Mary Beth Flynn Makic RN PhD CNS CCNS - vollman.com Beth Flynn Makic ... comorbidities, obesity Optimize nutrition & hydration Albumin, ... In ICU frequently it is antibiotics or tube

� Mary Lou Sole� Oral care in reducing VAP

� Chris Winkelman� Mobility practices to prevent VAP, pressure ulcers and long term functional

limitations

� Kathleen M. Vollman� Bathing & other basics care activities to reduce spread of microorganisms

� Mary Beth Flynn Makic� Prevention of incontinence-associated dermatitis & pressure ulcers

� Pat J. Posa� Eliminating catheter-associated blood stream infections

� Ginger S. Pierson� Prevention of Sternal Wound Infections Following Cardiac Surgery

Mary Beth Flynn Makic RN PhD CNS CCNS

� Pressure ulcers (PUs) can be identified,

measured, and reported

� Usually preventable

� Result in adverse patient outcomes,

prolonged/additional care, increased costs

� Significant body of scientific evidence is available

to guide practice and prevent PUs

� October, 2008: Stage III and IV PUs acquired

after admission will not be reimbursed

www.cms.hhs.gov April 14, 2008 fact sheet; www.qualityforum.org Serious Adverse Events

Working Group March 19, 2008

� 4th leading preventable medical error in the U.S.

� 2.5 million patients are treated annually

� 1993-2003 PU prevalence ↑63% in acute care

� National acute care prevalence rates 7-16%

� NDNQI data base: critical care 7-14%

� ↑LOS ~ 4 days

� Cost to treat PU $40-70,000 per PU; estimated $11 billion annually in the U.S.

� Estimated 60,000 deaths per year associated with PUs

� 1995 ANA identified PU prevention as a nursing sensitive indicator� National Database of Nursing Quality Indicators (NDNQI)

� www.nursingworld.org

� 2004 National Quality Forum � National Voluntary Consensus Standards for Nursing-Sensitive Care

http://www.qualityforum.org/publications/reports/nurse_tracking.asp

� IHI 5 Million Lives Campaign� http:/www.ihi.org/IHI/Programs/Campaigns

� 1992/1994 AHRQ published guidelines for

assessment and treatment of PU

� www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.

chapter.4409

� 2003 Wound Ostomy Continence Nurses Society

Guidelines for Prevention and Management of

PU

Braden Acute care, home care, nursing homes

Adult patient populations

6 subscales

Scores 6-23

Norton Acute care

Rehab

Adult patient populations

5 subscales

Scores 5-20

Gosnell Acute care, nursing home

Neurology, orthopedic, medical, ICU, geriatric patients

4 subscales

Scores 5-20

Braden Q Acute care Pediatrics 6 subscales + tissue perfusion

� Use standard EBP risk assessment tool

� Admission to hospital

� ?including ED

� Document PU present on admission (POA)

� Daily assessment throughout hospitalization

� Research has shown Risk Assessment Tools are more accurate than RN assessment alone.

� Braden Scale for Predicting Pressure Sore Risk

� 6 subscales

� Rated 1-4

� Pressure on tissues

� Mobility, sensory perception,

activity

� Tissue tolerance for pressure

� Nutrition, moisture,

shear/friction

� Score 6-23

� Frequent repositioning� CLRT and manual turning

� Managing moisture

� Developing and implementing a pressure ulcer prevent protocol� User friendly

� Products available

� RNs knowledge of protocol and products

�Assessment of risk�Other factors: age, vasopressors, instability, severe agitation, comorbidities, obesity

�Optimize nutrition & hydration

�Albumin, prealbumin

�Fluid balance

� Deep Tissue Injury (DTI)

� Stage I

� Stage II

� Stage III

� Stage IV

� Unstageable

� High risk patient population-ICU� Immobility

� Poor perfusion states

� Purple in color, “blood blister”

� Wound deteriorates quickly

� Usually progresses muscle, bone

� Heels are high risk areaswww.NPUAP DTI consensus statement

Fleck, C. (2007). Suspected DTI, FAQs.

Advances in Skin & Wound Care. 20(7),413

� Incontinence associated

dermatitis (IAD)

� Fecal > urine incontinence

� Patients with fecal

incontinence 22% >

chance developing PU*

� Immobility + fecal

incontinence = ↑↑ risk *Maklebust, J. & Magnan, M. Risk factors

associated with having a pressure ulcer: a

secondary analysis. Adv Wound Care 1994, 7:

25.

