Infection Prevention in the Perioperative Setting

HIPAN Conference

November 7, 2015

Anne K. Massie, RN, MSN, CICInfection Prevention CoordinatorCastle Medical CenterKailua, HI

Today’s Objectives:

• Describe the role of microorganisms in disease.• Describe how microorganisms are transmitted in

healthcare settings.• Define standard and transmission-based precautions in

healthcare settings.• Describe surgical site infections (SSIs).• Identify evidence-based SSI prevention measures.• Apply today’s knowledge to a patient case study.

What Is Infection Prevention?

1. More than control measures

2. Best outcomes for our patients - it is less expensive financially, emotionally, and physically not to acquire an infection

3. Everyone has a role - hand hygiene, isolation practices, clean environment and equipment, best practices for clinical and non-clinical associates

4. Evidence-based guidelines

5. Regulatory compliance s - TJC, CMS, AH, etc.

Why Prevent Transmission?

• Saves lives• Prevents pain, suffering , loss of function, and death• Prevents outbreaks• Saves money - for patients, healthcare facilities, and

taxpayers• Increases patient satisfaction• It is the caring way

Key Terms

• Infection: The invasion and multiplication of microorganisms such as bacteria, viruses, and parasites that are not normally present within the body. – An infection may cause no symptoms and be

subclinical, or it may cause symptoms and be clinically apparent.

• Infectious Disease: Illness (infection) caused by microorganisms. Identified public health diseases require reporting to local and/or federal authorities. – Measles, Chlamydia, Influenza, VRSA

Key Terms

• Colonization – Microorganism proliferation on host body sites without eliciting an immune response, cellular damage, or clinical expression of infection

• Symbiosis – Two dissimilar organisms living together to the mutual beneficial association of each other.– Many bacteria live on and in humans performing

necessary functions for survival of both species: Bacteroides, Staphylococcus, E. coli

Key Terms

• Community Acquired Infection – An infection that is present or incubating at the time of admission to a healthcare facility (e.g., acute care hospital, skilled nursing facility)

• Healthcare Acquired Infection (HAI) – An infection that develops in a patient who is cared for in any setting where healthcare is delivered and was not present or incubating at the time of the care (POA)– CMS requires public reporting of certain HAIs as part of pay

for performance:

Colon SSIs, Hysterectomy SSIs, CAUTI, CLABSI, Clostridium difficile, MRSA bacteremias

Micro 101: Bacteria, Fungi, Protists

• Prokaryotes – Bacteria: – Single cell, no true nucleus or organelles

(prokaryotes)– Staphylococcus aureus, Clostridium perfringens,

Mycobacterium tuberculosis, Neisseria meningitidis• Eukaryotes - Fungi & Protists:

– Single & multi celled organisms with a true nucleus and organelles;

– Fungi - Yeast, filamentous molds– Protists - Algae, protozoans, and slime molds

Streptococci & Filamentous Mold

Viruses

• Viruses: acellular, protein-based, intracellular parasites– Influenza,

Meningitis (viral), Pertussis, Rubella

Did You?

Prions

• Prions: acellular protein capable of folding in unique ways

• Cause spongiform encephalopathies (CJD, aka “Mad Cow”)

Chain of Infection

Germ Relationships

How Do YOU Break the Chain?

What Does Evidence-BasedPractice Say?

Hand Hygiene

• Oldest evidence-based practice (1847)

• National average = 48%• Decreases HAIs

dramatically when compliance is high

• Healthcare workers perceive their compliance is higher than what is observed (video, electronic systems, secret shopper)

• Alcohol-based rubs take less time, act faster, kill viruses, and are less irritating

• Soap and water removes visible soil and bacteria

• THE SINGLE MOST EFFECTIVE INFECTION PREVENTION MODALITY

WHO 5 Moments of Hand Hygiene

Missed Opportunity

Who Is Protected?

Protects The Patient Protects the HCW

Standard Precautions

• A group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed infection status.

• Determined by the extent of anticipated blood, body fluid or pathogen exposure.

• Standard Precautions is a combination and expansion of Universal Precautions and Body Substance Isolation.

• WEAR WHAT YOU NEED TO PROTECT YOURSELF AND YOUR PATIENTS.

What are Standard Precautions?

