Prevention of Surgical Site Infections (SSI): Tried and

255_1_Lundi_ISC_Dr_PerlPrevention of Surgical Site Infections (SSI): Prevention of Surgical Site Infections (SSI): Tried and True or New?Tried and True or New?
Trish M. Perl, MD, Trish M. Perl, MD, MScMSc Hospital Epidemiologist, Johns Hopkins HospitalHospital Epidemiologist, Johns Hopkins Hospital Professor of Medicine, Johns Hopkins UniversityProfessor of Medicine, Johns Hopkins University
Research funding from Research funding from Sage ProductsSage Products 3M Corporation3M Corporation
Advisory Board and honorariumAdvisory Board and honorarium 3M3M Cadence PharmaceuticalsCadence Pharmaceuticals ViropharmaViropharma
DisclosuresDisclosures
•• To describe several strategies to prevent SSITo describe several strategies to prevent SSI –– PrePre--operativeoperative –– IntraIntra--operativeoperative –– PostPost--operativeoperative
•• To review the data behind these strategiesTo review the data behind these strategies
ObjectivesObjectives
•• Frequency of surgery : Frequency of surgery :
In the US: 40.3 million inpatient & 31.5 In the US: 40.3 million inpatient & 31.5 million outpatient procedures annuallymillion outpatient procedures annually
234 million operations worldwide234 million operations worldwide
•• Frequency of SSI: Frequency of SSI: SSI rates vary from < 1 to SSI rates vary from < 1 to over 25 per 100 procedures over 25 per 100 procedures
•• SSI is 2nd to 3rd most common HAISSI is 2nd to 3rd most common HAI
Wenzel NEJM: 1992Wenzel NEJM: 1992
Putting SSI in Perspective: Frequent Putting SSI in Perspective: Frequent Adverse EventsAdverse Events
Brennan. N Engl J Med. 1991;324:370Brennan. N Engl J Med. 1991;324:370--376376
SSI: OutcomesSSI: Outcomes •• SSI doubles likelihood of deathSSI doubles likelihood of death
–– 20,000 in hospital deaths annually20,000 in hospital deaths annually
•• Doubles length of hospital stayDoubles length of hospital stay –– 6.5 6.5 --16.7 extra days16.7 extra days
•• Readmission 30% higher among SSIReadmission 30% higher among SSI
•• Average excess costs $3500 per SSIAverage excess costs $3500 per SSI –– Cardiac surgery: increased charges 1.8 Cardiac surgery: increased charges 1.8 -- 2.8 X2.8 X
•• Net loss of $2,344/SSI Net loss of $2,344/SSI
•• Total excess costs $ 3 billion annuallyTotal excess costs $ 3 billion annually
•• Most costs not reimbursed if under capitationMost costs not reimbursed if under capitation Loop, et al. Ann Loop, et al. Ann ThoracThoracSurgSurg49:17949:179--187, 1990 , Nelson, et al. Ann 187, 1990 , Nelson, et al. Ann ThoracThoracSurgSurg42: 24042: 240--246, 246,
1986, Boyce, et al. ICHE 11:891986, Boyce, et al. ICHE 11:89--93, 1990,Briggs et al ICHE 1999;20;72593, 1990,Briggs et al ICHE 1999;20;725--3030
Host factorsHost factors
Contamination Contamination BodyBody
Decreased PO2 in tissue Decreased oxidative killing of PMN’s (>300 mm Hg)
Disruption of vascular supply leads to injury and thrombosis and tissue hypoxia (<30 mm Hg)
Decreased PO2 in tissueDecreased PO2 in tissue Decreased oxidative killing of Decreased oxidative killing of PMNPMN’’ ss (>300 mm Hg)(>300 mm Hg)
Disruption of vascular supply leadsDisruption of vascular supply leads to injury and thrombosis and tissueto injury and thrombosis and tissue hypoxia (<30 mm Hg)hypoxia (<30 mm Hg)
What can we do?What can we do?