� Skin exposure to irritants

(urine, feces)

� Inflammatory response

initiated

� ↑skin transepidermal water loss (TEWL) →↓loss of moisture barrier properties of

skin

� Ammonia (urine), enzymes (stool) alter skin protection

� ↑ skin pH→↓protection

� ↑risk PU, infection, painGray,M., Bliss, D., Doughty, D., et al., Incontinence-

associated dermatitis: a consensus. JWOCN, 2007,

34(1); 45-54.

� 1st identify the source of IAD

� In ICU frequently it is antibiotics or tube feeding

� Consult nutritionist: evaluate osmolarity of tube feeding; add fiber to diet

� Consider medications to slow diarrhea

� Evaluate medications that

may be causing diarrhea

� Ace inhibitors, beta-blockers, digoxin, lasix, mannitol,

octreotide, lactulose

� Absorbent underpads,

changed frequently

� Low airloss therapeutic

mattress

� First, do no harm…

� Soaps ↑ skin pH

� Wash clothes rough-up already fragile skin

� Diapers keep moisture, enzymes in…

� Cleans frequently and avoid scrubbing

� Apply barrier creams that: moisturize and protect skin

� Polymer-based underpads; limit linensGray, M. Incontinence-related skin

damage: essential knowledge. OWM,

2007; www.o-wm.com/article/8161

� Skin pH is acidic (5.0 to 6.0)

� Cleansing products should be pH balanced or neutral (7)

� Soaps are alkaline →↑dryness, irritation, breakdown, ↓ barrier

� Soap pH

� Dove 7.0

� Dial 7.9

� Zest 10� Use pH balanced no-rinse

cleansing products

� Wash clothes irritate skin

� Perineal wipes

� Are pH balanced

� Contain moisturizers and emollients

� Skin protectant creams� Dimethicone, petrolatum,

zinc oxide� Use antifungal as indicated,

early

� Keep skin clean, dry, moisturized, protected

� Containment devices� What’s the evidence?

� Rectal pouches

� 1-2 days; 2 individuals to apply correctly

� May still tear intact skin upon removal

� Nasopharyngeal airway

� Mushroom catheter or balloon tipped catheter

� Bowel Management Systems (BMS)

BMS system

Balloon and nasal

trumpet system

� Assess on admission and daily

� Implement interventions

driven by your assessment

� Excessive moisture?

� Apply barrier cream

� NMBAs, Sedated, Intubated?

� Turn frequently, prop and tuck

bony prominences frequently,

assess pressure redistribution

bed/cushions

� Moisturize and hydrate the skin

� Critically evaluate your

bathing/skin care system

� Minimize friction and shear

� HOB 300, lift sheet, airpals

� Document POA and new

pressure ulcers

� Develop interprofessional plan of

care

� Preventing pressure ulcers and IAD through

evidence-based nursing practice…

Patricia J Posa RN, BSN MHA

Special Projects Coordinator-Keystone

St Joseph Mercy Health System

Ann Arbor, MI

� Incidence and risk factors

� Evidence based strategies to eliminate CLA-BSI

� Additional strategies

� Insertion process standardization, education and

evaluation

� Michigan Hospital Association Keystone ICU

Collaborative

� Incidence and risk factors

� Evidence based strategies to eliminate CLA-BSI

� Additional strategies

� Insertion process standardization, education and

evaluation

� Michigan Hospital Association Keystone ICU

Collaborative

� 80,000 CLA-BSI in U.S. ICUs annually

� Mortality: 18% (0-35%)

� Annual deaths: 500 - 28,000

� Cost per episode: $25,000-$45,000

� Annual cost: $296 million -$2.3 billion

CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001

� Cutaneous colonization of insertion site

� Moisture under the dressing

� Prolonged catheter time

� Technique of care and placement

� Remove/Avoid unnecessary lines

� Hand hygiene

� Maximal barrier

� Chlorhexadine for skin prep

� Avoid femoral lines

CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29]

www.ihi.org

What Does the ‘Bundle’ Evidence

Tell Us?

