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Today’s Webinar will begin at Today’s Webinar will begin at 11:00 PST11:00 PST
4/12/12
Welcome from Barb DeBaun, RN, MSN, CIC
IntroductionIntroduction
Please do not put your phone on hold; use Please do not put your phone on hold; use the mute function or *6the mute function or *6
Please type questions or comments into Please type questions or comments into text boxtext box
Interactive question sessionInteractive question session
If time permits, we will open up the phone If time permits, we will open up the phone lines at the conclusion of the presentationlines at the conclusion of the presentation
Introducing Sue Barnes, RN, Introducing Sue Barnes, RN, BSN, CICBSN, CIC
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Beyond SCIP – SSI Prevention
Sue Barnes RN, BSN, CIC National Program Leader
Infection Prevention & Control Kaiser Permanente
ObjectivesObjectives
1.1. Discuss strategies to optimize 4 Discuss strategies to optimize 4 specific SCIP measures, beyond specific SCIP measures, beyond regulatory complianceregulatory compliance
2.2. Discuss 11 products and practices Discuss 11 products and practices above and beyond SCIP – i.e. “plus” above and beyond SCIP – i.e. “plus” measuresmeasures
3.3. Provide resources and references Provide resources and references relative to “plus” measuresrelative to “plus” measures
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SCIP Measures
http://intranet.uchicago.edu/quality/SCIP_files/page0001.htm
SCIP INF 1 Prophylactic antibiotic received within one hour prior to surgical incision
SCIP INF 2 Prophylactic antibiotic selection for surgical patients SCIP INF 3 Prophylactic antibiotics discontinued within 24 hours
after surgery end time (48 hours for cardiac patients) SCIP INF 4 Cardiac surgery patients with controlled 6 a.m. post
op serum glucose (200 mg/dL) SCIP INF 6 Surgical patients with appropriate hair removal SCIP INF 7 Colorectal surgical patients with immediate
postoperative normothermia SCIP INF 9 Urinary catheter removed on post op day 1 SCIP INF 10 Surgery patients with perioperative temperature
management
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3 grams Ancef for Bariatric Patients3 grams Ancef for Bariatric Patients
1. Freeman JT, Anderson DJ, Hartwig MG, Sexton DJ. “Surgical site infections following bariatric surgery in community hospitals: a weighty concern?” Obes Surg. 2011 Jul;21(7):836-40.
2. Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston CE Jr. “Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery”. Obstet Gynecol. 2011 Apr;117(4):877-82.
3. Roe JL, Fuentes JM, Mullins ME. “Under dosing of common antibiotics for obese patients in the ED”. Am J Emerg Med. 2011 Dec 12. [Epub ahead of print]
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SAFE Pre-op Hair RemovalRemoval outside of OR or clipper with vacuumPre op patient teaching no leg shavingDisposable clipper head or reprocess b/w
patients
1. Adisa AO, Lawal OO, Adejuyigbe O. “Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection”. J Infect Dev Ctries. 2011 Oct 13;5(10):717-22.
2. Broekman ML, van Beijnum J, Peul WC, Regli L. “Neurosurgery and shaving: what's the evidence?” J Neurosurg. 2011 Oct;115(4):670-8. Epub 2011 Jul 1.
3. Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N, Demartines N. “Measures to prevent surgical site infections: what surgeons (should) do”. World J Surg. 2011 Feb;35(2):280-8.
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Unless your patient looks like this, consider NOT clipping hair
Mangram AJ et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp
Epidemiol 1999; 20:250‐278; quiz 279‐280.
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Normothermia
1. Esnaola NF, Cole DJ. “Perioperative normothermia during major surgery: is it important?” Adv Surg. 2011;45:249-63.
2. Hart SR, Bordes B, Hart J, Corsino D, Harmon D. “Unintended perioperative hypothermia”. Ochsner J. 2011 Fall;11(3):259-70.
3. Moola S, Lockwood C. “Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment”. Int J Evid Based Healthc. 2011 Dec;9(4):337-45.
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Glucose Control = minimizing extremes
1. Chi A, Lissauer ME, Kirchoffner J, Scalea TM, Johnson SB. “Effect of glycemic state on hospital mortality in critically ill surgical patients”. Am Surg. 2011 Nov;77(11):1483-9.
2. Martinez EA, Chavez-Valdez R, Holt NF, Grogan KL, Khalifeh KW, Slater T, Winner LE, Moyer J, Lehmann CU. “Successful implementation of a perioperative glycemic control protocol in cardiac surgery: barrier analysis and intervention using lean six sigma”. Anesthesiol Res Pract. 2011;2011:565069. Epub 2011 Sep 6.