Risk Factors for SSI: A View Towards Risk Factors for SSI: A View Towards PreventionPrevention
Endogenous Endogenous Flora/Flora/
Microbial Microbial FactorsFactors
FactorsFactors
••nasal/skinnasal/skin carriagecarriage ••virulencevirulence ••adherenceadherence
Summary DocumentsSummary Documents
Why Am I Talking to You?Why Am I Talking to You?
•• 589 surgeons from Alberta Canada surveyed589 surgeons from Alberta Canada surveyed
•• 247 (42%) responded247 (42%) responded
•• 156 (63%) reported not following guidelines for156 (63%) reported not following guidelines for
–– PeriPeri--operative bathingoperative bathing
–– Hair removalHair removal
–– Antimicrobial prophylaxisAntimicrobial prophylaxis
–– IntraIntra--operative prophylaxisoperative prophylaxis
•• Plastic surgeons were the least likely to feel that Plastic surgeons were the least likely to feel that prevention strategies prevented SSI (prevention strategies prevented SSI (pp=0.045)=0.045)
Davis et al ICHE 2008:29;1164Davis et al ICHE 2008:29;1164--66
What Can We Do PreWhat Can We Do Pre--operatively and operatively and We Are Not Going to Discuss?We Are Not Going to Discuss?
•• Reduce hemoglobin A1c < 7%Reduce hemoglobin A1c < 7%
•• Stop smoking >30 days before the Stop smoking >30 days before the operationoperation
•• Rx preoperative infectionsRx preoperative infections
What Can We Do PreWhat Can We Do Pre--operatively?operatively?
1. Pre1. Pre--operative Bathingoperative Bathing
What the Guidelines SayWhat the Guidelines Say
•• Require patients to shower or bathe with Require patients to shower or bathe with an antiseptic agent on at least the night an antiseptic agent on at least the night before the operative stay (1B)before the operative stay (1B)
PrePre--operative CHG bathing or showering operative CHG bathing or showering with CHG vs placebo: SSIwith CHG vs placebo: SSI
Webster J and Osborne S Cochrane Collaboration 2007 and 2008Webster J and Osborne S Cochrane Collaboration 2007 and 2008
ButBut……....
•• No standardized concentrations of CHGNo standardized concentrations of CHG
•• No measures of complianceNo measures of compliance
Are We Applying CHG Correctly? 4% vs. Are We Applying CHG Correctly? 4% vs. 2% cloth2% cloth
EdmistonEdmistonet al. J Am et al. J Am CollColl SurgSurg2008:207;2332008:207;233--66
Group 1: morning cleansingGroup 1: morning cleansing Group 2: evening cleansingGroup 2: evening cleansing Group 3: both morning and Group 3: both morning and evening cleansingevening cleansing
TMPMM2
2. Stop 2. Stop inappropriate/unnecessary inappropriate/unnecessary
hair removalhair removal
Bottom Line on Hair RemovalBottom Line on Hair Removal
•• Shaving Shaving vsvs no hair removal: no hair removal: 17/177 (9.6%) 17/177 (9.6%) vsvs 11/181 11/181 (6%), RR 1.59 (95% 0.77(6%), RR 1.59 (95% 0.77--3.27)3.27)
•• Shaving Shaving vsvs clipping: clipping: 2.8% (46/1627) 2.8% (46/1627) vsvs 1.4% 1.4% (21/1566), RR=2.02 (95% 1.21,3.36)(21/1566), RR=2.02 (95% 1.21,3.36)
•• Depilatory cream Depilatory cream vsvs no hair removal: no hair removal: 7.9% (10/126) 7.9% (10/126) vsvs 7.8% (11/141), RR 1.02 (0.45,2.31)7.8% (11/141), RR 1.02 (0.45,2.31)
Tanner J, Tanner J, WoodingsWoodingsD, D, MoncasterMoncasterK. Cochrane Reviews, 2006K. Cochrane Reviews, 2006 Issue 2, No CD004122,pub 2.Issue 2, No CD004122,pub 2.
