Text of Preventing Surgical Site Infections in the Diabetic Cardiac Surgical Patient Paula Pintar BSN, RN...
Preventing Surgical Site Infections in the Diabetic Cardiac Surgical Patient Paula Pintar BSN, RN Alverno College MSN Student Tutorial Project Spring 2010
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Tutorial Menu Learning Objectives Tying It All Together Surgical Site Infection What is it? Why are Surgical Site Infections a Problem? Significance Of Diabetes Mellitus Stages of Surgical Wound Healing Age & Wound Healing Inflammation & Wound Healing Genetics & Wound Healing Key Risks With Wound Healing Activation of Stress Response And Surgery Case Study Part 2 Bundle Elements & Nsg. Interventions Best Practice Standards Bundle Case Study Part 1 References Click on the button you would like to view more information about.
Learning Objectives The Learner Will: Identify criteria used for classifying a surgical site infection (SSI). Identify why Surgical Site infections are a problem. Review of Diabetes Mellitus and the genetic link of incidence. Identify what risk factors can put Diabetic patients at a higher risk to developing a Surgical Site infection. Review the three main stages of wound healing: Inflammation, Proliferation, Remodeling. Be able to correlate the factors of Age, Inflammation, and the Generalized Stress Response in the diabetic patient; relate how these factors impact the stages of wound healing. Review Best Practice Standards and Nursing interventions for a Surgical Site infection prevention plan. Apply Nursing indicators to a case study. Understand how applying best practice guidelines will support positive outcomes for the patient, family, staff, health system, and community.
Surgical Site Infection (SSI) What Is It? Clinical and laboratory signs of infection at the surgical site within: 30 days of the surgery or Within 1 year if an implant was used (heart valve/joint) Criteria for Defining a Surgical Site Infection (SSI) Documented at various tissue levels: Superficial (skin/subcutaneous) Deep (soft tissue/muscle) Deep/organ space (organ space) Caused by: Endogenous bacteria patients own skin flora Exogenous bacteria environmental bacteria or surgical material Source: 1
SSI As Defined by the CDC Superficial Infection within 30 days after procedure Involves the skin and subcutaneous tissue (and meets one of the following criteria) Has purulent drainage Organisms cultured from fluid or tissue Displays at least 1 of the following pain, local swelling, redness, and incision is opened by surgeon Diagnosis of superficial incision SSI by the surgeon or attending MD Source:1
SSI As Defined by the CDC Deep Incisional SSI Occurs within 30 days of procedure 1 year if implant Involves deep soft tissue ( fascial and muscle layers) And patient displays at least one of the following Purulent drainage Spontaneously dehisces or opened by the surgeon and the patient has at least one of the following: Fever, pain, abscess, or diagnosis by MD Source: 1
SSI As Defined by the CDC Organ space Occurs with in 30 days 1 year if implant used Includes any part of the body excluding skin, fascia, or muscle layer. Must meet the following criteria Purulent drainage from a drain that is place through a stab wound Isolated organisms from an aseptic culture Abscess Diagnosis by MD Source: 1
Lets Review What are the 3 tissue levels of a Surgical Site Infection? PrimaryScar Organ Space Deep Superficial Acute
Surgical Site Infection Why Is It A Problem? According to the Institute for Healthcare Improvement (IHI) 38% of all Healthcare Associated Infections are SSIs 2 5% of patients operated on will develop an SSI Developing an SSI will extend the hospital stay by 5 to 7 days One SSI will increase cost by $2,734 - $26,019 (estimated on 1985 dollars) Estimated national costs of 130 million to 845 million dollars spent a year on SSIs. Source: 1
What Does this Mean at a Local Level? Higher cost related to longer stays Decreased patient turnover translates into less income for healthcare facility Healthcare facility develops a reputation of poor patient outcomes. Decreased reimbursement by The Centers for Medicare and Medicaid (CMS) as of October 1, 2008 stopped reimbursement for hospital acquired infections Source : 16 Microsoft clipart