3. Pichardo-Lowden A, Gabbay RA. “Management of Hyperglycemia During the Perioperative Period”. Curr Diab Rep. 2011 Nov 12. [Epub ahead of print]
4. Stawicki S, Schuster D, Liu J, Kamal J, Erdal S, Gerlach A, Whitmill M, Lindsey D, Murphy C, Steinberg S, Cook C. “The glucogram: A new quantitative tool for glycemic analysis in the surgical intensive care unit”. Int J Crit Illn Inj Sci. 2011 Jan;1(1):5-12.
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“Plus” Measures for SSI Prevention
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Eliminate or cover cloth skull cap when in surgery
Double gloving Change sterile gloves
before closing Permit ONLY scrubs
laundered by hospital Red caps for visitors
Attire - SurgicalAttire - Surgical
Double GlovingDouble Gloving: : Phillips S. “The comparison of double gloving . “The comparison of double gloving to single gloving in the theatre environment.”to single gloving in the theatre environment.” J Perioper Pract. 2011 Jan;21(1):10-5. 2011 Jan;21(1):10-5.
Changing glovesChanging gloves: : Epstein NE. “Preoperative, intraoperative, . “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections.” and postoperative measures to further reduce spinal infections.” Surg Neurol Int. 2011 Feb 21;2:17. 2011 Feb 21;2:17.
Hair coverageHair coverage : :Frey K, Ross T. eds. Frey K, Ross T. eds. Surgical Technology for the Surgical Technology for the Surgical Technologist: A Positive Care ApproachSurgical Technologist: A Positive Care Approach. 3rd ed. Clifton . 3rd ed. Clifton Park, NY: Delmar Cengage; 2008.Park, NY: Delmar Cengage; 2008.
ScrubsScrubs: Belkin NL. Home laundering of soiled surgical scrubs. : Belkin NL. Home laundering of soiled surgical scrubs. American Journal of Infection ControlAmerican Journal of Infection Control. 2001; . 2001; 2929: 58-64.: 58-64.
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Attire - SurgicalAttire - Surgical
Blood – Minimizing TransfusionsBlood – Minimizing Transfusions
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Blood - Minimizing TransfusionsBlood - Minimizing Transfusions
1.1. Young H. Et al. “Statewide collaboration to evaluate the effects of Young H. Et al. “Statewide collaboration to evaluate the effects of blood loss and transfusion on surgical site infection after blood loss and transfusion on surgical site infection after hysterectomy”. ICHE Jan 2012, Vol. 33, No 1 pp 90-93.hysterectomy”. ICHE Jan 2012, Vol. 33, No 1 pp 90-93.
2.2. Schwarzkopf R et al. “Effects of Perioperative Blood Product Use Schwarzkopf R et al. “Effects of Perioperative Blood Product Use on Surgical Site Infection Following Thoracic and Lumbar Spinal on Surgical Site Infection Following Thoracic and Lumbar Spinal Surgery”. Surgery”. Spine.Spine. 2010;35(3):340-346. 2010;35(3):340-346.
3.3. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and predisposing factors. the incidence, timing, and predisposing factors. Clin Orthop Relat Clin Orthop Relat ResRes. 2008; 466(7):1710-1715.. 2008; 466(7):1710-1715.
4.4. Talbot TR et al. “Perioperative Blood Transfusion Is Predictive of Talbot TR et al. “Perioperative Blood Transfusion Is Predictive of Poststernotomy Surgical Site Infection: Marker for Morbidity or Poststernotomy Surgical Site Infection: Marker for Morbidity or True Immunosuppressant?” True Immunosuppressant?” Clinical Infectious DiseasesClinical Infectious Diseases 2004; 2004; 38:1378–8238:1378–82
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Drains, Drapes, DressingsDrains, Drapes, Dressings
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Drains, Drapes and DressingsDrains, Drapes and Dressings
1.1. DRESSING - DRESSING - Epstein NE. “Preoperative, intraoperative, and . “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections.” postoperative measures to further reduce spinal infections.” Surg Neurol Int. 2011 Feb 21;2:17. 2011 Feb 21;2:17.
2.2. DRESSING - DRESSING - Krieger BR, , Davis DM, , Sanchez JE, , Mateka JJ, , Nfonsam VN, , Frattini JC, , Marcet JE. “The use of silver nylon dressing in . “The use of silver nylon dressing in preventing surgical site infections following colon and rectal surgery”. preventing surgical site infections following colon and rectal surgery”. Dis Colon Rectum. 2011 Aug;54(8):1014-9. 2011 Aug;54(8):1014-9.