3. Assure appropriate 3. Assure appropriate periperi-- operative prep (agent and operative prep (agent and
technique)technique)
Skin Prep: What the Guidelines SaySkin Prep: What the Guidelines Say
•• Clean around incision site to remove gross Clean around incision site to remove gross contamination before performing antiseptic skin contamination before performing antiseptic skin preparation (1B)preparation (1B)
•• Use an appropriate antiseptic agent for skin Use an appropriate antiseptic agent for skin preparation and follow manufacturer's guidelines preparation and follow manufacturer's guidelines (1B)(1B)
•• AORN recommends sufficient contact time of AORN recommends sufficient contact time of antiseptic agents before applying sterile drapes to antiseptic agents before applying sterile drapes to achieve maximum effectiveness of the agent.achieve maximum effectiveness of the agent.
Comparison of ScrubsComparison of Scrubs
•• Prospective study of Prospective study of 127 patients PI paint 127 patients PI paint and scrub and scrub vsvs CHG/ETOH scrubCHG/ETOH scrub
•• Cultures obtained 3 Cultures obtained 3 sites, no outcome datasites, no outcome data
•• Among cultures, S. Among cultures, S. aureus isolated among 9 aureus isolated among 9 patients (7patients (7--PI, 2PI, 2--CHG)CHG)
BibboBibboet al et al ClinClin Ortho Related Research 2005;438:204Ortho Related Research 2005;438:204--88
Efficacy of Various Surgical Skin Preparations Efficacy of Various Surgical Skin Preparations (scrub) During Surgery(scrub) During Surgery
% o
100% 100% 100%
Ostrender, R. J Bone Joint Surg AM 2005;87:980Ostrender, R. J Bone Joint Surg AM 2005;87:980--985.985.
P<0.01P<0.01--0.050.05
CHG CHG vsvs PI: SSIPI: SSI
Edwards P, Lipp A, Holmes A, Cochrane Analysis Edwards P, Lipp A, Holmes A, Cochrane Analysis ““ Preoperative skin antiseptics for preventing surgical wound infePreoperative skin antiseptics for preventing surgical wound infections ctions after clean surgery (Review)after clean surgery (Review)”” 20092009
U. Penn AnalysisU. Penn Analysis——Efficacy of CHGEfficacy of CHG
Miller et al, SHEA abstract 2008, Orlando FLMiller et al, SHEA abstract 2008, Orlando FL
Skin Prep: Should we move to CHG?Skin Prep: Should we move to CHG?
•• After a single application, CHG achieves greater After a single application, CHG achieves greater reduction in skin flora and has longer residual activity reduction in skin flora and has longer residual activity (48 hours) than povidone(48 hours) than povidone--iodine . iodine .
•• CHG, unlike the iodophors, is active even in the CHG, unlike the iodophors, is active even in the presence of blood or serum proteins. presence of blood or serum proteins.
•• There is extensive data demonstrating the reduction in There is extensive data demonstrating the reduction in skin flora by these products, but, no clear comparison skin flora by these products, but, no clear comparison demonstrating superiority of either of these products demonstrating superiority of either of these products to reduce SSI. to reduce SSI.
