Cuts Like a New Knife - Current Practice and Emerging Evidence in Preventing Surgical Site Infections

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Cuts Like a New Knife - Current Practice and Emerging Evidence in Preventing Surgical Site Infections


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Host and Presenters

Marlies van Dijk Dr. Claude Laflamme

Paule Bernier Anne MacLaurin Nadine Glenn

Dr. Giuseppe Papia

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Greetings from CPSI

6

Kim Stelmacovich, Senior Director

Patient Safety Forward with Four

• The Canadian Patient Safety Institute has a new 2013-2018

Business Plan • Four goals to move us forward • Four Clinical Priority Areas • http://www.patientsafetyinstitute.ca/English/About/PatientSafety

ForwardWith4/Pages/default.aspx?utm_source=CPSI&utm_medium=HomeSideAd&utm_campaign=ForwardWithFour

http://www.patientsafetyinstitute.ca/English/About/PatientSafetyForwardWith4/Pages/default.aspx?utm_source=CPSI&utm_medium=HomeSideAd&utm_campaign=ForwardWithFour



Forward with Four

Four goals Provide leadership on the

establishment of a National Integrated Patient Safety Strategy

Inspire and sustain patient safety knowledge within the system, and through innovation, enable transformational change

Build and influence patient safety capability at organizational and system levels

Engage all audiences across the health system in the national patient safety agenda

Four Clinical Priority Areas 1. Medication safety 2. Surgical care safety 3. Infection Prevention &

Control 4. Home care safety

SSI Prevention Emerging Evidence

Claude Laflamme MD, FRCPC, MHSc Medical Director, Cardiac Anesthesia Sunnybrook Health Sciences Centre

Assistant Professor University of Toronto

Disclosure • Charles E. Edmiston Jr., PhD., CIC,

Milwaukee • Frank Mazza, Vice President/Chief Patient

Safety Officer Associate Chief Medical Officer Seton Family of Hospitals, Austin

• Paula Mendes, RN, CPN(c) Perioperative Professional Services

Specialist, 3M, London

© 3M 2013. All Rights Reserved

AIPI 2013

Updated Recommendations for SSI Prevention

• Annals of Surgery June 2011 • Recommendations from CDC 1999 • Review of current literature has been done to update the

recommendations • Adherence to the proposed guidelines could reduce wound

infections significantly. – Target of less than 0.5% in clean wounds – Target of less than 1% in clean-contaminated wounds – Target of less than 2% in highly contaminated wounds – Decrease costs to less than one-half of the current amount

Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

Multiple factors play a Role in SSI (CDC)

• Reduction in contamination (asepsis) OR environment • Preoperative bathing with antiseptic agents • Hair Removal • Skin decontamination • Incise drapes • Reduction in consequences of contamination (antisepsis) sutures

– Suture composition

• Tissue damage and foreign bodies – Use of electrocautery

• Drains – Drains that exit through a working incision increases SSI


Multiple factors play a Role in SSI • Prophylactic topical antimicrobials

– Topical antibiotics are effective – Using other antimicrobials (PI/CHG) to decontaminate wounds are not

effective and has been shown to inhibit wound healing and increase SSI.

• Systemic prophylactic antibiotics – Preoperative antibiotics is among the most important of the currently

available methods to prevent SSI. – 30 min before incision except for vancomycin (1-2 hours before

incision) – Redosing is important (short acting, body size, and renal function)

• Improvement of host defense influence of body temperature


Multiple factors play a Role in SSI • Effect of oxygen therapy

– O2 should start with induction, but optimal concentrations and duration of therapy have not been established. Current data suggests it should be given at least 2 hrs after closure.

• Glucose control – Hyperglycemia is a risk factor for SSI independent of diabetes. – Close monitoring is essential.

• Transfusions and fluid management – Blood transfusions increase the risk of infection in surgical patients.

• Smoking – Increases surgical wound infection

• Delayed primary closure – Benefit of delayed primary closure in highly contaminated wounds


Reduction in Contamination (Asepsis) OR Environment

• CDC guidelines and regulations from various accrediting agencies are good resources for providing details related to effective techniques – Air handling (HEPA filters, Laminar Air flow) – Cleaning of environmental surfaces – Sterilization techniques – Activities of surgical team members (limit traffic and idle conversations) – Surgical attire (perforations of surgical gloves are major source of

contamination, and gown strike-through – sleeves/abd area also a potential source)

– Drapes – Asepsis

• The above should be regarded as recommendations set in stone.


