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Surgical Site Infections: Preparing Our Patients For Surgery

Surgical Site Infections: Preparing Our Patients For Surgery

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Page 1: Surgical Site Infections: Preparing Our Patients For Surgery

Surgical Site Infections:Preparing Our Patients For Surgery

Page 2: Surgical Site Infections: Preparing Our Patients For Surgery

Our Last Call Together• Three problems that sit at the core of surgical

site infections– Doing reliably what we know needs to be done– Teamwork and communication– Always being vigilant about keeping the patient

safe• The South Carolina Surgical Safety Checklist

as a drug

Page 3: Surgical Site Infections: Preparing Our Patients For Surgery

Preventing SSI’sPre-Incision Incision/Surgery Post Op

Patient

• Basics of Skin Prep

• Showers• Skin Wipes

• Hair Removal• Weight Based

Dosing• MRSA Screening • Glucose Control

• Glucose Control• Hyperoxia

• Wound care• Dressings

Operation

• Antibiotic• Bowel Prep

• Re-dosing• Operating Time• Use of Tourniquet• Surgical Technique• Wound protectors

Environment

• Basics of Sterility• Instrument Sterility• Hand Hygiene• Temperature

Control• Teamwork• Culture

• Basics of Sterility• Instrument Sterility• Hand Hygiene• OR Traffic• Temperature Control• Teamwork• Culture

• Discontinue antibiotics

• Teamwork• Culture

Page 4: Surgical Site Infections: Preparing Our Patients For Surgery

Todays Topics• Chlorhexidine Wipes• Preoperative Bacterial Screening• Keeping Your Patient Warm• Alcohol-Based Skin Preps

Page 5: Surgical Site Infections: Preparing Our Patients For Surgery

Chlorhexidine Wipes:Common Sense Science

• Bacteria on the skin is bad. Wiping the skin with chlorehexidine could be good

• Started in the ICU when patients who bathed with chlorexidine impregnated cloths on a daily basis developed fewer bloodstream infections

• Patients are less likely to develop a SSI if they use wipes the night and morning before their procedure1

• 50% overall reduction in SSI in orthopaedic surgery1

• Studies show that even if patients are not fully compliant wipes still can have an impact2

1. Eiselt. Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical Patients. Orthopaedic Nursing. 2009; 28: 141-145 .2. Zywiel et al. Advance pre-operative chlorhexidine reduces the incidence of surgical infections in knee arthroplasty. International Orthopaedics. 2011; 35; 1001-1006.

Page 6: Surgical Site Infections: Preparing Our Patients For Surgery

Useful Resources

The Institute for Healthcare

Improvement has examples of patient

materials for preparing skin before surgery

http://www.ihi.org/knowledge/Pages/Tools/PreparingYourSkinBeforeSurgeryPatientInstructionsSSI.aspx

Page 7: Surgical Site Infections: Preparing Our Patients For Surgery

Preoperative Bacterial Screening:Common Sense Science

• Patients who carry Staphylococcus aureus (SA) are more likely to develop a surgical site infection

• Patients should be screened prior to surgery

• Schedule the screening so there is enough time to kill the bacteria

How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)

Page 8: Surgical Site Infections: Preparing Our Patients For Surgery

S. Aureus Nasal Carriage

Kluytmans. Clin Microbiol Rev 1997; 10:505

Persistent carriersAlways carry one strain of S.

aureus20%

Intermittent carriersCarry different strains of S.