What Does this Mean at a Local Level? Negative Outcomes Linked to SSIs Trend is toward public reporting of infection rates for healthcare facilities. This will impact consumer decisions as to where they will go to have procedures performed. Consumers have greater access to information - Intranet Milwaukee has number of facilities with duplicative resources. Patients may begin shopping around for facility with lowest infection rates. Source: 16 Microsoft Clipart
Lets Review According to the Institute for Healthcare Improvement (IHI) 38% of all Healthcare Associated Infections are SSIs. Developing an SSI will extend the hospital stay by 5 to 7 days. Increased reimbursement by The Centers for Medicare and Medicaid (CMS) as of October 1, 2008 started for hospital acquired infections. Trend is toward public reporting of infection rates for healthcare facilities. True False TrueFalse TrueFalse TrueFalse
Now With The Problem Identified Lets take a closer look at a patient population (diabetes mellitus), and apply nursing indicators and medical knowledge to decrease and prevent the development of Surgical Site Infections. Microsoft Clipart
Significance of Diabetes Mellitus Diabetes mellitus affects approximately 2.8 million people in the United States The disease is a metabolic process that results from a lack of insulin secretion or action. Insulin is a hormone that is secreted by the beta cells in the pancreas. This hormone then allows the cells in our body to absorb the glucose and convert it into energy to maintain metabolic processes. There are two main types of diabetes mellitus that the majority of diabetics are classified into. Microsoft Clipart Source: 6
Diabetes Mellitus & Genetic Link Type 1: This is characterized by an complete lack of insulin secretion and elevated blood sugar, related to destroyed pancreatic beta cells (6) Usually occurs at an early age (childhood) 5 to 10% of the diabetic population have this type of diabetes (~ 1 million people) (6) These individuals have been associated with an autoimmune link to the disease. (4) autoimmune This autoimmune response is the cause of beta cell destruction (4)autoimmune response The other factor identified is an exposure to an environmental mediator, such as having an infection. (6) Microsoft Clipart Source: 4, 6
Diabetes Mellitus & Age Link Type 2 : This is characterized by having insulin resistance Approximately 90 to 95% of diabetics present with this type (~19 million people) 18 -20% of persons 65 and older have diabetes 40% have the disease or precursor to disease Obesity and older individuals is commonly associated with Type 2older individuals There is multiple hypothesis as to the causal agents of this form. Due to the variability of the causal agents, it is difficult to predict or identify specific factors that lead to disease. It is known that autoimmune destruction of the beta cells, as in Type 1 does not occur. Microsoft Clipart Source: 6
Diabetes Mellitus & Link to Developing an SSI Studies correlating elevated levels of hemoglobin A1C 6.5 (HgA1C) and uncontrolled blood sugars in the postoperative period have had a higher incidence of postoperative wound infections. Blood glucose levels >200mg/dL in immediate postoperative period and up to 48 hours post operatively are a key link to SSI development. Phagocyte activity is altered by the elevated blood glucose levels. Source: 6
Lets Review What is the key reference data used to monitor blood sugar stability over time? CorrectIn Correct Hgb A1C Blood pressure Urine glucose Amylase Finger stick glucose C reactive protein K level
Review of the Surgical Wound Healing Process There are 3 main stages of wound healing 1. Inflammation 2. Proliferation 3. Remodeling Within each stage there is a complex system of cellular functions that occur. (5) Factors that can impede good wound healing are: Poor diet/uncontrolled blood sugars Compromised blood flow Disruption of inflammatory response Infection Effects of age (14) Microsoft Clipart Source: 5,14
Surgical Wound Healing Stages Stage 1 Inflammatory (acute) Incision initial vasoconstriction followed by platelet aggregation to damaged endothelium (14) Followed by a dilation of capillaries Around 24 hours macrophages enter the area and remain there to clean up cellular debris and stimulate the healing process (5) Microsoft Clipart Source: 5,15
Surgical Wound Healing Stages Stage 2 Proliferation 24-48 hours after wound occurrence the fibroblast and vascular endothelial cells begin formation (5) This is a fragile per