3.3. DRAINS - DRAINS - Rao SB, , Vasquez G, , Harrop J, , Maltenfort M, , Stein N, , Kaliyadan G, , Klibert F, , Epstein R, , Sharan A, , Vaccaro A, , Flomenberg P. . “Risk factors for surgical site infections following spinal fusion “Risk factors for surgical site infections following spinal fusion procedures: a case-control study”. procedures: a case-control study”. Clin Infect Dis. 2011 Oct;53(7):686-92. 2011 Oct;53(7):686-92.
4.4. DRAPE - DRAPE - Kramer A, , Assadian O, , Lademann J. “Prevention of . “Prevention of postoperative wound infections by covering the surgical field with iodine-postoperative wound infections by covering the surgical field with iodine-impregnated incision drape (Ioban 2)”. impregnated incision drape (Ioban 2)”. GMS Krankenhhyg Interdiszip. 2010 Sep 21;5(2). 2010 Sep 21;5(2).
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Hand Scrub – Brushless & Dual AgentHand Scrub – Brushless & Dual Agent
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Olson LK et al. “Prospective, randomized in vivo Olson LK et al. “Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand two alcohol-only waterless antiseptics for surgical hand antisepsis”. antisepsis”. American Journal of Infection Control Volume 40, Issue 2, March 2012, Pages 155–159., March 2012, Pages 155–159.
Usavadee Asdornwised “An Evaluation of Brush, Usavadee Asdornwised “An Evaluation of Brush, Brushless, and Waterless Surgical Hand Scrubs among Brushless, and Waterless Surgical Hand Scrubs among Health Care Workers in Operating Rooms at a University Health Care Workers in Operating Rooms at a University Hospital in Thailand “. J Nurs Sci Vol.29 No.3 July-Hospital in Thailand “. J Nurs Sci Vol.29 No.3 July-September 2011.September 2011.
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Hand Scrub - Brushless & Dual Agent Hand Scrub - Brushless & Dual Agent
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Irrigation: Intra-operative
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Irrigation: Intra-operative
1.COPIOUS IRRIGATION - Watanabe M, Sakai D, Matsuyama D, Yamamoto Y, Sato M, Mochida J. “Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation”. J Neurosurg Spine. 2010 May;12(5):540-6.2.CHG - Han Y, Giannitsios D, Duke K, Steffen T, Burman M. “Biomechanical analysis of chlorhexidine power irrigation to disinfect contaminated anterior cruciate ligament grafts”. Am J Sports Med. 2011 Jul;39(7):1528-33. 3.PULSATILE - Nikfarjam M, Kimchi ET, Gusani NJ, Avella DM, Shereef S, Staveley-O'Carroll KF. “Reduction of surgical site infections by use of pulsatile lavage irrigation after prolonged intra-abdominal surgical procedures”. Am J Surg. 2009 Sep;198(3):381-6. 4.OPHTHALMOLOGY - Fernandes M, Pathengay A. “Reduction of anterior chamber contamination rate after cataract surgery by intraoperative surface irrigation with 0.25% povidone-iodine”. Am J Ophthalmol. 2011 Aug;152(2):320; author reply 320-1.
OR ObservationsOR Observations
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“Almost no matter what experimental conditions were imposed, increases in output occurred….The investigators had obviously influenced the
subjects’ behavior merely by studying that behavior, and this phenomenon has become known as the Hawthorne effect.” (Kelly Shaver, Principles of
Social Psychology, 2nd ed., Winthrop, 1981)
Oxygen - SupplementalOxygen - Supplemental
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Qadan M, , Akça O, , Mahid SS, , Hornung CA, , Polk HC Jr. . “Perioperative supplemental oxygen therapy and “Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized surgical site infection: a meta-analysis of randomized controlled trials.” controlled trials.” Arch Surg. 2009 Apr;144(4):359-66; 2009 Apr;144(4):359-66; discussion 366-7.discussion 366-7.
James T. Lee, MD, PhD “Supplemental Oxygen and , MD, PhD “Supplemental Oxygen and Risk of Surgical Site Infection”JAMA Risk of Surgical Site Infection”JAMA 2004;291(16):1957-1958. 2004;291(16):1957-1958.
Hopf H, Hunt T, Rosen N. “Supplemental Oxygen and Hopf H, Hunt T, Rosen N. “Supplemental Oxygen and Risk of Surgical Site Infection”. Risk of Surgical Site Infection”. JAMA. 2004;291(16):1956.JAMA. 2004;291(16):1956.
