HEN 2.0 SSI WEBINAR SURGICAL SITE INFECTION (SSI) RISK REDUCTION. February 4, :00 a.m. 12:30 p.m. CT

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1 HEN 2.0 SSI WEBINAR SURGICAL SITE INFECTION (SSI) RISK REDUCTION February 4, :00 a.m. 12:30 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Natalie Erb, Program Manager, HRET 11:00 11:05 2

3 WEBINAR PLATFORM QUICK REFERENCE Mute your computer audio Download today s slides and resources 3

4 ADDITIONAL REMINDERS Quality of video and audio (if listening through your computer) depends on your internet connection To maximize the size of any one pod, simply press the four-way arrow icon in the top right corner 4

5 HEN DATA UPDATE Rich Rodriguez, Data Analyst, HRET 11:05 11:10 5

6 HEN 2.0 SSI EVALUATION MEASURES Number of observed infections, number of predicted infections (for NHSN users), number of procedures Outcomes: SIR (for NHSN users), rates Procedure types: COLO, HYST, HPRO, KPRO Baseline period: Calendar year 2012, OR Next oldest calendar year Jul - Sept

7 SSI PROCESS MEASURES 7

8 SSI PROCESS MEASURES 8

9 SSI PROCESS MEASURES 9

10 OBJECTIVES FOR TODAY Explore the why and how of perioperative glucose control Discuss what is unique in knee and hip SSI prevention Hear from a hospital what strategies they have used to reduce SSI Discover how well-designed processes for pre-op bathing can set you and your patients up for success 10

11 SSI How Sweet it is? And Are Joints Unique? Cheryl Ruble, Improvement Advisor, Cynosure Health 11:10 11:30 11

12 SSI How Sweet It Is? Hyperglycemia and the SSI connection 12

13 Polling Question: Is glucose management part of your SSI prevention efforts? a. Yes b. Working on it c. No 13

14 HYPERGLYCEMIA & SSI RISK 14

15 SSI RISK TOO SWEET 15

16 SSI RISK TOO SWEET 11,633 patients 29.1% hyperglycemia (> 180 mg/dl) Hyperglycemia significantly increased risk of Infection Reoperative interventions Death Increases risk for patients with/without diabetes 2-fold higher risk infection, in-hospital mortality and operative complications DOS hyperglycemia treated with insulin had NO significant increase Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets. 16

17 SSI RISK TOO SWEET Ata, Lee, Bestle, Desemore, & Stain (2010): Post-operative hyperglycemia independent of the presence of diabetes, appears to be the single most important risk factor for SSI in general & colorectal Richards, Kauffman, Zackerman, Obremsky, & May (2012): Hyperglycemia was independent risk factor for 30 day SSI in orthopedic trauma patients without history of diabetes Toth Martin et al. (2015): Individuals with diabetes 50% more likely to develop SSI than non-diabetic 17

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19 Recommendations Control blood glucose immediate post op period for cardiac and noncardiac Target 180 mg/dl Intensive control ( 110 mg/dl) NOT recommended Does not reduce SSI Higher rates of adverse outcomes 19

20 Chat Box: Advice to the Sugar-lorn What advice would you give to others about implementing perioperative glucose management? 20

21 And Are Joints Unique? Knee and Hip SSI prevention 21

22 SSI Risk in Knees and Hips Risks studied specifically in total joints BMI > 40 Smoking Staphylococcus aureus carriage Duration of pre-hospital stay > 3 days Diabetes Revision surgery Prolong duration of surgery Hypertension Nutritional status Kopp SL, et al. (2015). The impact of anesthetic management on surgical site infections in patients undergoing total knee or total hip arthroplasty. Anesth Analg, 121(5): Puely AJ, Martin CT, Gao Y, Schwizer ML, Callagan JJ. (2015). The incidence of and risk factors for 30-day surgical site infection following primary and revision total joint arthroplasty. J Arthroplasty, 30(9 Suppl):

23 SSI Risk in Knees and Hips Mitigating the Risk Joint Bundle Pre-op skin prep: alcohol-containing antiseptic CHG bathing with soap or wipes at least 3-days before surgery Screen for Staphylococcus aureus (SA) Decolonize SA carriers with intranasal mupirocin 5 days pre-op, AND At least 3 days of CHG bathing How-to-Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA: Institute for Healthcare Improvement (Available at 23

24 SSI Risk in Knees and Hips Mitigating the Risk Beyond the Bundle Nutrition SA carrier decolonization Targeted antibiotic prophylaxis 24