• Hand Hygiene• Personal Protective

Equipment (PPE):– Gloves, gown, goggles

• Appropriate disposal of sharps

• Respiratory Etiquette• Safe injection practices:

– One needle, one syringe, one time only (The One & Only Campaign)

• Clean up biohazardous spills wearing PPE

• Textiles and laundry– Store and transport

appropriately• Clean shared patient

equipment– Sani Wipes, High

Level Disinfection or Sterile Processing

– Single Use Items – Do NOT Reuse (Label)

Transmission-Based Precautions

• Used when Standard Precautions alone do not completely interrupt transmission of infectious agents

• Three types:– Airborne– Contact– Droplet

• Use in addition to Standard Precautions• Some diseases have multiple routes of transmission

requiring more than one precaution type, e.g., MERS, Measles, Varicella, SARS, Ebola

• Use: Patients with suspect or confirmed infections

Airborne Transmission

• Dissemination of either airborne droplet nuclei or small particles from the respiratory tract containing infectious agents that remain suspended in the air for long periods of time

• PPE: N95 Respirator• Requires negative pressure

room• Diseases: TB, Measles,

Chicken Pox, Shingles (disseminated), Ebola

Contact Transmission

• Most important and frequent mode of transmission of HAIs

• Direct: Body surface to body surface

• Indirect: Susceptible host touches contaminated surface

• PPE: Gown and gloves• Use for MDROs, infectious

diarrhea, Ebola, conjunctivitis, draining wounds, bed bugs

Droplet Transmission

Droplet Transmission

• Droplets generated from the infected person are propelled a short distance through the air and deposited on the host’s conjunctivae, nasal mucosa, and mouth

• A form of contact transmission

• Influenza, Neisseria meningitidis (Bacterial Meningitis), Pertussis

PPE: Surgical Mask, Eye Protection within 6 feet

Defining SSIs

Perioperative Setting

• The area utilized immediately before, during and after the performance of a clinical intervention or clinically invasive procedure– Complex healthcare area: procedures, instruments,

technologies– Regulatory scrutiny: CDC, FDA, EPA, CMS, TJC

• Summary: Unique and challenging environment• Goal: Ensure the highest standard of care to each

patient during their journey within the perioperative arena• Infection Prevention Goal: Prevent surgical site

infections and disease transmission

Surgical Site Infections (SSIs)

• SSI – Infection following an operative procedure that was performed in an inpatient or outpatient setting where:– Procedure performed in an operative setting per

FGI/AIA criteria when constructed or renovated– Procedure or reoperation (via an incision that was left

open) involved at least one incision• Now account for 31% of all HAIs• Most prevalent HAIs today replaced CAUTIs as #1• Associated with prolonged hospitalization, increased

morbidity and mortality, and loss of function• Mortality rate = 3%

Surgical Site Infections (SSIs)

• Patients with an SSI:– 3-5x higher readmission risk and rates than non-SSI

patients– More likely to be admitted / transferred to the ICU– More likely to die if SSI is due to MRSA

• Average cost of an SSI > $20,000• Average cost of an orthopedic SSI > $90,000• SSIs are devastating to the patient, the perioperative

team, and the hospital

SSIs – Superficial

• Superficial Incisional– Occurs within 30 days of procedure– Involves only the skin and subcutaneous tissue– Primary or secondary incision (CABG graft site)– Purulent drainage, pain, tenderness, swelling,

erythema, heat– Positive culture collected aseptically– May exhibit spontaneous dehiscence or be

deliberately reopened by physician

SSIs – Deep Incisional*

• Deep Incisional– Occurs within 30 or 90 days (depending on NHSN

procedure type)– Involves deep soft tissues: fascial and muscle layers– Purulent drainage, fever, pain, tenderness– Abscess– Positive culture collected aseptically– May exhibit spontaneous dehiscence or be

deliberately reopened by physician

SSIs – Deep Incisional

• Organ Space– Occurs within 30 or 90 days (depending on NHSN

procedure type)– Involves any part of the body deeper than the fascial

and muscle layers that was opened or manipulated during the surgical procedure

– Purulent drainage – Closed drainage, T-tube, CT guided drain

– Abscess– Positive culture collected aseptically

Oh my gosh!