� For Provider:

� Hands hygiene

� Non-sterile cap and mask

� All hair should be under cap

� Mask should cover nose and mouth tightly

� Sterile gown and gloves

� For the Patient

� Cover patient’s head and body with a large sterile

drape

Minimal@ Maximum*

Local inf. 7.2% 2.3%

CVC-BSI 3.6% 0.6%

*cap, mask, sterile gloves, sterile gown, head/body of patient covered with

large sterile drape

@ sterile gloves, small sterile drape

Raad II, et al. Infect Control Hosp Epidemiol 1994;15:231-8

� Rapid bactericidal activity

� (affective after 30 sec vs. 2 min)

� Persistent activity on the skin & cumulative

� Maintains its activity in the presence of other organic

material

� Low allergic or toxic response

� None or mild systemic absorption

Chalyakunapruk N. et al. Ann Intern Med. 2002;136:792-801

� RCT of femoral and SC lines in the ICU� 145 pts femoral/144 pts SC

� Outcomes� Higher rate of infectious complications in femoral grp:

19.8% vs 4.5% (p<.001)

� Higher rate of thrombotic complications in femoral grp: 21.5% vs 1.9% (p<.001); complete thrombosis 6% vs 0%

� Similar rates of mechanical complications: 17.3% vs 18.8% (p=NS)

JAMA 2001,286: 700-7

� Replace all catheters inserted under emergency conditions within 48 hours

� Do not routinely replaced non-tunnelled CVC catheters

� PA catheters should be changed no more frequently than every 7 days.

� Use a guidewire assisted catheter exchange if infection is not suspected.

� Do not use guidewire technique to replace catheters if there is a clinical suspicion for CR-BSI.

� Routine culture of the tip is not recommended.

� For arterial lines: changed no more frequently than q 5 days along with the transducer and tubing.


� Use either sterile gauze or transparent dressing (High MVP rate) to cover the site (Cat 1A)

� If you place the 2x2 under the transparent it becomes a gauze dressing

� Change gauze q 2 days & transparent q 7 days (Cat 1A)

� Replace dressing if damp, loosened or soiled or inspection of the site is necessary

� Chlorhexidine/Alcohol skin prep recommended for every dressing change.

� Do not routinely apply antimicrobial ointments to the site (Cat 1A)


Additional Strategies:

� CHG Baths

� CHG Dressings

� Antimicrobial impregnated CVC

� 52 week, 2 arm, cross-over design clinical trial

� 22 bed MICU with 11 beds in 2 geographically

separate areas

� 836 MICU patients

� 1st 28 weeks: 1 hospital randomize to bathe with (Sage 2%) CHG cloths & the other unit bathe with

soap & water

� 2 week wash out period

� 2nd 24 weeks: methods were crossed over

� Measured: Primary outcomes: incidence of CA-BSI’s & clinical sepsis. Secondary: other infections

Bleasdale SC. et al. Arch Internal Med, 2007;167(19):2073-2079

CHG Bathing Reduces CLA-BSI

Bleasdale SC. et al. Arch Internal Med, 2007;167(19):2073-2079

Results:�CHG arm were significantly less likely to acquire a CLA-BSI 6.4 vs. 16.8 infections per 1000 catheter days�Benefit against primary CLA-BSI’s by CHG cleansing after 5 days in MICU�No difference in clinical sepsis or other infections

CHG Bathing Reduces CLA-BSI

� BSI bundle implementation resulted in reduction of CA-BSI’s

from 24.8 to 3.1 per 1000 catheter days in 4 adult ICU’s (30

beds)

� 8 month implementation regarding addition of the

Chlorhexidine patch as part of site care

Results: Compared� 277 patients with CVC from May-April 2005 (Bundle)

� 226 patients with CVC from Sept- Dec 2005 (Bundle & Patch) with 98% compliance of patch

� CA-BSI went 3.1 to 0 per 1000 catheter days (p < 0.05)

� Cost savings estimate: $314, 678

Garcia R et al. AJIC, 2006;34(5):E42

� Prospective 2 year before and after study (1998-

2000 compared to 2000-2002)

� Use of chlorhexidine/silver-sulfadiazene catheter

in 6 ICUs at large teaching hospital

Results:

� CRBSI decreased from 8.2 per 1000 catheter days

to 5.4 per 1000 catheter days (p=.003)

� Prevention strategies used: maximal barrier

precautions (not using CHG for skin prep)

Borschel DM, et al Am Jo Infect Control 2006;34

CDC Recommendations:

� Use of an antimicrobial or antiseptic-

impregnated CVC in adults whose catheter is

expected to remain in place for > 5 days if,

after implementing a comprehensive strategy

to reduce rates of CRBSI, the CRBIS rate

remains above benchmarked goal (IE: 3.3/1000

catheter days)