4. Decolonization among 4. Decolonization among highhigh--risk patientsrisk patients
•• SternalSternalwound infectionwound infection –– Odds ratio = 9.6, 95% CI 3.9Odds ratio = 9.6, 95% CI 3.9––23.723.7 –– Attributable risk = 86.3%Attributable risk = 86.3%
•• Harvest site infectionHarvest site infection –– Relative risk = 7.12, 95% CI 2.22Relative risk = 7.12, 95% CI 2.22––3.03.0 –– Attributable risk = 86%Attributable risk = 86%
•• Orthopedic infectionOrthopedic infection –– Relative risk = 8.9, P=0.002Relative risk = 8.9, P=0.002
•• Surgical site infectionSurgical site infection –– Relative risk = 4.5 (95 %CI:2.47,8.21; P < Relative risk = 4.5 (95 %CI:2.47,8.21; P <
0.001)0.001) Kluytmans, et al JID 1995;171:216Kluytmans, et al JID 1995;171:216--19, Morales et al. ICAAC abstract 1994, Kalmeijer et al. ICHE 19, Morales et al. ICAAC abstract 1994, Kalmeijer et al. ICHE 2000;21:319, Perl et al NEJM 20022000;21:319, Perl et al NEJM 2002
S. aureusS. aureusNasal Carriage and Attributable Risk Nasal Carriage and Attributable Risk of SSIof SSI
CardiothoracicCardiothoracic NeuroNeuro General surgeryGeneral surgery
UIHCUIHC Iowa Iowa CityVACityVA PreopPreopscreening and screening and Study drugStudy drug
MARS Study DesignMARS Study Design
Perl et al. NEJM 2002:346;1871Perl et al. NEJM 2002:346;1871--66
%
P<0.0001P<0.0001
Perl et al. NEJM 2002:346;1871Perl et al. NEJM 2002:346;1871--66
SSI Rates among SSI Rates among S. aureusS. aureusNasal CarriersNasal Carriers
11.6%11.6% 9.9%9.9%
1.6%1.6% 1.8%1.8%
OR: 0.61, 95% CI (0.3, 1.2)OR: 0.61, 95% CI (0.3, 1.2) pp=0.15, 37% reduction in infection=0.15, 37% reduction in infection
3.7%3.7%
p = nsp = ns
OR: 0.49, 95 %CI, 0.25, 0.92; P = 0.02OR: 0.49, 95 %CI, 0.25, 0.92; P = 0.02
12.8%12.8%16.1%16.1%
Nosocomial Infection Rates among Nosocomial Infection Rates among S. S. aureusaureusNasal CarriersNasal Carriers
Summary Results: CochraneSummary Results: Cochrane
Van Van RijenRijenet al. Cochrane Analysis 2008et al. Cochrane Analysis 2008
What Can We Do IntraWhat Can We Do Intra--operatively?operatively?
1. Use 1. Use periperi--operative operative antibiotics, antibiotics, perioperativelyperioperatively
and appropriatelyand appropriately
Stone HH et al. Ann Surg. 1976;184:443Stone HH et al. Ann Surg. 1976;184:443--452.452.
Does Antibiotic ProphylaxisDoes Antibiotic Prophylaxis Work? GI operationsWork? GI operations
ClassenClassen. NEJM. 1992;328:281. NEJM. 1992;328:281..
Timing of Administration of Perioperative Timing of Administration of Perioperative Prophylactic AbxProphylactic Abx
R el
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is k
R el
at iv
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Why are Timing and ReWhy are Timing and Re--dosing Important? dosing Important? Cardiac SurgeryCardiac Surgery
NoneNone
PP = .002= .002
Single vs Multiple Dose Surgical Prophylaxis: Single vs Multiple Dose Surgical Prophylaxis: Systematic ReviewSystematic Review
0.01
0.1
1
10
100
McDonald. Aust NZ J Surg 1998;68:388McDonald. Aust NZ J Surg 1998;68:388
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Do Repeat Doses Reduce the Risk of Infection? Do Repeat Doses Reduce the Risk of Infection?
•• 1548 cardiac operations longer than 240 min1548 cardiac operations longer than 240 min
•• 459 (30%) received repeat doses459 (30%) received repeat doses
•• 276 (18%) re276 (18%) re--dosed within 240 mindosed within 240 min
•• 6 additional post6 additional post--operative doses givenoperative doses given
Zanetti. Emerg Inf Dis 2001;7:828Zanetti. Emerg Inf Dis 2001;7:828
Do Repeat Doses Reduce the Risk of Infection?Do Repeat Doses Reduce the Risk of Infection?