SSI Prevention

Infection Prevention Management

• Evidence-based guidelines: – SHEA / IDSA 2014 Update (Anderson et al.)– 7S Bundle (Spencer)– NHSN SSI Definition (CDC)

• Apply appropriate precautions for suspect or confirmed infection status: Standard + Transmission-Based

• Communicate plan to the entire healthcare team• Process Improvement Teams• Report suspected infections to Infection Preventionist• Report breaches in infection prevention practices per

hospital policy/protocol

Patient SSI Risk Factors

• Patient Risk Factors– Glycemic control (Diabetes)– Smoking status– Steroid Use, other medications– Obesity– Preoperative albumin level (malnutrition)– MRSA and MSSA colonization– Renal function– Prolonged hospitalization prior to surgical procedure– Medical and surgical history

Pre OP Nursing Assessment

• Physical assessment: rash with fever and/or cough, cough – wet or paroxysmal, chronic wound infection, abscess

• Patient history: Recent surgical procedure, wound healing, diarrhea with recent antibiotic use or hospitalization, cough with weight loss, paroxysmal cough, physician notes, SNF resident, HD

• Lab & Imaging: Abnormal chest x-ray, culture results, HbA1C, albumin level, renal function

• Antimicrobials – Which one and Why?• Travel History: Foreign vs. domestic • Patient knowledge

Patient Decolonization

• Staphylococcus aureus carriers have a 3-6x higher risk of SSI than non-carriers (colonized)

• Management:

1. Screen for Staphylococcus aureus colonization (MSSA and MRSA)

2. Intranasal treatment with mupirocin

3. Chlorhexadine gluconate (CHG) bathing • 2% CHG wipes persist for 12 hours while 4%

solution does not

Shared Patient Equipment

• Clean, disinfect, and/or sterilize per manufacturer’s instructions (IFUs)

• Use correct products for the equipment

• Use correct reprocessing methods

• Reduce “flashing” (IUSS)– Purchase additional

instrumentation– OR Scheduling

Pre OP Prep &

• Clipping preferred method for hair removal when indicated

• Surgical site prep: Follow (IFUs) during application– Allow to completely air dry; no “fanning”

• Surgical hand scrub– First scrub of the day– Avagard® for subsequent scrubs

Antimicrobial Prophylaxis

• Antimicrobial prophylaxis: Recommended antimicrobial for procedure type and known allergies– Administer within 1 hour of incision cut time– Two (2) hours for fluoroquinolones and vancomycin– Fluoroquinolone use linked to C. diff infections

• “Scrub the Hub” for 15 seconds or use CHG impregnated hub cover

• Hand hygiene, don clean gloves• Disinfect med vial rubber septum

prior to accessing

Perioperative Environment

• OR Room Ventilation– Positive to the outside hallway or clean/sterile core

• OR Temperature and humidity– Temperature range: 62 - 75 F⁰– Humidity: 20 to 60%

• Minimize OR traffic• Between case cleaning• Daily Terminal OR

cleaning

Quality Improvement Processes

• PDCA (Plan, Do, Check/Study, Act) – RCI (Rapid Cycle Improvement) – 90 day process

• SSI Drilldown Team with each SSI or cluster• Periop Rep attends Infection Control Meetings• Hand hygiene and PPE audits and feedback• Physician notification of SSIs -> results in improved SSI

risk reduction• Surgical Technique - physician dependent

– Peer Review process when a high SSI rate is attributed to an individual surgeon

• Collaboratives and Bundles: Premiere, Quest, SUSP

Application

CASE STUDY• Teams will work together (Just like at work!)• Review case scenario to develop a plan addressing

these questions:• What risk factors are present?• What disease(s) are of concern in this case?• What interventions should be done?• How does this differ from your current practice?

What YOU Learned Today

Today’s Objectives:

• Describe the role of microorganisms in disease.• Describe how microorganisms are transmitted in

healthcare settings.• Define standard and transmission-based precautions in

healthcare settings.• Describe surgical site infections (SSIs).• Identify evidence-based SSI prevention measures.• Apply today’s knowledge to a patient case study.