aureus intermittently60%

Noncarriers 20%

Page 9: Surgical Site Infections: Preparing Our Patients For Surgery

S. Aureus Nasal CarriageUsual PrevalencePopulation Percentage

General population 20%

Health care workers 27%

Patients on admission 36%

Patients on insulin 56%

Hemodialysis patients 52%

Chronic renal failure 21%

I.V. drug users 55%

Kluytmans. Clin Microbiol Rev 1997; 10:505

Page 10: Surgical Site Infections: Preparing Our Patients For Surgery

Useful Resources

The Institute for Healthcare

Improvement has sample tools for

educating patients

http://www.ihi.org/knowledge/Pages/Tools.aspx

Page 11: Surgical Site Infections: Preparing Our Patients For Surgery

Keeping Your Patient Warm: Common Sense Science

• Human beings are warm-blooded• The body fights infection better when it is

warm• The operating room is a cold place• Keeping patients warm can be a challenge• The best thing to do is to never let your

patient get cold

Page 12: Surgical Site Infections: Preparing Our Patients For Surgery

Redistribution Hypothermia

Core37°C

Vasoconstricted

Periphery31-35°C

Anesthesia

Periphery33-35°C

Core36°C

VasodilatedDellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012 .

Page 13: Surgical Site Infections: Preparing Our Patients For Surgery

Perioperative Warming, Intraoperative Temperature and

Complications

Wong. Br J Surgery 2007; 94: 423-6

PeriopN=47

StandardN=56

P Value

Blood loss 200 ml 400 ml 0.011

Any complication 32% 54% 0.027

SSI 13% 33% 0.09

Page 14: Surgical Site Infections: Preparing Our Patients For Surgery

Temperature and SSI Following Colectomy

Kurz. NEJM 1996;334:1209

Normo (104)

Hypo(96)

P Value

SSI 6 18 .009

Page 15: Surgical Site Infections: Preparing Our Patients For Surgery

Keep your patient warm before they go to surgery

• It is like “money in the bank”• Use warming blankets before they go into

the OR• Think about putting a hat on your patient

Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. .

Page 16: Surgical Site Infections: Preparing Our Patients For Surgery

Keeping Your Patient Warm in the O.R.

• Pre-warming and active warming in the OR is much more important than the OR room temperature

• Put warming blankets under and over your patient on the operating table (if possible)

• Use warmed fluids for IVs• Use warm irrigation on the field (if possible)

Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. .

Page 17: Surgical Site Infections: Preparing Our Patients For Surgery

Alcohol-Based Skin Preps: Common Sense Science

• The combination of alcohol together with another agent is probably better because there are two things killing the bacteria

• An antibacterial prep that lasts on the skin is better than one that doesn’t1

• If you don’t let the prep dry or wipe it off it can’t work because it is not on the skin anymore

1. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18-26.2. Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infectionrates: A prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol.

Page 18: Surgical Site Infections: Preparing Our Patients For Surgery

No skin prep will be effective if you don’t use it the way that

you are supposed to• Let the prep completely dry prior to draping• Avoid pooling of the skin prep

How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012

Page 19: Surgical Site Infections: Preparing Our Patients For Surgery

Take Home MessagesPre-Incision Incision/Surgery Post Op

Patient

• Basics of Skin Prep

• Showers• Skin Wipes

• Hair Removal• Weight Based

Dosing• MRSA Screening • Glucose Control

• Glucose Control• Hyperoxia

• Wound care• Dressings

Operation

• Antibiotic• Bowel Prep

• Re-dosing• Operating Time• Use of Tourniquet• Surgical Technique• Wound protectors

Environment

• Basics of Sterility• Instrument Sterility• Hand Hygiene• Temperature

Control• Teamwork• Culture

• Basics of Sterility• Instrument Sterility• Hand Hygiene• OR Traffic• Temperature Control• Teamwork• Culture

• Discontinue antibiotics

• Teamwork• Culture

Page 20: Surgical Site Infections: Preparing Our Patients For Surgery

??Questions

Page 21: Surgical Site Infections: Preparing Our Patients For Surgery

Upcoming Calls

Thursday, June 13th 2:00-2:45Preventing VTE’s in Surgical Patients

Thursday, June 27th 2:00-2:45Other Ways of Preventing Venous

Thromboembolism

Page 22: Surgical Site Infections: Preparing Our Patients For Surgery

Office Hours:Wednesday 2:00-3:00

Page 23: Surgical Site Infections: Preparing Our Patients For Surgery

Resources

Website:www.safesurgery2015.org

Email: [email protected]