•• 38% increase SSI rate per extra hour 38% increase SSI rate per extra hour duration of operationduration of operation
•• For procedures > 400 min reFor procedures > 400 min re--dosing dosing resulted in 56% reduction in SSIresulted in 56% reduction in SSI
•• ReRe--dosing before 240 min was more dosing before 240 min was more effective than reeffective than re--dosing after 240 min and dosing after 240 min and would have reduced total SSI rate by 16% would have reduced total SSI rate by 16% if had been done in all cases.if had been done in all cases.
ZanettiZanetti. . EmergEmergInfInf DisDis 2001;7:8282001;7:828
Are We Implementing Are We Implementing PeriPeri--operative operative Antibiotic Prophylaxis Guidelines Well?Antibiotic Prophylaxis Guidelines Well?
From Jan1, 2001 to Nov 30, 2001, From Jan1, 2001 to Nov 30, 2001, a random sample of 34,133a random sample of 34,133
Bratzler DW, Houck PM, et al. Arch Surg :2005: 140:174Bratzler DW, Houck PM, et al. Arch Surg :2005: 140:174--182182
R e
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•• Prospective surveillance 2641 patients undergoing Prospective surveillance 2641 patients undergoing cardiac surgerycardiac surgery
•• Exposure outcome: cephalosporin resistant Exposure outcome: cephalosporin resistant enterobacteriaceae and VREenterobacteriaceae and VRE
•• Prolonged antibiotic prophylaxis (>48 h) increase Prolonged antibiotic prophylaxis (>48 h) increase the risk of acquired resistance (OR 1.6, CI 1.1the risk of acquired resistance (OR 1.6, CI 1.1--2.6), 2.6), age >65 (OR 1.3, CI 1.0age >65 (OR 1.3, CI 1.0--1.6), combined 1.6), combined CABG/valve (OR 2.7, CI 1.4CABG/valve (OR 2.7, CI 1.4--5.1), antibiotics after 5.1), antibiotics after Rx (OR 1.8, CI 1.0Rx (OR 1.8, CI 1.0--3.3) 3.3)
Back to the FutureBack to the Future
The unnecessary and improper use of antibacterial The unnecessary and improper use of antibacterial agents in treatment, and particularly for agents in treatment, and particularly for
prophylaxisprophylaxis…….will have to be modified or stopped .will have to be modified or stopped completely.completely.
Maxwell Finland, 1970Maxwell Finland, 1970
2. Oxygenation2. Oxygenation----should we be should we be doing this?doing this?
Supplemental Supplemental PeriPeri--operative Oxygenoperative Oxygen
•• 4 RCT in general surgery (colorectal)4 RCT in general surgery (colorectal) •• Compared 30Compared 30--35% O35% O22 to 80% Oto 80% O22
•• Outcomes include SSI, wound healing, LOS and Outcomes include SSI, wound healing, LOS and mortalitymortality
•• Different definitions of SSI used in trialsDifferent definitions of SSI used in trials
AlAl--NiaimiNiaimi, et al. 2009 J , et al. 2009 J EvalEval ClinClin Practice; March:360Practice; March:360--55
Supplemental Supplemental PeriPeri--operative Oxygenoperative Oxygen
AlAl--NiaimiNiaimi, et al. 2009 J , et al. 2009 J EvalEval ClinClin Practice; March:360Practice; March:360--55
3. Normothermia?3. Normothermia?
Should the patient be maintained Should the patient be maintained normothermic perioperatively? normothermic perioperatively?
•• Randomized controlled trial in 200 patients with Randomized controlled trial in 200 patients with colectomy colectomy
•• Standard anesthesia and Standard anesthesia and periperi--operative antibioticsoperative antibiotics
T T ooCC SSISSI LOSLOS
HypoHypo 34.734.718/96 (19%)18/96 (19%) 14.714.7
NormoNormo 36.636.6 6/104 (6%)6/104 (6%) 12.112.1
Sutures were removed one day later in the hypothermia Sutures were removed one day later in the hypothermia groupgroup
Kurz et al 1996 NEJM;334;1209Kurz et al 1996 NEJM;334;1209
What Can We Do Intra/PostWhat Can We Do Intra/Post-- operatively?operatively?
