• VAPVentilator Associated Pneumonia

• CA-UTICatheter-Associated Urinary Tract Infections

• Other / MDROs*Multi-Drug Resistant Organisms (e.g., MRSA, C. difficile, VRE, etc.)

Est. Annual # of Infections

Est. Annual # of Infections

Direct Cost per Patient (2007$)Direct Cost per Patient (2007$)

Avg. Increased Length of StayAvg. Increased Length of Stay

Attributable Mortality

Attributable Mortality

290,485(~17% of HAIs)

248,678(~14% of HAIs)

250,205(~15% of HAIs)

561,667(~32% of HAIs)

386,090(~22% of HAIs)

$34,670

$29,156

$28,508

$1,007

~$30,000

~12 days

~10-24 days

~9-13 days

1 day

~9.1 days

4%

26%

24%

1%

~4%

* NOTE: MDRO often cause other infection types (e.g., SSI, BSI, VAP, UTI); MDRO statistics reflect CDC estimates for methicillin-resistant Staphylococcus aureus (MRSA) only.SOURCES: Klevens, et al., “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Review, 2007; CDC: “The Direct Medical Cost of HAIs in U.S. Hospitals and the Benefits of Prevention”, March 2009; Kirkland, et al., “The Impact of Surgical Site Infections”, Infect Control Hosp Epidemiol, 1999; Arch Internal Med, 1988; Arch Internal Med, 1974; Infect Control Hosp Epidemiol, 2002; CareFusion MedMined Analysis, 2009.

Pathogens survive on surfacesPathogens survive on surfacesOrganism Survival period

Clostridium difficile 35- >200 days.2,7,8

Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days.1,5,10

Vancomycin-resistant enterococcus (VRE) 58- >200 days.2,3,4

Escherichia coli >150- 480 days.7,9

Acinetobacter 150- >300 days.7,11

Klebsiella >10- 900 days.6,7

Salmonella typhimurium 10 days- 4.2 years.7

Mycobacterium tuberculosis 120 days.7

Candida albicans 120 days.7

Most viruses from the respiratory tract (eg: corona, coxsackie, influenza, SARS, rhino virus)

Few days.7

Viruses from the gastrointestinal tract (eg: astrovirus, HAV, polio- or rota virus)

60- 90 days.7

Blood-borne viruses (eg: HBV or HIV) >7 days.5

1. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5.2. BIOQUELL trials, unpublished data.3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-24. Boyce. 2007. J Hosp Infect. 65:50-4.5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200.

6. French et al. 2004. ICAAC.

7. Kramer et al. 2006. BMC Infect Dis. 6:130.8. Otter and French. 2009. J Clin Microbiol. 47:205-7.9. Smith et al. 1996. J Med. 27: 293-302. 10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4. 11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.

Why Better Environmental Cleaning?Why Better Environmental Cleaning?Prior room occupancy increases riskPrior room occupancy increases risk

Study Healthcare associated pathogen Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room)

Martinez 20031 VRE – cultured within room 2.6x

Huang 20062VRE – prior room occupant 1.6x

MRSA – prior room occupant 1.3x

Drees 20083

VRE – cultured within room 1.9x

VRE – prior room occupant 2.2x

VRE – prior room occupant in previous two weeks

2.0x

Shaughnessy 20084 C. difficile – prior room occupant 2.4x

Nseir 20105A. baumannii – prior room occupant 3.8x

P. aeruginosa – prior room occupant 2.1x

1. Martinez et al. Arch Intern Med 2003; 163: 1905-12.2. Huang et al. Arch Intern Med 2006; 166: 1945-51.3. Drees et al. Clin Infect Dis 2008; 46: 678-85.4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.5. Nseir et al. Clin Microbiol Infect 2010 (in press).

New England Baptist HospitalNew England Baptist HospitalBoston, MABoston, MA

Working Toward Zero TeamsWorking Toward Zero Teams

150-bed adult medical/surgical hospital located in Mission Hill area of Boston

Orthopaedic subspecialty hospital & “Center of Excellence” Acute inpatient discharges:

75% Orthopedic 8% General Surgery 17% Medical

Orthopaedic Surgery ~ 12,000/cases a year >4700 total joints >1500 spine >3600 other (foot, shoulder, etc) > 3100 outpatient

Instituted incisional adhesives and AMD Gauze

MRSA/MSSA Eradication Program

Antibacterial sutures

Increase in Lami infections due to locally administered steroids

Chloroprep

Increase in total knee infections – due to improper use of needles for OR pain meds

Post-op hematomas being investigated

Making the Case to Cover Incisions While Hospitalized

Post-op Skin Issues in OrthopedicsPost-op Skin Issues in Orthopedics

Anterior fusion with tape burns

Posterior fusion with contaminated steri-strips

Contaminated steri-strips

Staples increase infection rate

Obesity and Surgical IncisionObesity and Surgical Incision

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Incision collects fluid – serum, blood - growth medium for organisms