25 Mitigating the Risk Beyond the Bundle Nutrition Nutritional status is a predictive factor for SSI in joint surgery. Significant predictor for SSI Serum albumin levels Alfargieny R, Bodalal Z, Bendardaf R, El-Fadli M, Langhi S. (2015). Nutritional status as a predictive marker for surgical site infection in total joint arthroplasty. Avicenna Journal of Medicine, 5(4): Consider: Pre-op serum albumin in select patients Diet optimization preoperative Registered dietician consult 25

26 Mitigating the Risk Beyond the Bundle Enhanced Bundle Focus on Staphylococcus aureus SA targeted intervention to reduce SSI SA screening Chlorhexidine (CHG) bathing Targeted perioperative antibiotic prophylaxis Significant reduction in complex S. aureus ( SA) SSIs Number of months without SA from 2 to 29 months Bundle compliance constant 83% Schweizer ML, et al. (2015). Association of a bundle intervention with surgical site infections among patients undergoing cardiac, hip or knee surgery. JAMA, 313(21):

27 Mitigating the Risk Beyond the Bundle SA Carrier decolonization and CHG bathing SA targeted intervention to reduce SSI Patients screened for SA Positive for SA Mupirocin twice a day x 5 days If patient had fewer than 10 doses, received remaining doses post-op Chlorhexidine (CHG) bathing every day up to 5 days Negative for SA CHG bathing night before and morning of Schweizer ML, et al. (2015). Association of a bundle intervention with surgical site infections among patients undergoing cardiac, hip or knee surgery. JAMA, 313(21):

28 Mitigating the Risk Beyond the Bundle SA Carrier decolonization and CHG bathing Consider: Screen all patients for SA Treat positive screens with intra-nasal application Positive screens bath with CHG 5 days prior to surgery 28

29 Mitigating the Risk Beyond the Bundle Targeted Antibiotic Prophylaxis Antibiotic prophylaxis varied depending on SA carrier status Non-carriers and MSSA carriers cefazolin or cefuroxime MRSA carriers both cefazolin or cefuroxime AND vancomycin Negative carrier w/history of SA carrier were treated as carriers Consider: Working with infection preventionist to explore targeted antibiotic prophylaxis for your facility and community Schweizer ML, et al. (2015). Association of a bundle intervention with surgical site infections among patients undergoing cardiac, hip or knee surgery. JAMA, 313(21):

30 Chat Box: Ah moment to share with the Disjointed What ah moment can you share about your organizations journey preventing SSI in patients undergoing joint surgery? 30

31 RESOURCES HRET HEN Infections List Serv. Sign up at HRET HEN SSI Resources and Change Package Institute for Healthcare Improvement Project Joints How to Guide and other resources. Schweizer ML, et al. (2015). Association of a bundle intervention with surgical site infections among patients undergoing cardiac, hip or knee surgery. JAMA, 313(21):

32 CASE STUDY: HOSPITAL STORY Saint Mary s Regional Medical Center, Hospital Speaker 11:30 11:50 32

33 ORTHOPEDIC EXCELLENCE AT SAINT MARY'S REGIONAL MEDICAL CENTER Tim Copeland, MT(ASCP), MHSA Chief Quality Officer Monica Baxter, MSN, CIC Infection Preventionist Bridget Davis, RN, BSN Nursing Director, Surgical Services 33

34 ABOUT SAINT MARY S REGIONAL Russellville, AR, Population 27,920 Primary Service Area Population 56,000 Private For Profit Facility Part of Capella Healthcare 170 Licensed Beds Services include: Gen Surg,Gen Med, Orthopedics, Cardiology, ENT, GI, OB/GYN, Pulmonology, Oncology, Acute Rehab, Behavioral Health 34

35 ABOUT SAINT MARY S REGIONAL 35

36 TESTS OF CHANGE & WHAT WE LEARNED Chlorhexidine Wipes Given to all patients at time of preadmission registration Instructions to use the night before Then used again upon arrival at hospital in prep Nasal Swabs (4% Betadine) Within 1 hour of procedure Replaces Mupericin treatment (Abx Stewardship!) Pre-op Blood Sugar for Diabetic Patients Also patients with a high glucose at time of preadmission testing With Subsequent testing during surgery for long procedures Focus to minimize flashing 36

37 OFF THE BEATEN PATH Alcohol cleanse of limb in pre-op holding Site covered by sterile towels until the patient is rolled into the OR After scrubbing in, the surgeon dons three pairs of gloves Following the prep and drape of the patient, the outer pair is removed. Periodic ATP Monitoring in the Operative Suite Minimal blood loss Therefore lower transfusion rates Therefore less transfusion related immunosuppression Consistent surgical support team assigned for Ortho cases Traffic in and out of OR minimized 37