4. Control glucose 4. Control glucose perioperativelyperioperatively
Host Risk Factors: Diabetes Mellitus and Host Risk Factors: Diabetes Mellitus and Risk of Developing an SSI?Risk of Developing an SSI?
Diabetes Diabetes Diabetes Diabetes ReferenceReference
presentpresent not presentnot present
14%14% 1.4%1.4% Cruse, 1973Cruse, 1973 25%25% 6.3%6.3% Diamond 1986*Diamond 1986* 75%75% 16%16% Nafziger,1992**Nafziger,1992**
*p=0.03*p=0.03 **p=<0.001, OR=10.5**p=<0.001, OR=10.5
Diabetes, Glucose Control, and Diabetes, Glucose Control, and SSIsSSIs After Median After Median SternotomySternotomy
Latham. ICHE 2001; 22: 607Latham. ICHE 2001; 22: 607--1212
Do Patients Get Hyperglycemic After Do Patients Get Hyperglycemic After Operations?Operations?
•• Hyperglycemia after cardiac operations Hyperglycemia after cardiac operations 48% of diabetics48% of diabetics 12% of 12% of nonnondiabeticsdiabetics 30% of all patients30% of all patients
•• 47% of hyperglycemic episodes were in 47% of hyperglycemic episodes were in nondiabeticsnondiabetics
Latham. Latham. InfInf Cont Hosp Cont Hosp EpidemiolEpidemiol. 2001;22:607. 2001;22:607 Dellinger. Dellinger. InfInf Cont Hosp Cont Hosp EpidemiolEpidemiol. 2001;22:604. 2001;22:604
FurnaryFurnary A. A. J J ThoracThoracCardiovascCardiovascSurgSurg2003;125:10072003;125:1007
Does PostDoes Post--operative Glucose Control operative Glucose Control Decrease the Risk of SSI after CABG?Decrease the Risk of SSI after CABG?
5. Rooms, Cleaning and Other 5. Rooms, Cleaning and Other StuffStuff
VentilationVentilation
Owens et al J Hosp Infection 2008; 70:3Owens et al J Hosp Infection 2008; 70:3--1010
VentilationVentilation
–– 1) turbulent with HEPA or 1) turbulent with HEPA or
–– 2) HEPA (laminar or vertical flow)2) HEPA (laminar or vertical flow)
•• OR of SSI (after hip prosthesis) laminar OR of SSI (after hip prosthesis) laminar vsvs HEPA = 1.63 HEPA = 1.63 (95%CI 1.06, 2.52)(95%CI 1.06, 2.52)
•• Adjusted OR after knee prosthesis 1.76 (0.80,3.85); Adjusted OR after knee prosthesis 1.76 (0.80,3.85); appendectomy 1.52 (0.91,2.53); appendectomy 1.52 (0.91,2.53); cholecystectomycholecystectomy1.37 1.37 (0.63, 2.97), colon surgery 0.85 (0.49, 1.49) and (0.63, 2.97), colon surgery 0.85 (0.49, 1.49) and herniorrhaphyherniorrhaphy1.48 (0.67,3.25)1.48 (0.67,3.25)
CleaningCleaning
Owens et al J Hosp Infection 2008; 70:3Owens et al J Hosp Infection 2008; 70:3--1010
What Can We Do Overall?What Can We Do Overall?
1. Pathways, checklists and 1. Pathways, checklists and ““ total programstotal programs””
Do Patient Care Pathways Work?Do Patient Care Pathways Work?