Spine fusions -incisions close to the buttocks or neck

Heavy perspiration common Body fluid contamination

from bedpans/commodes Friction and sliding - skin

tears and blisters Itchy skin - due to pain

medications - skin breakdown

Due to Environmental Contaminants – Do Not Due to Environmental Contaminants – Do Not Recommend Incisions Opened to AirRecommend Incisions Opened to Air

Bacteria use blood (and sugar) as a fuel source

Incisions are in exudative stage of wound healing first 2-3 days postop

Proliferative stage begins ~ day 3-4 and most patients are sent home around that time

Incisions are best protected if sealed – or covered with an antimicrobial gauze, silver dressing

Resident and PA Direct Observation Study: Resident and PA Direct Observation Study: ABD with Paper or Gauze TapeABD with Paper or Gauze Tape

Check residents and physician assistant dressing technique

ABD pads may be stuffed in lab coat pockets during rounds and gloves may not be worn for dressing changes

Lack of hand hygiene before and after patient contact

Bandage scissors often used between patients with no cleaning

Discard bloody dressings in regular waste

Facility Approach: Standardization to an Facility Approach: Standardization to an Antimicrobial Dressing (AMD)Antimicrobial Dressing (AMD)

AMD secured with MeFix tape and dated for protection from exogenous contamination

Standardization of Post-operative Dressings

Goal Primary goal is to cover all incisions with AMD

gauze dressing (antimicrobial) Leave primary dressing in place for at least 2

days post-op or until the day of discharge to create an occlusive environment for wound healing

Nursing staff will assume responsibility for dressing changes, assessments, and reporting of complications to MD, PA, or NP

Initial Dressing Change

Will be completed as specified on the orthopedic order sheet

Example: POD # 2 Preferably dressing would be left in

place until day of discharge

Exception: Significant strike through (post-op drainage)

Alert the MD, PA, NP Initially reinforce and change

dressing in 24 hrs

Subsequent Dressing Changes

On the morning of discharge change the dressing and record the condition of the incision in the progress notes

Notify the Attending MD if available or resident, PA, or NP of any significant findings

Report Significant Findings

Notify the Attending MD: Evidence of wound

dehiscence Drainage

Sanguinous and Purulent drainage

Moderate or Copious amount of drainage

Incisional Complication Blisters Erythema Edema Skin Tears Warmth Ecchymosis Incisional Breakdown

Postop Dressing Care Sanitize hands Wear clean gloves to remove primary

dressing Sanitize bandage scissors with alcohol

between use Discard old dressing in red bag if saturated

and dispose in soiled utility room Apply a sterile dressing using Kendall’s AMD

gauze (antimicrobial dressing – purple package)

Affix gauze with MeFix tape (hypoallergenic self-adhesive fabric tape), Tegaderm, or Ace Wrap as appropriate

MeFix Tape Pull the sides of the

tape to break open the backing

Remove one side all the way down the piece of tape

Tape one side of the gauze and then the other

Do not stretch as you apply to prevent blisters

Hip Dressing

Typically the original dressing will be covered with either Microfoam or Tegaderm

Microfoam dressing

Tegaderm dressing

Dressing Treatments

Hip Incisions Apply 2 - 4 AMD Gauze Over

Incision Loosely secure with MeFix

tape to allow for swelling Date and initial the dressing If dressing is removed for a

brief inspection it may be re-secured in place

If dressing removed entirely by surgeon or other – reapply as soon as possible

Dressing Treatments

Knee IncisionsAMD gauze directly over

incision6 inch Ace wrap

dressing Applied distal to proximal and

should extend to mid-thigh level above any suprapatellar pouch swelling to avoid a tourniquet affect just above the knee

Spine Service and Shoulders

AMD sealed with Tegaderm left on until discharge

AMD Island dressing – left on until discharge

Rotator cuff (and total shoulders) – Dermabond is being used or an AMD gauze covered by tegaderm – left on until discharge

Strike Through

Minimal strike-through drainage

Leave dressing intact

Change dressing as indicated on orders

Significant strike-through drainage

Notify MD, PA, or NP and reinforce unless otherwise ordered

Change dressing on Post-op Day1

Documentation: Daily Skin Assessment in Meditech

Location Description Drainage Periphery Wound Edges Amount of Exudate Type of Exudate Nursing Intervention Comment: Incisional Complications

Progress Notes for any complications Specify who was notified and when Specify treatment and plan for any incisional complications

Discharge Dressings

Hip, Knee, Spine, and Shoulder Discharge Dressings Apply same dressing used in the hospital

Wounds Without Drainage Patient should be instructed to remove the dressing after 2 days. It can then be

left open to air. Once the dressing has been removed, the patient may shower after the 2 days

but should be instructed not to use washcloths or scrub the incision with any soap.

Wounds With Drainage VNA services required at home Dressings may vary depending on amount of drainage

Wounds with Sutures or Staples Should be kept covered until the sutures or staples are removed

Cost Savings Discharge Supplies

Patients with Sutures or Staples: Supply patient with 2 additional dressing changes at home Shower drapes: (for patients without Tegaderm)

2 per patient or more if appropriate They can be cut in half

Patients with Steri Strips Unless draining, patient will not need any supplies for home

Questions?