Prevention of Catheter Infection: MMWR 2002;51

� Create Culture of Safety: � Completed unit education on patient safety� Training to senior medical staff and residents� Education to nurses and respiratory therapists� Empower nurses/RT to stop line placement� Pre-procedure Briefing

� Improve Processes� Reduce complexity: Line cart� Create independent checks for key processes: BSI

checklist� Nurse in room during line insertion� Sign on door: ‘Procedure in progress’ to decrease traffic in

room

� Automate:� Put checklist and standard documentation in new bedside

computer system

How to Implement the Evidence

Through a State-wide Collaborative

� Make introductions

� Discuss patient information and procedure

� Agree upon a time for line insertion

� Review best practice for line insertion(if necessary)

� Nurse defines their role to physician: provide equipment, monitor patient, provide patient comfort, observe for compliance with best practices and STOP procedure if sterile process compromised

� Establish communication expectation for sterile procedure breaks

� Examples include: your sleeve has touched the IV pole, the guidewire touched the headboard

� Identify any special supply or procedural needs

� Discuss any special patient issues (IE: patient confused, patient awake)

� Answer any additional questions

� TIME OUT: RIGHT PATIENT---RIGHT PROCEDURE

Are We Implementing the

Prevention Strategies and are

They Effective???

Use of CVC-Related Bloodstream Infection

Prevention Practices by US Hospitals

� National survey of infection control coordinators regarding CVC related BSI prevention practices

� Maximal Barrier Precautions, CHG prep or composite (MSP + CHG +

avoidance of routine central line changes)

� March 2005 to August 2005

� Random sample of non-federated hospitals with ICU and

more than 50 beds (n=600) and VA hospitals (n=119)

� 72% response rate (n=516):

� VA hospitals: n=95

� Non-VA hospitals: n=421

Krein SA, et al. Mayo Clin Proc. 2007;82(6):672-678

Use of CVC-Related Bloodstream Infection

Prevention Practices by US Hospitals

� Results:� Use of maximal barrier precautions: 84% for VA vs 71% non-VA (p=.01)

� Use of CHG for insertion site prep: 91% for VA vs 69% non-VA (p=.001)

� Use of Composite approach: 62% for VA vs 44% for non-VA (p=.003)

� Antimicrobial catheter use: 32% for VA vs 38% for non-VA (p=.30)

� Use of CHG dressing: 29% for VA vs 25% for non-VA (p=.47)

Hospitals with higher safety culture score, having a certified infection control professional and participating in an infection prevention collaborative were more

likely to use CR-BSI prevention practices

Krein SA, et al. Mayo Clin Proc. 2007;82(6):672-678

� 103 ICU’s in state of Michigan reported data

� Examine 375,757 catheter days

� Implementation of the BSI Bundle/checklist

Results�Median rate of CLA-BSI per 1000 catheter days

went 2.7 to 0 at 3 months ((p<0.002)

�Mean rate of CLA-BSI’s per 1000 catheter days

went 7.7 to 1.4 at 18 month follow up (p<0.002)

Pronovost P et al, N Engl J Med;2006;355:2725-2732

Intervention to Decrease CLA-BSI

Statewide Collaborative-Keystone ICU

� 3 hospital system: 2 hospital having 4 ICUs

� Implemented BSI Bundle in July 2004� 5 best practices

� BSI checklist

� Line cart

� Empower nurses to stop line placement if procedure not followed

� Nurse in room during line insertion

� Education—Education --Education

� Share data monthly and chart review each of CLA-BSI (Learn from a Defect)

Posa, P Harrison, D & Vollman, K AACN Advanced Critical Care, 2006; 17(4):446-454

St. Joseph Mercy Health System

Ann Arbor, MI

Results:

� Baseline rate: 7.6 per 1000 catheter days

� 2005: 2.12 per 1000 catheter days




Ann Arbor, MI

Results::� Livingston CCU: 38 months without a BSI

� MICU: 29 months without a BSI

� CCU: 17 months without a BSI

� SICU: 6 months without a BSI


Ann Arbor, MI

Results:� Marginal cost avoidance of $8,800 per BSI prevented

� 2004: 38 BSIs

� 2005: 13 BSIs

� 2006: 8 BSIs

� 2007: 8 BSIs

St. Joseph Mercy Health SystemJuly 2004 to December 2007

$ 220,000 marginal cost avoidance

between 2004 and 2005

Our Next Steps

� Implement the CHG Bath in all ICUs

� Explore the use of the CHG dressing

� Explore use of antimicrobial/antiseptic CVC

catheters in certain high risk populations

Keys to Success

� Team in place with key stakeholders overseeing implementation

� Project coordinator with lead clinical staff on each unit

� Strong physician leadership on team

� Education of staff through use of BSI checklist

� Empowerment of nursing staff to prevent errors

� Administrative support to help manage barriers

� Review data monthly for opportunities for improvement (if further analysis is needed can use Learn from a Defect Tool )