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OO2 2 - Supplemental- Supplemental
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Estimates of costs/mortality associated with infections
Skin Antisepsis
Skin AntisepsisSkin Antisepsis
1.1. SKINSKIN - - Lee I, , Agarwal RK, , Lee BY, , Fishman NO, , Umscheid CA. “Systematic . “Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection”. preoperative skin antisepsis to prevent surgical site infection”. Infect Control Hosp Epidemiol. 2 2010 Dec;31(12):1219-29. 010 Dec;31(12):1219-29.
2.2. SKINSKIN-- Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM, Connor Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM, Connor DL, Lee I, Muder RR, Lee BY DL, Lee I, Muder RR, Lee BY Economic value of dispensing home-based preoperative chlorhexidine bathing cloths to prevent surgical site infection. Infect Control Hosp Epidemiol. 2011 May;32(5):465-71. Infect Control Hosp Epidemiol. 2011 May;32(5):465-71.
3.3. NASALNASAL - - Pofahl WE, , Ramsey KM, , Nobles DL, , Cochran MK, , Goettler C. . “Importance of methicillin-resistant Staphylococcus aureus eradication in “Importance of methicillin-resistant Staphylococcus aureus eradication in carriers to prevent postoperative methicillin-resistant Staphylococcus aureus carriers to prevent postoperative methicillin-resistant Staphylococcus aureus surgical site infection”. surgical site infection”. Am Surg. 2011 Jan;77(1):27-31. 2011 Jan;77(1):27-31.
4.4. ORALORAL - - Segers P, , Speekenbrink RG, , Ubbink DT, , van Ogtrop ML, , de Mol BA. . “Prevention of nosocomial infections after cardiac surgery by decontamination “Prevention of nosocomial infections after cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine; a prospective, of the nasopharynx and oropharynx with chlorhexidine; a prospective, randomised study”. randomised study”. Ned Tijdschr Geneeskd. 2008 Mar 29;152(13):760-7.2008 Mar 29;152(13):760-7.
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Skin Antisepsis: Pre-op bathing with CHG cloths
Also used as pre-op skin prep for emergency C-sections
Skin ClosureSkin Closure
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Skin Closure
1. Fraeman KH, Reynolds MW, Vaughn BB, Hart JC. “Patient outcomes associated with 2-octyl cyanoacrylate topical skin adhesive in coronary artery bypass graft surgery”. Surg Infect (Larchmt). 2011 Aug;12(4):307-16.
2. Singer AJ, Chale S, Giardano P, Hocker M, Cairns C, Hamilton R, Nadkarni M, Mills AM, Hollander JE. “Evaluation of a novel wound closure device: a multicenter randomized controlled trial”. Acad Emerg Med. 2011 Oct;18(10):1060-4.
3. Iyer A, Gilfillan I, Thakur S, Sharma S. “Reduction of surgical site infection using a microbial sealant: a randomized trial”. J Thorac Cardiovasc Surg. 2011 Aug;142(2):438-42..
4. Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ. “Randomized trial of antimicrobial-coated sutures to prevent surgical site infection after breast cancer surgery”.Surg Infect (Larchmt). 2011 Dec;12(6):469-74.
Reducing Traffic in the ORReducing Traffic in the OR
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Reducing OR TrafficReducing OR Traffic
1. Dunbar MJ, , Richardson G. “Minimizing infection risk: . “Minimizing infection risk: fortune favors the prepared mind.”fortune favors the prepared mind.”Orthopedics. 2011 Sep 2011 Sep 9;34(9):e467-9. 9;34(9):e467-9.
2. Lynch RJ, , Englesbe MJ, , Sturm L, , Bitar A, , Budhiraj K, , Kolla S, , Polyachenko Y, , Duck MG, , Campbell DA Jr. . “Measurement of foot traffic in the operating room: “Measurement of foot traffic in the operating room: implications for infection control”. implications for infection control”. Am J Med Qual. 2009 2009 Jan-Feb;24(1):45-52.Jan-Feb;24(1):45-52.
3. Young RS, , O'Regan DJ. “Cardiac surgical theatre traffic: . “Cardiac surgical theatre traffic: time for traffic calming measures?” time for traffic calming measures?” Interact Cardiovasc Thorac Surg. 2010 Apr;10(4):526-9. 2010 Apr;10(4):526-9.
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Wound edge protectorWound edge protector
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Wound Edge ProtectorWound Edge Protector
1. Green C, , Molony D, , Cashman J, , Burke T, , Masterson E. . “Another string.... but no bow”. “Another string.... but no bow”. Acta Orthop Belg. 2011 2011 Apr;77(2):258-9.Apr;77(2):258-9.