Preoperative Bathing with Antiseptic Agents

• Infections in clean surgery are most often caused by skin organisms

• Preoperative bathing with chlorhexidine – Reduces pathogenic organisms on the skin but has a non-significant

reduction in wound infections • Chlorhexidine

– Shown to reduce the number of organisms at the incision site better than using povidone iodine or soap and water

– Showering the night before and the morning of surgery is more effective in colony reduction than a single shower

• Cleansing with a chlorhexidine impregnate cloth just before operation will provide additional removal of dirt and further reduction in skin bacteria


Presurgical Skin Preparations as a Pathway

to Improving Surgical Outcomes • Reducing the risk of SSI in orthopaedic surgery

• Standardized precleansing initiative (CHG cloths) in total joint patients (night before/morning of surgery)

• SSI rate prior to intervention – 3.2% (N=727) • SSI rate post intervention – 1.6% (N=824) 50% reduction

Eiselt – Orthopaedic Nursing 2009;28:141-145

• Bundling risk reduction strategies – Quality initiative • MRSA prescreening in orthopaedic, obstetric, bariatric patients

– decolonization • Presurgical antisepsis (CHG cloths) prior to surgery • Preintervention SSI rate 1.6% (N=17/1,095) vs postintervention

SSI rate 0.57% (N=7/1,225 ) >60% reduction

• MRSA SSI rate 0.73% vs 0.16% >75% reduction Lipke VL, Hyott AS. AORNJ 2010’;62:288-296

Best Practice # 1: All patients undergoing an elective surgical procedure will take at least 2 CHG antiseptic shower/cleansings using a standardized regimen

Hair Removal

• NOT removing hair is associated with least infection • When it is deemed by the surgeon that hair should be

removed, shaving should never be used • Clipping the hair with care to avoid skin damage is to be the

most satisfactory method • Most studies support hair removal done immediately before

operation – Associated with lower infection rate


Skin Decontamination • Alcohol

– Used as a skin disinfectant for more than 150 years – Remains the most effective short-term antimicrobial but it is highly

flammable – Provides no persistent antimicrobial activity

• Chlorhexidine is more effective in reduction of skin bacterial vs. povidone iodine – Chlorhexidine and alcohol provide even better reduction of bacteria

• Hand scrubs – Using a chlorhexidine/alcohol based product will provide the greatest

reduction in skin bacteria • The best reduction in microbes at the operative site seems to be with

an iodine povacrylex/alcohol or chlorhexidine/alcohol based products


Antiseptic Skin Preparation

SHN RECOMMENDATIONS • To maximize its efficacy, CHG alcohol skin prep should not be

washed off following surgery. • In order to prevent a fire hazard, it is imperative that CHG-

alcohol skin prep be allowed to air dry for at least 3 minutes, or longer if there is excessive hair insitu.

• Povidone-iodine should be used as a skin preparation in emergent cases when there is not enough time to allow CHG-alcohol solution to completely dry before incision.

• Chlorhexidine-alcohol solutions must not be used for procedures involving the ear, eye, mouth or neural tissue.

Safer Healthcare Now, Getting Started Kit: Prevent Surgical Site Infections, How to Guide, May 2007/2010

Incise Drapes

• Use of an adhesive antimicrobial incise drape may or may not decrease the incidence of wound infection; – Depending upon the composition of the drape – Preparation of the skin and adherence to the wound edges.

• Technique is important • With proper application of the incise drape to prevent lifting

from the skin edge, contamination of the wound with skin organisms is not possible.


Antibiotic doses and redosing

Am J Health-Syst Phar- Vol 70 Feb 1, 2013 p.195-283

Effect of Maternal Obesity on Tissue Concentration Of Prophylactic Cefazolin During Cesarean Delivery

Pevzner L, Edmiston CE, et al. Obstet & Gynecol 2011;117:877-882

Best Practice # 2: All surgical patients will receive a minimum dose of 2 gr unless their BMI is >30 – Then the correct dose is 3 gr

Improvement of Host Defense Maintaining Normothermia

• Mild hypothermia 34-36 degrees celcius has a large number of adverse effects – Increased blood loss and transfusion requirements – Prolonged ICU and hospital LOS – Increase in morbid myocardial events – Increase in wound infection

• Hypothermia increases the development of wound infection due to the adverse effects on the physiological and immunologic functions necessary to kill contaminating bacteria

Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis

of outcomes with costs. AANA Journal. 1999;67(2):155-164.

Hypothermia and SSI

*Adapted from: Sessler, Anesthesiology 2000

1hr

0

-1

-2

-3

0 2 4 6

Δ C

ore

Tem

p (°C

)

Elapsed Time (h)

-1.6°C

Anesthesia-Induced Hypothermia

Characteristic Patterns of General Anesthesia-Induced Hypothermia

Impaired thermoregulation under anesthesia Heat redistribution

Heat loss:

Convection Conduction Evaporation Radiation

Culprits of Perioperative Hypothermia

American College of Surgeons Vol. 209 No 4 October 2009

Perioperative Normothermia Normothermia (core temperature 36⁰C–38⁰C) should be maintained

preoperatively, intraoperatively, and in PACU by implementing any combination of the following:

• Warmed forced-air blankets when surgery is expected to last >30 minutes • Warmed Intravenous fluids for abdominal surgeries of >1 hour duration

• Fluid warming is an important adjunct therapy. • Warmed lavage liquids for colorectal surgery • Increase the ambient temperature in the operating room to 20⁰C-24⁰C • Hats and booties on patients during surgery • Pre-warming should be initiated between 30 minutes to 2 hours prior to

major surgery.