� Support from state-wide collaborative

Prevention of Sternal Wound Infections Following Cardiac Surgery

Ginger S. Pierson MSN, RN, CCRN, CNSCardiovascular & Critical Care CNS

CNS, New Grad RN Program

Hoag Hospital,

Newport Beach, California

Surgical Site Infections

� Post-operative infection is a major cause of patient injury, mortality and healthcare costs

� A surgical site infection (SSI) is defined as:� An infection that develops within 30 days after an operation

� Occurs within one year, if an implant was placed, and relates to the surgery

� It is estimated that approximately 500,ooo to 750,000 surgical site infections (SSI) occur annually in the USA

Rhee, H. & Harris, B., Infection Control Today, March, 2008

Surgical Site Infections (SSI)

� Patients who develop an SSI –� Require significantly more medical care

� Are 60% more likely to spend time in ICU

� May have an ↑ LOS by ~ 2 weeks

� Have twice the mortality (cardiac surgery patients ↑↑)

� SSIs develop in almost 2% of patients after discharge and are five times as likely to be readmitted


� Surgical Infection Prevention (SIP) Project developed in 2002

� National, collaborative quality initiative to substantially reduce surgical mortality and morbidity through collaborative efforts

� SCIP became the expanded project to include surgical complications in 2005 by CMS and the CDC

Fitzgerald, J. et. al, Nursing Management, Nov, 2007, 35

SCIP Steering Committee

� American College of

Surgeons

� American Hospital

Association

� American Society of

Anesthesiologists

� Association of

Peri-Operative RNs

� Agency for Healthcare

Research and Quality

� Centers for Medicare &

Medicaid Services

� Centers for Disease Control

and Prevention

� Department of Veteran’s

Affairs

� Institute for Healthcare

Improvement

� Joint Commission on

Accreditation of Healthcare

Organizations

SIP/SCIP National Expert Panel

� Society for Healthcare Epidemiology of America

� Association of Peri-Operative Registered Nurses

� American Association of Critical Care Nurses

� American College of Obstetricians & Gynecologists

� Society of Thoracic Surgeons

� Surgical Infection Society

� VHA, Inc.

� American Academy of Orthopedic Surgeons

� American Society of Anesthesiologists

� American Society of Health System Pharmacists

� American Geriatrics Society

� And more………..

SCIP- Opportunity to Prevent

Surgical Site Infections

� Evidence shows that approximately 40 – 60% of SSIs can be prevented

� GOAL: To reduce incidence of surgical complications by 25% by the year 2010*(*in selected surgical procedure patients)

SCIP Selected Surgical Procedures

� Cardiac Surgery

♥ Coronary Artery Bypass Graft (CABG)

� Colon

� Hip & Knee Arthroplasty

� Abdominal & Vaginal Hysterectomy

� Vascular Surgery:

� Aneurysm repair

� Thromboendarterectomy

� Vein Bypass

SCIP Quality Initiatives and Application to

Cardiac Surgery Patients

� Appropriate use of prophylactic antibiotics� Antibiotic selection

� Timing of administration

� Timing for discontinuation post-op

� Appropriate hair removal and skin prep

� Controlled post-operative serum glucose

Deep Sternal Wound

Following Cardiac SurgeryCDC and DHS definition:� Infection occurs within 30 days of surgery AND

� Involves the deep, soft tissues (fascial and muscle layers) of the incision AND

� Patient has at least ONE of the following:� Purulent drainage from the deep incision

� Incision spontaneously dehisces or is deliberately opened by the surgeon and is culture +, or fever, pain or tenderness

� Abscess/ infection found on exam, re-operation, histopathology or radiologic exam

� Diagnosis of deep incisional SSI is made by the surgeon/attending MD

CDC& DHS, National Healthcare Safety Network Manual, October, 2007

Who is at Risk for Sternal SSI?