38 OFF THE BEATEN PATH SSI spike in 2013 led to investigation that pointed to overaggressive Bovie use Literature provided Behavior changed Rates lowered 38

39 BARRIERS AND HOW WE RESOLVED THEM Facility Factors Aging plant Small rooms No laminar air flow 39

40 BARRIERS AND HOW WE RESOLVED THEM People Factors Physicians are reluctant to judge others techniques Strong physician opinions Two Ortho surgeons in solo practices with different buttons Fortunately, both surgeons get it when it comes to public reporting and are highly competitive 40

41 MEASURES WHAT & HOW Overall SSI Rates NHSN SSI Rates Flashing Rates ATP Monitoring Provided to Medical Staff Quality Committee and Surgery Committee 41

42 MEASURES WHAT & HOW 42

43 ADVICE FOR OTHERS Find the surgeon s Button Provide data obtained from public sources Develop a culture of pride in performance on public measures 43

44 WRAP UP AND NEXT STEPS We are not to zero, yet! But we are taking the journey Trialing Wound Protectors for General Surgery and, given success we will encourage the adoption for Ortho Surgery as well Any other suggestions? 44

45 Suds Up! Jackie Conrad RN, MBA, RCC Improvement Advisor, Cynosure Health 11:50 12:10pm 45

46 Engaging Patients in Reducing Bioburden on the Big Day 46

47 THE IMPACT OF AN INFECTED JOINT 47

48 THE GOAL OF PRE-OP BATHING Decolonize the skin Decrease the bacterial counts Prevent SSI Results are dependent upon how effectively the process in implemented, monitored and results reported 48

49 THE POWER OF 3 Bode L, Kluytmans J, Wertheim H, Bogaers D, Vandenbroucke-Grauls C, Roosendaal R, et al. Preventing surgical site infections in nasal carriers of Staphylococcus aureus. New England Journal of Medicine. 2010;362(1):9-17 Byrne D, Napier A, Phillips G, Cushieri A. Effects of whole body disinfection on skin flora in patients undergoing elective surgery. The Journal of Hospital Infection. 1991;17(3):

50 CHLORHEXIDINE GLUCONATE BASED PRODUCTS CHG significantly decreases the count of bacteria that cause SSI Bactericidal, veridicidal, fungicidal Not effective against Cdiff or mycobacteria not sporicidal Available in liquid soaps and no rinse wipes Sequential daily application or one time application both reduce bacterial load Most important predictor of reduction in bacterial load is patient understanding and ability to perform the skin antisepsis. 50

51 THE MOST IMPORTANT FACTOR TO SUCCESS Froimson, M., Olivio, K.,Schill, M., Horrigan, M.A.(2013, June) Preventing Surgical Site Infection: Preoperative Bathing. The American Journal of Orthopedics. Retrieved from: 51

52 THE IDEAL STATE The patient has CHG supplies The patient is able to bathe or wipe their entire body from their neck to toes The patient starts the process on the right day and completes it three times. 52

53 REALITY The patient may not be able to reach all body parts The patient may not have access to CHG soap or wipes due to financial or transportation concerns The patient does not remember to initiate 3 days pre op The patient may not understand why antiseptic is required for the whole body The patient only bathes the surgical site 53

54 FROM THE PATIENT S PERSPECTIVE Anxiety about the procedure. Many arrangements being made prior to elective joint replacement. Belief that preventing infection is the hospital s responsibility. Bathing is the last thing on my mind. 54

55 ENGAGE AND BUILD SUPPORT Build the business case to create buy in Engage surgeons with evidence Tap into your customers for insights Patients Surgeons Office Support Staff Pre admission testing What is important for success in implementing pre op bathing? How will this intervention fail? What is important to you in implementing pre-op bathing? sinesscasepreventssihipknee.aspx KneeOnePagerForSurgeons.aspx 55

56 FOUR PROCESSES FOR SUCCESS Educate Distribute Remind Validate 56

57 PROCESS DESIGN Understand current process Pre op education and other pre op touch points Surgeon office visit PT eval for crutches Group education classes Pre Op testing Pre Op calls Link new processes to current touch point 57

58 TEST YOUR PROCESSES How small can you start? What will you measure? 58

59 PROCESS DESIGN CONSIDERATIONS 59

60 BUILD A PROCESS THAT WORKS - TEACH Coordinate with the orthopedic surgeon s office Engage Surgeon, RNs, PAs, NPs, MAs Assign responsibility for pre op education and distribution of skin prep Use multiple education venues group classes, PAT, Ortho office Create patient-friendly written materials Include skin prep in written pre op instructions and pre admission testing Include family or support person in instruction on bathing Be very clear on scheduling Cleanser #1 Cleanser # 2 Cleanser #3 Surgery Dates 12/15/15 12/16/15 12/17/15 12/18/15 Initial when complete X 60

