9/9/2011. Speaker Disclosures. Kathleen Kohut, RN, MS, CIC, CNOR AMN Healthcare. The Compass Group. BE Smith Consulting

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1 Kathleen Kohut, RN, MS, CIC, CNOR Speaker Disclosures 3M AMN Healthcare The Compass Group BE Smith Consulting Johns Hopkins Hospital NCH Healthcare System 1. Describe the 3 main concepts related to the Joint Commission s 2011 NPSGs that will engage IPs and OR staff in effective SSI reduction strategies. 2. Examine the 2 main causes of intra-operative wound contamination. 3. Create process measures related to the 5 areas of opportunity for improvement to reduce the risk of SSIs. 1

2 National Patient Safety Goal: NPSG Main Concepts: 1. Educate Yourself All Surgery Personnel (upon hire and annually) Patients and Families 2. Measure Conduct risk assessments with the OR to determine process and outcome measurements 3. Communicate 1. Aseptic Technique 2. Sterilization 3. ABX Prophylaxis 4. Hair Removal 5. Skin Antisepsis Principles were developed to reduce the risk of wound contamination. 2

3 Defining the Risk of SSI Risk of SSI = Dose of Bacterial Contamination X Virulence Resistance of Host (patient) Berry & Kohn s, Operating Room Technique, 11 th ed., p Exogenous sources Cleanliness of environment, lack of proper airflow, shedding by the Surgical Team 2. Endogenous sources Patient s own skin/hair Infection at a remote site People = Shedding ,000 particles per minute (Berry & Kohn s, Operating Room Technique, 11 th ed., p. 252) Carried by wind currents to the sterile field which results in wound contamination. 1. Patient 2. Surgical Team 3. Ancillary Personnel 4. Sales Reps 5. Students 6. Passersby 3

4 Shedding plus Wind Currents Requires the control of: Amount of Traffic Traffic Patterns Sherertz, et al. Cloud HCWs. Emerging Infect Dis. 2001;7(2): Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6): Traffic Control Essential personnel only One foot (min) perimeter around sterile field Sterile fields should be a destination, not a thoroughfare Limit students and observers The right of the student to learn vs. the right of the patient to receive safe patient care Utilize alternative methods of communication Kohut SSI Equation People + Wind + (-) Aseptic Technique > ABX + Skin Prep = Wound Contamination = SSI 4

5 Patient/Family Teaching Opportunities Pre-op showering program -At least 2 showers Hat and clean gown/linen for patient transport Nasal Decolonization Association of perioperative Registered Nurses (AORN). Recommended Practices for Perioperative Nursing: Skin Antisepsis. Perioperative Standards and Recommended Practices 2008 ed., pp Webster, J, Osborne, S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database of Systemic Reviews 2007 Between 25-30% of all patients are colonized at any given time Another 60% carry it intermittently. Carriers are at higher risk S. aureuscauses 25-35% of all HAIs Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med2002; 346(24): % of all surgical pts acquire some type of HAI during their postoperative course 85% of S. aureus infections were endogenous in SSI study populations MRSA SSI rates decreased from.23% to.09% (5,094 pts) with MRSA eradication program Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61: Pofahl, WE, et al. Active Surveillance Screening of MRSA and Eradication of the Carrier State Decreases Surgical-Site Infections Caused by MRSA. J Am Coll Surg 2009;208:

6 Containment is the key Surgical Team Hand Hygiene Nocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998) Proper aseptic technique Properly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire) Ban Skull Caps Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov) Room Requirements Ventilation System (min 15- recommended /hr, 3 fresh) Positive pressure Temperature (68-73 F) Humidity (20-60%) Room Cleaning Between cases Terminal cleaning Types of construction materials Clutter AORN, Recommended Practices for Perioperative Nursing: Patient & Worker Safety. (2011 ed., p ) 6

7 Aseptic Technique Process Measures 1. Hand Hygiene compliance 2. Hair containment 3. Proper OR attire 4. Traffic patterns 5. Cleanliness Ventilation and environment documentation Terminal clean, turn around 2. Sterilization Proper Management of Sterile Processing Departments Technology Workflow Staff certification Proper Sterilization Processes Focus area for The Joint Commission Cleaning, sterilization, and storage Utilized for: Dropped instruments Poorly designed work processes Lack of instrumentation Surgeon scheduling Results in contamination due to: Poor cleaning due to lack of time Methods of delivery to the sterile field A closed container is best practice TJC will be looking for them Spry, C. Understanding Current Steam Sterilization Recommendations and Guidelines. AORN 2008; 88(4): p