2. Kadowaki Y, , Kurokawa T, , Tamura R, , Okamoto T, , Ishido N, , Mori T. “Lap-Protector and Circular Stapler Are Useful in . “Lap-Protector and Circular Stapler Are Useful in Cystogastrostomy for Large Pancreatic Pseudocyst with Cystogastrostomy for Large Pancreatic Pseudocyst with Severe Infection”. Severe Infection”. Case Rep Gastroenterol. 2010 Jul 2010 Jul 21;4(2):215-219.21;4(2):215-219.
3. Nakamura Y, , Matsumoto S, , Tajiri T, , Uchida E. “A safe . “A safe technique for laparoscopic distal pancreatectomy involving a technique for laparoscopic distal pancreatectomy involving a large cystic tumor”. large cystic tumor”. J Nihon Med Sch. 2011;78(6):374-8. 2011;78(6):374-8.
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1. AORN/APIC ASC Toolkit/library contents http://www.aboutinfectioncontrol.com/SubWebs/APIC/MAIN_Toolkits.htm
2. APIC Cost Calculator http://www.apic.org/Content/NavigationMenu/PracticeGuidance/GuidelinesStandards/TMIT_V1_CostCalculator02082011.xls
3. APIC/SHEA Compendium http://www.shea-online.org/GuidelinesResources/CompendiumofStrategiestoPreventHAIs.aspx
4. KP Patient Story Video Clip http://nursingpathways.kp.org/national/quality/infectioncontrol/toolkit/index.html
5. KP Infection Prevention “Plus Measures” Toolkit http://nursingpathways.kp.org/national/quality/infectioncontrol/toolkit/index.html
RESOURCES:
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Surgical Site Infection (SSI) Prevention The following standard bundle of prevention measures (supported by category 1 level evidence) are recommended in: SHEA/APIC Compendium: http:/ /www.shea-online.org/about/ compendium.cfm IHI How To Guide: http:/ /www.IHI SSI Prevention How To Guide
1. Appropriate use of antibiotics 2. Appropriate use of prophylactic antibiotics 3. Appropriate hair removal 4. Controlled 6 AM postoperative serum glucose in cardiac surgery patients 5. Immediate postoperative normothermia for colorectal surgery patients 6. Pre op antiseptic shower category (1B HICPAC guidelines SSI Prevention)
If zero infections have not sustained, consider adding one or more of the following “PLUS” prevention measures (less than category 1 level evidence): DOUBLE CLICK ON ICONS IN TABLE BELOW TO OPEN EMBEDDED DOCUMENTS
Measure
References Product Order Info Tools
1. Antibiotic prophylaxis: A. For Bariatric surgery use 3 grams
ancef routinely instead of 2 pre-operatively A
3 gms ancef references 2012.doc
N/A N/A
2. Antisepsis – skin and oral: A. Surgical skin prep:
Chlorhexidine/alcohol (Chloraprep) B. Pre op CHG (chlorhexidine) bathing
cloths C. Decolonization MRSA - test and
decolonize + MRSA patients prior to high risk procedures
ACHG skin prep
2012.doc
BCHG Cloths 2012.doc
C Decolonization
references 2012 .doc
A CHG skin prep: http:/ /www.chloraprep.com/
B CHG cloth product info: http:/ /www.Sage CHG Cloths
C Mupirocin: KP pharmacy 3M Nasal Antiseptic:
3M™ Skin and Nasal Antiseptic (Povidone-
Patient instructions CHG Cloths
C:\Documents and Settings\DNSSAB\My Documents\My Documents\PDF Docs\PDF Docs\IHI\Plus Measures Toolkit\NW region CHG pt instructions.pdf Decolonization Guidelines
C:\Documents and Settings\DNSSAB\My Documents\My Documents\Word Docs A-P\MRO\Guidelines\MRSA Decolonization Regional ID Chiefs Aug 2006.doc
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Thanks for your time!Any Questions?
Next Beyond SCIP Webinar Next Beyond SCIP Webinar
May 17May 17th: th: 12:30-1:30 PST 12:30-1:30 PST
Pascal Fuchshuber, MD, PhD, FACSPascal Fuchshuber, MD, PhD, FACS
The Power of NSQIP data to drive change The Power of NSQIP data to drive change and improvementand improvement
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Cynosure Quality Swap MeetCynosure Quality Swap MeetMay 21, 2012May 21, 2012
www.cynosurehealth.org
Thanks for joining us todayThanks for joining us today