Host Risk Factors:

� Obesity

� Diabetes Mellitus

� Use of IMA grafts

� Advanced age

� Male gender

� COPD

� Smoking

� Prolonged mechanical ventilation

� Steroids

� Pre-op hospital stay > 5 days

Surgical Risk Factors:

� Duration of surgery and perfusion time

� Use of an IABP

� Post-operative bleeding

� Re-operation

� Sternal re-wiring

� Extensive electrocautery

� Shaving with razors

� Use of bone wax

Hollenbeak, C. et. al., Chest, 2000, 118(20):397

Prophylactic Antibiotic Selection

and Timing for Cardiac Surgery

� Pre-op dose of 2 gm IV Cefazolin for a patient >60 kg body weight

� Repeat dose every 3- 4 hours (while surgical incision remains open)-if normal renal function

� If IgEIgE allergy to Penicillin or Cephalosporin: give Vancomycin

� Vancomycin dose of 1 to 1.5 gm IV or a weight-adjusted dose of 15 mg/kg administered IV slowly over 1 hour, with completion within 1 hour of skin incision

� A 2nd dose of Vanco 7.5 mg/kg can be considered during CPB

� Mupirocin topical antibiotic in nares pre-op and post-op

Engleman, R. et. al., STS, Annals of Thoracic Surgery, 2007;83: 1569-1576

Perioperative AntibioticsTiming of Administration

14/ 369

5/ 6995/ 1009

2/ 180

1/ 81

1/ 41

1/ 47

15/ 441

Classen, et al., N England J Med., 1992;328:281

Discontinuation of Antibiotics

SCIP Guidelines:

� Most surgical procedures- D/C antibiotics within

24 hours of surgery end time

� Cardiac surgery- may D/C antibiotics within 48 hours of

surgery end time

STS Guidelines: do not favor 24 hours over 48 hours for

discontinuation (surgeon/ team preference)

Hall, M., SCIP: Medscape.com, Module 1, May, 2006

Serum Glucose Control

� Strong relationship between hyperglycemia and surgical site infections

� Latham (2001) found that any cardiac surgery patient who had a serum glucose > 300 mg/dl within 48 hours post-op, was 3.3 times more likely to develop SSI than if glucose was kept < 200 mg/dl

� Evidence supports keeping serum glucose levels

< 200 mg/dl in the peri-op and post-op phases

Latham, R, et. Al., Infection Control Hosp Epidemiol, 2001

Other Strategies

� Appropriate hair removal

� Clipped (never shave), just before surgery

� Adequate skin antisepsis/ pre-op skin preparation

� Agent with broad spectrum of activity

� Rapid onset

� Persistent effects

* Most common- Iodine, alcohol-based products and chlorhexidine (2% vs. 4%)


Hall, M., SCIP: Medscape.com, Module 1, May, 2006

Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com

� Methodology� Observational study with a pre & post intervention

period

� Baseline: Actively part of National SCIP program

� Pre-intervention pre-op prep was night before in home

showering or washing with 4% CHG solution

� Post intervention: Pre-op prep preformed with a pre-

packaged 2% CHG prep product with instructions on its

use

� Pre-package prep preformed at hospital prior to surgery

� Measured:

� Change in baseline SSI would occur with new prep

process

Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com

� Results:

� 25 SSI’s during

historical period out of

5174 procedures (rate

of 2.1%)

� 11 SSI’s during

interventional period

out of 4266

procedure(rate 0 .7%)

� 72% reduction

Other Strategies- Continued

� Mupirocin (Bactroban)-intranasal-recommended as a routine prophylactic measure to eradicate the nasal colonization of S. Aureus-including MRSA:

� Begin at least the day before surgery

� Continue for 2 – 5 days post-op

� Post-op wound care and dressing changes� No concensus on best practice

Engleman, R. et. al., STS, Annals of Thoracic Surgery, 2007;83: 1569-1576

Haycock, C., et. al, Journal of Cardiovascular Nursing, 2005, 20(5): 299-305

In Summary � Antibiotics selection: Give Cefazolin, if allergic- give

Vancomycin (and may consider aminoglycoside 1-2 doses)

� Antibiotics are infused/completed within 1 hour of surgical incision

� D/C antibiotics within 48 hours of end of surgery

� Maintain serum glucose < 200mg/dl peri-op & post-op

� Appropriate hair removal just before surgery; complete skin antisepsis

� Mupirocin intranasally pre-op and post-op

Project overview available at: www.medqic.org/scip

[email protected]

[email protected]@hoaghospital.org

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Mary Beth Flynn Makic RN PhD CNS CCNS - vollman.com Beth Flynn Makic ... comorbidities, obesity Optimize nutrition & hydration Albumin, ... In ICU frequently it is antibiotics or tube