•• Before (Before (nn=808) and after (=808) and after (nn=674) evaluation of a =674) evaluation of a QA/QI initiative to improve QA/QI initiative to improve periperi--incisionalincisionalabxabx administration, tight glucose control and hair removal administration, tight glucose control and hair removal with clippers among patients undergoing CABGwith clippers among patients undergoing CABG
•• SSI decreased from 3.5% to 1.5% (SSI decreased from 3.5% to 1.5% (pp=0.001, =0.001, OR=0.21)OR=0.21)
•• Predictors of infection included DM (Predictors of infection included DM (pp=0.001, =0.001, OR=4.71), female gender (OR=4.71), female gender (pp=0.001, OR=2.83 and =0.001, OR=2.83 and wound class II (wound class II (pp=0.04, OR=2.07)=0.04, OR=2.07)
•• Limitation is the quasi experimental design without Limitation is the quasi experimental design without concurrent control groupsconcurrent control groups
TrussellTrussellet al Am J et al Am J SurgSurg2008:196;8832008:196;883--99
Do IntraDo Intra--operative Checklists Work?operative Checklists Work?
Haynes et al NEJM 2009:360;491Haynes et al NEJM 2009:360;491
••Before (Before (nn=3733) and =3733) and after (after (nn=3955) evaluation =3955) evaluation of a 19 element checklist of a 19 element checklist ••8 hospitals representing 8 hospitals representing a variety of economic a variety of economic circumstances & diverse circumstances & diverse patient populations patient populations (WHO Safe Surgery (WHO Safe Surgery Saves Lives Study Saves Lives Study Group).Group).
Do IntraDo Intra--operative Checklists Work?operative Checklists Work?
Haynes et al NEJM 2009:360;491Haynes et al NEJM 2009:360;491
Avoid RazorsAvoid Razors
Avoid HypothermiaAvoid Hypothermia
Give Correct AntibioticsGive Correct Antibiotics
Give Antibiotics at the Right Time Give Antibiotics at the Right Time
RedoseRedose Antibiotics AppropriatelyAntibiotics Appropriately
Antibiotics at 24 HoursAntibiotics at 24 Hours
****Within 60 minutes prior to incisionWithin 60 minutes prior to incisionWithin 60 minutes prior to incisionWithin 60 minutes prior to incisionWithin 60 minutes prior to incisionWithin 60 minutes prior to incisionWithin 60 minutes prior to incisionWithin 60 minutes prior to incision
FeedbackFeedback
Dear Dr. Blalock and group, Dear Dr. Blalock and group, I identified 1 SSI this week:I identified 1 SSI this week:
Patient was AQ, #3497276, admitted 7/5/2006 and Patient was AQ, #3497276, admitted 7/5/2006 and operated on the same day for a operated on the same day for a laminectomylaminectomy and spinal fusion. He/she had an infection onset and spinal fusion. He/she had an infection onset of 7/10/2006of 7/10/2006--and returned to the OR after and returned to the OR after readmission 7/28/2006. A complex wound readmission 7/28/2006. A complex wound closure was required. A culture obtained during closure was required. A culture obtained during the I & D grew the I & D grew Enterococcus Enterococcus faecalisfaecalis (VSE) and (VSE) and Staphylococcus aureusStaphylococcus aureus (MSSA). We classified (MSSA). We classified this as a deep infection.this as a deep infection.
Surgical Procedure XSurgical Procedure X 2004 2004 ––20072007
So where do we go from here?So where do we go from here?
Closing ThoughtsClosing Thoughts
•• SSI are associated with significant morbidity and costsSSI are associated with significant morbidity and costs •• Process of care data is critical to best identify areas to Process of care data is critical to best identify areas to
interveneintervene •• Evidence based best practice should be implemented.Evidence based best practice should be implemented.
–– Appropriate use of Appropriate use of perioperativeperioperativeprophylaxisprophylaxis –– Glucose controlGlucose control –– Temperature controlTemperature control –– Appropriate skin preparationAppropriate skin preparation----hair and cleansinghair and cleansing –– ? Oxygenation? Oxygenation –– DecolonizationDecolonization
•• Novel interventions and ideas need to be identified and tested Novel interventions and ideas need to be identified and tested given public reportinggiven public reporting
•• We must work together.We must work together.