Safer Healthcare Now, Getting Started Kit: Prevent Surgical Site Infections, How to Guide, May 2007/2010

Best Practice # 3: Core temperature less then 36 degree celsius at the end of surgery is a failure

Cutting Edge Evidence

Making an Evidence-Based Argument for Antimicrobial (Triclosan) Coated Sutures

1. Ford et al. Pediatric surgery- Surg Infect 2005;3:313 2. Rozzelle et al. Cerebro-spinal shunt surgery – J Neurosurg Pediatr

2008;2:111-1117. 3. Mingmalairak et al. Appendectomy – J Med Assoc Thai 2009;92:770-775. 4. Zhuang et al. Abdominal surgery – J Clin Rehab Tiss Eng Res

2009;13:4045-4048. 5. Zhang et al. Radical mastectomy – Chin Med J 2011;124:719-724. 6. Galal et al. General, GI surgery - Am J Surg 2011;202:133-138. 7. Rasic et al. Colorectal surgery – Colleg. Antropologicum 2011;35:439-443. 8. Williams et al. Breast CA surgery – Surg Infect 2011;12:469-474. 9. Barac et al. Colorectal surgery – Surg Infect 2011;12:483-489. 10.Isik et al. Cardiac surgery – Heart Surg Forum 2012;15:E40-E45. 11.Turtainen et al. Lower limb revascularization surgery – World J Surgery

2012; May 23 [Epub ahead of print]. 12.Seim BE et al. Cardiac surgery – Interact Cardiovasc Thorac Surg 2012:

June 12 [Epub ahead of print]. 13.Nakamura T, et al. Colorectal surgery – Surgery 2013 [Epub ahead of print]. 14.Laas E, et al. Breast surgery – Int J Breast Cancer 2012 [Epub ahead of

print].

Edmiston, Daoud, Leaper, Submitted: 2012 Surgery

Checklist /Recommendation 1. The guidelines provided by the CDC and accrediting agents

such as JACO have been followed. These include effective techniques for asepsis, air handling, cleaning of environmental surfaces, sterilization techniques, activities of surgical team members and surgical attire.

2. All members of the operative team have double gloved and changed gloves when any perforation is identified. Gowns and drapes have been used which prevent liquid penetration.

3. Preoperative showering with chlorhexidine within a few hours of the operation and the night before has been done and preoperative cleansing of the operative site with a chlorhexidine-impregnated cloth just before entering the operating room.


Checklist /Recommendation

4. When hair removal is done, clippers have been used shortly before operation.

5. Reduction of skin organisms of both the surgical team and patient have been done using a combination of alcohol and chlorhexidine although other effective products including alcohol with iodophors are acceptable.

6. An antimicrobial incise drape has been used at operative sites where it is technically feasible to get good adherence to the skin.

7. Suture material has been selected which resists infection. 8. Dead spaces have been obliterated, where possible.


Checklist /Recommendation

9. Minimal trauma to the wound itself by gentle handling of tissues and limited use of electrocautery has been accomplished.

10. Conduit drains and drainage through a working incision have not been used.

11. Prophylactic topical antibiotic solution have been used vigorously by pressure irrigation several times during an operation and before closure in all but the simplest cases to remove clots and devitalized tissues and to ensure high-tissue levels of antibiotic.


Checklist /Recommendation 12. Prophylactic systemic antibiotics have been used according to

guidelines in all surgical cases where the incidence of infections exceeds approximately 0.5% or when any foreign body is implanted.

13. Core temperature has been maintained at 36°C or higher throughout the perioperative period.

14. Inspired oxygen has been given at a sufficient concentration to maintain subcutaneous oxygen concentrations of approximately 100 mm Hg and pulse oxygen readings above 96.

15. All diabetic and hyperglycemic patients have received tight glucose control during the perioperative period and for 2 to 3 days afterward in high-risk patients.


Where?

Newfoundland - 2 Quebec - 1 Ontario - 3

British Columbia – 24 Coming!? Alberta Saskatchewan Atlantic Canada

What’s Next!

• Lots of opportunity in the system • Obligation • Reducing SSIs is doable • New Evidence Emerging • Successful strategies focus on front

line/clinician ownership


Surgical Safety Checklist


Merci - Questions?


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Cuts Like a New Knife - Current Practice and Emerging Evidence in Preventing Surgical Site Infections