Microbiology and Precautions

• Microorganisms can colonize or infect humans• Hand hygiene is the single most effective method to

prevent infection transmission in healthcare settings• Standard Precautions are used for every patient• Transmission-Based Precautions are used for patients

with suspect or confirmed infections– Includes Airborne, Droplet and Contact Precautions– Some diseases require multiple types of precautions

SSIs: Definition and Risks

• SSIs are costly to both patients and healthcare facilities• There are 3 types of SSIs per the CDC:

– Superficial Incisional– Deep Incisional – Organ Space

• Patients present with a variety of SSI risk factors• Healthcare facilities have risk factors for SSIs

– Temperature and humidity– OR ventilation– Cleaning, disinfecting, and sterilizing equipment

SSI Prevention

• SSI Prevention includes (not limited to):– Using evidence-based guidelines: SHEA, 7S Bundle– Patient decolonization and CHG bathing– Hand hygiene and PPE– Antimicrobial Stewardship: Right drug, Timing– Surgical site prep– Scrub the Hub– Process Improvement Teams– Reporting infections to surgeons– Collaborative and Bundles

SSI Prevention Goals

• Goal: Ensure the highest standard of care to each patient during their journey within the perioperative arena

• Infection Prevention Goal: Prevent surgical site infections and disease transmission

Scrub Your Paws!

References

• Anderson, D., et al. (2014). SHEA / IDSA Practice Recommendations: Strategies to Prevent Surgical Site Infections in Acute Care Hospitals – 2014 Update. Retrieved from

• http://www.jstor.org/stable/10.1086/676022• Bode, L., et al. (2010). Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. The New

England Journal of Medicine, 362:9-17.• Centers for Disease Control and Prevention. (2007). Guidelines for Isolation Precautions: Preventing

Transmisison of Infectious Agents in Healthcare settings. Retrieved from http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

• Centers for Disease Control and Prevention. (2011.) Healthcare associated infections (HAIs). Retrieved from http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/transmission-based-precautions.html

• Centers for Disease Control and Prevention. (2006). Management of Multi-Drug Resistant Organisms in Healthcare Settings. Retrieved from http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf

• Centers for Disease Control and Prevention. (2015). National Healthcare Safety Network: Surgical Site Infection (SSI) Event. Retrieved from http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

• Darouiche, R., et al. (2010). Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. The New England Journal of Medicine, 362:18-26.

• Gibbs, J., et al. (1999). Preoperative serum albumin level as a predictor of operative mortality and morbidity . Archives of Surgery, 134(1).

• Gokce, N., et al. (2002). Risk stratification for postoperative cardiovascular events via noninvasive assessment of endothelial function. Circulation, 105, 1567-1572.

References

• Infectious Disease Society of America. (n.d.). What is an infectious disease specialist? Retrieved from http://www.idsociety.org/ID_Specialist

• Khuri, S. F., et al. (1995) The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. Journal of the American College of Surgeons, 180(5), 519-531.

• Magill, S.S., et al. (2012). "Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida". Infection Control Hospital Epidemiology, 33(3): 283-91.

• Pittet, D. (2001). Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerging Infectious Diseases. 7(2), 234-240.

• Plodkowski, R. A. (2001). Pre-surgical evaluation of diabetic patients. Clinical Diabetes, 19(2), 92-95.• Spencer, M. (2013). The 7S Bundle. Retrieved from

http://eo2.commpartners.com/users/apic/downloads/130828_PPT_Final_[Compatibility_Mode].pdf• St. Jacques, P., Minear, M. (n.d.) Improving perioperative patient safety through the use of information technology.

Retrieved from http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-StJacques_105.pdf

• Sweeney, W. B. (2009). Preoperative evaluation and risk management. Clinics In Colon and Rectal Surgery, 22(1), 5-13.

• Ryder, M. (n.d.) Improving Skin Antisepsis: 2% No-Rinse CHG Cloths Improve Antiseptic Persistence on Patient Skin Over 4% CHG Rinse-Off Solution. Retrieved from http://www.hqinstitute.org/sites/main/files/file-attachments/ryder_poster_0.pdf

References

• Waisbren, E., et al. (2010). Percent body fat and prediction of surgical site infection . Journal of the American College of Surgeons, 210(4), 381-389.

• World Health Organization. WHO 5 Moments of Hand Hygiene. Retrieved from

http://www.who.int/apsc/tools/Five_Moments• Xu, J., et al. (2007). Evolution of Symbiotic Bacteria in the Distal Human Intestine. PLOS Biology, 5(7).

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