61 BE CLEAR ON SCHEDULING This option assures at least one CHG total body antisepsis is completed under supervision Cleanser #1 Cleanser # 2 Cleanser #3 Surgery Day Dates 12/16/15 12/17/15 12/18/15 Initial when complete Skin Cloths will be used at the hospital 61

62 Patient Education Resources CHG wipes instructions 1. Shower or bathe with regular soap, if needed, allowing 2 hours for the skin to dry and pores to close, before applying the skin prep. 2. Use one cloth to prepare each area of the body. 3. Wipe each area back and forth. 4. Use all six cloths in the order shown on the diagram. 5. Allow the skin to dry. 6. Dress in clean clothes. nbeforesurgerypatientinstructionsssi.aspx 62

63 Patient Education Resources CHG liquid soap bathing instructions Patient instructions on bathing Apply antiseptic with clean washcloth from neck to toes Keep soap on the skin for 5 minutes Rinse Use fresh towel to dry Skin will feel sticky until dry Put on fresh, clean clothes Form includes specific dates of bathing Patient signs off to validate 63

64 BUILD A PROCESS THAT WORKS - SUPPLIES DISTRIBUTE PAT Pre OP PT visit Surgeon s office OR PATIENT PURCHASE Pharmacy on site Local pharmacy Mail order / Amazon Bailey RR, Stuckey DR, Norman BA, et al. Economic Value of Dispensing Home-Based Preoperative Chlorhexidine Bathing Cloths to Prevent Surgical Site Infection. Infection Control and Hospital Epidemiology. 2011;32(5):

65 CHOOSING THE RIGHT PRODUCT Form Method Considerations Pt Cost 4% CHG Liquid soap Apply liquid soap with a clean washcloth. Rinse and dry with clean towel. Good for patients who prefer showers. Keep soap on skin for 5 minutes before rinsing. $16 2% CHG Cloths Use a fresh wipe for each area of the body. Do NOT rinse. Good for pt who needs help reaching all body parts. Easy to use. $28 65

66 BUILD A PROCESS THAT WORKS - REMIND Establish a process to remind patients with text messages, s or phone calls. Include in pre op reminders. Example of patient activated reminder system. 66

67 BUILD A PROCESS THAT WORKS - VALIDATE Establish a process on the day of surgery to validate if the patient completed the pre op cleansing Ask the patient, review the instruction sheet Provide cloths for patients who were unable to complete the bathing prior to the day of surgery, or schedule the third cleansing at the hospital Document CHG bathing 67

68 RESOURCES HRET HEN Infections List Serv. Sign up at HRET HEN SSI Resources and Change Package Institute for Healthcare Improvement Project Joints How to Guide and other resources. lt.aspx Bailey RR, Stuckey DR, Norman BA, et al. Economic Value of Dispensing Home- Based Preoperative Chlorhexidine Bathing Cloths to Prevent Surgical Site Infection. Infection Control and Hospital Epidemiology. 2011;32(5):

69 BRING IT HOME Natalie Erb, Program Manager, HRET 12:00 12:15 69

70 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Examine current state of our SSI prevention efforts focusing on glycemic management, reducing skin bioburden pre-op and SA carrier patients. Engage an orthopedic surgeon and an anesthesiologist to plan glycemic management interventions. What are you going to do in the next month? Share the SSI data with surgeons and the leadership. Support unit based team in evaluating SA screening and decolonization cycles. 70

71 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Engage surgeon lead to explore pre-op CHG bathing. Engage front line staff member to plan and test patient CHG bathing education. What are you going to do in the next month? Evaluate the PDSA cycles done with the patient CHG bathing education, adapt, adopt, and spread. Test CHG bathing documentation tool and day of surgery follow up. 71

72 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Review your organization s SSI rates. What are you going to do in the next month? Review SSI rates by surgical type and surgeon with operating room medical and nursing staff to identify opportunities. Work with operating room leadership to conduct a gap analysis to identify evidence based practices that are currently not in practice and prioritize adoption of targeted interventions. 72

73 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Evaluate current pre-op education materials. What are you going to do in the next month? Interview three post operative patients to assess their perception of the effectiveness of pre-op instructions. Share patient interview results with operating room leadership. 73

74 THANK YOU! Find more information on our website: Questions/Comments: 74