Kathleen Kohut, RN, MS, CIC, CNORKlkohut@gmail.com

Speaker Disclosures

3M

AMN Healthcare

BESmith

The Compass Group

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

National Healthcare Safety Network (NHSN)

1999 HICPAC SSI Guidelines

AORN Guidelines

Surgical Care Improvement Project (SCIP) Measures

1. Antibiotic Prophylaxis Drug, Timing, Dosing

2. Hair Removal

3. Glycemic Control

4. “Normothermia” Expanded in June All surgical patients

Qualitynet.org

1. Aseptic Technique2. Traffic

Aseptic Technique

3. SterilizationAseptic Technique

4. ABX ProphylaxisAseptic Technique

5. Hair RemovalAseptic Technique

6. Skin AntisepsisAseptic Technique

7. Dressings

Principles were developed to reduce the risk of wound contamination.

Defining the Risk of SSI

Risk of SSI = Dose of Bacterial Contamination X VirulenceResistance of Host (patient)

Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254

1. Exogenous sources Cleanliness of environment, lack of proper

airflow, shedding by the Surgical Team

2. Endogenous sources Patient’s own skin/hair Infection at a remote site

People = Shedding4000-10,000 particles per minute

(Berry & Kohn’s, Operating Room Technique, 11th ed., p. 252)

Carried by wind currents to the sterile field which results in wound contamination.

1. Patient2. Surgical Team 3. Ancillary Personnel4. Sales Reps5. Students6. Passersby

Shedding plus Wind Currents

Requires the control of: Amount of Traffic Traffic Patterns

Sherertz, et al. “Cloud” HCWs. Emerging Infect Dis. 2001;7(2): 241-44.

Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6): 1169-1183.

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 careDeKastle, R. Telesurgery: Providing Remote Surgical Observations for Students.

AORN 2009; 90 (1): 93-101.

Utilize alternative methods of communication

Kohut SSI EquationPeople + Wind + (-) Aseptic Technique

> ABX + Skin Prep =

Wound Contamination =

SSI

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)

Ban Skull Caps

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

Lack of Containment

BAD VERY BAD

Standards of Excellence

PETA APPROVED GOLD STANDARD

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)

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.

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_sterilization.htm

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.

Flash Data

Calculation: # of flash events = rate x 100 # of cases/month

OR Flash Rate 2004- 1st Q 2007

42

33

15

22

16

23

16

11 11 11

14

12 11

14

12

1516

10

61 60

0

10

20

30

40

50

60

70

Fla

sh

Rate

SCIP Measures INF 1,2,3

Goal >90%

Best Practice- Anesthesiologists Proper dosage for obese population (BMI>30) Don’t forget redosing q 3 hours

OR ABX Compliance

72

88 89 91

93 95 9497 98

95 94 93 94 9495 96

92

97 97

0

10

20

30

40

50

60

70

80

90

100

Co

mp

lian

ce

Ra

te

SCIP INF 6: Surgery patients with appropriate hair removal.

Minimize as much as possible Clippers only Not in the OR!

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)

Other Skin Antisepsis Considerations

1. Procedure2. Prep area3. Application Methodology

Scrubbing vs. Painting4. Length of the procedure5. Challenges to the prep area

-blood, saline, friction6. Patient Safety

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.

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

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

Current Research

1. Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91:1949053

Microbial culture study of 150 patientsCompared 3 methods

Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™

ResultMicrobial counts were less using ChloraPrep®SSI Outcome was no SSIs in any of the groups

Current Research2. Swenson, et al. Preoperative skin preparation on

postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30:964-971

SSI Outcome study of 3209general surgery patients

Compared 3 methods Iodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™

ResultSSI Outcomes- A statistical difference with lower SSI

rates using iodine based products.

Current Research

3. 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 patientsCompared 2 methods

Iodophor Scrub/Paint vs. Chlorhexidine-alcohol

ResultSignificantly lower SSI rates with Chlorhexidine-alcohol

prep for surperficial and deep incisional wounds

Clear as Mud……..

Prewash prior to application

Follow manufacturer’s directions

Utilize proper aseptic technique during application & gloves to contain shedding

Optimal dressings are:

Permeable to gas exchange

Impermeable to microbes/contamination

Create a moist healing environment (37°C)

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 SpecialistsSussman, C, Bates-Jensen, B. Wound Care: A Collaborative Practice Manual

for Health Professionals 2006; (Chap11)

The “New Basics”

Glycemic Control

Nasal Decolonization

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

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; 61:254-261.

Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24): 1871-7.

Speciality Specific Opportunities

Cardiac

Spinal Fusions

Labor and Delivery

Cath Lab

Cardiac Surgery

2 concurrent surgeries

Skin antisepsis

Bone wax

Traffic and # of people

Hypothermia

Spinal Surgery Equipment

Amount, position, cleanlinessWeiner, BK, Kilgore, WB. Bacterial shedding in common spine procedures: headlamp/loupes

and the operative microscope. Spine 2007;32(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)

L&D and Cath Lab

Aseptic technique

Skin antisepsis

Facilitating Process Improvements

1. Provide the data Trend and report ABX and flash data monthly SSI Outcome data Quarterly

2. Utilize data to implement change NPSGs

3. Multidisciplinary- IP, Quality, nurses, techs, surgeons, anesthesia, schedulers, housekeeping

Process Improvements

Make regular observations of aseptic technique

Standardize

Use forms to quantify when possible

Simplify- pick one thing to get started

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!

Total Knee SSI 1st Q CY 2007

0.49

0 0

2.23

0.65

0

1.04

0 0 0 0 0

2.04

2.31

0.850.66

0.34

1.09

0

0.5

1

1.5

2

2.5

2004 2005 2006 1st Q '07 Overall NNIS

SS

I Rat

e 0

1

2,3

KLKohut@gmail.com