8 IUS (Flash) Data Calculation: # of IUS events = rate x 100 # of cases/month OR Flash Rate st Q Flash Rate st Q '05 2nd Q 3rd Q 4th Q Jan '06 Feb March April May June July Aug Sept Oct Nov Dec Jan'07 Feb March Sterilization Process Measures 1. Sterilization Records for all processes 2. Cleaning Procedures 3. Proper Storage 4. IUS Sterilization 3. Antibiotic Prophylaxis SCIP Measures - INF 1,2,3 and NPSG (#7) Goal >95% Challenge the organization to 100% RCA or Med Error if missed Proper dosage for obese population (BMI>30) (Surg 1989;106:750) Redosing q 3 hours (Ann Surg 2009; 250:10) Medical Letter. Treatment Guidelines from the Medical Letter: Antimicrobial Prophylaxis for Surgery. Medical Letter 2004; 2 (20):

9 Antibiotic Prophylaxis Process Measures 1. SCIP measures 2. Dosing for BMI 3. Redosing 4. Hair Removal 1. SCIP measure deleted in April NPSG (#8) Goal Minimize as much as possible Clippers only 3. Not addressed: Location of hair removal Hair Removal Literature 1999 HICPAC Guideline 16. Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60(1): Mishriki SF, Law DJ, Jeffery PJ. Factors affecting the incidence of postoperative wound infection. J Hosp Infect 1990;16: Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971;121: Hamilton HW, Hamilton KR, Lone FJ. Preoperative hair removal. Can J Surg 1977;20:269-71, Olson MM, MacCallum J, McQuarrie DG. Preoperative hair removal with clippers does not increase infection rate in clean surgical wounds. Surg Gynecol Obstet 1986;162: Mehta G, Prakash B, Karmoker S. Computer assisted analysis of wound infection in neurosurgery. J Hosp Infect 1988;11: Alexander JW, Fischer JE, Boyajian M, Palmquist J, Morris MJ. The influence of hair-removal methods on wound infections. Arch Surg 1983;118(3): Masterson TM, Rodeheaver GT, Morgan RF, Edlich RF. Bacteriologic evaluation of electric clippers for surgical hair removal. Am J Surg 1984;148: Sellick JA Jr., Stelmach M, Mylotte JM. Surveillance of surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1991;12(10): Ko W, Lazenby WD, Zelano JA, Isom W, Krieger KH. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg 1992;53: Moro ML, Carrieri MP, Tozzi AE, Lana S, Greco D. Risk factors for surgical wound infections in clean surgery: a multicenter study. Italian PRINOS Study Group. Ann Ital Chir 1996;67: Winston KR. Hair and neurosurgery. Neurosurgery 1992;31(2): One more just in case Celik, SE, Kara, A. Does shaving the incision site increase the infection rate after spinal surgery. Spine 2007;32(15):

10 Hair Removal Process Measures 1. NPSG (#8) 2. Location of hair removal The attributes of an appropriate surgical skin antiseptic require: The ability to significantly reduce microorganisms (2 log-dry sites, 3 log-wet sites) Provide broad spectrum activity Be fast acting Have a persistent effect All products with FDA approval meet this criteria AORN, Recommended Practices for Perioperative Nursing: Skin Antisepsis. (2008 ed., pp ) Other Skin Antisepsis Considerations 1. Procedure (length, incision site) 2. Application Methodology Scrubbing vs. Painting 3. Challenges to the prep area blood, saline, friction 4. Patient Safety 10

11 CDC SSI guideline states to use an appropriate antiseptic SHEA Compendium - Optimal preparation and disinfection of the operative site AORN compares products but does not provide specific product recommendations NFQ 2011 recommendation: use solutions that contain isopropyl alcohol as skin antiseptic preparation until other alternatives have been proven as safe and effective, and allow appropriate drying time per product guidelines. National Quality Forum: _Safe_Practice_to_Prevent_Surgical_Site_Infection.aspx Surgical Skin Antisepsis Research Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes The majority of the literature compares microbial counts Much more work must be done to create a body of evidence to guide practice Current Research 1. Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91: Microbial culture study of 150 patients Compared 3 methods Iodophor Scrub/Paint vs. ChloraPrep vs. Duraprep Result Microbial counts were less using ChloraPrep SSI Outcome was no SSIs in any of the groups 11

12 Current Research 2. Swenson, et al. Preoperative skin preparation on postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30: SSI Outcome study of 3209 general surgery patients Compared 3 methods Iodophor Scrub/ETOH/Paint vs. ChloraPrep vs. DuraPrep Result SSI Outcomes- A statistical difference with lower SSI rates using iodine based products. Current Research 3. Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362(1): Microbial culture study of 849 patients Compared 2 methods Iodophor Scrub/Paint vs. Chlorhexidine-alcohol Result Significantly lower SSI rates with Chlorhexidinealcohol prep for surperficial and deep incisional wounds (16.5% to 9.5%) Clear as Mud.. 12

13 Alcohol Isopropyl Alcohol Created by the fermentation process of Clostridium Acetobutylicum Mechanism of actions: Denatures (kills) proteins Bactericidal Fungicidal Does not kill spores* Virucidal** AORN (2008). Patient Skin Antisepsis. AORN Perioperative Standards and Practices, p Product Application Methodology Follow manufacturer s directions Utilize proper aseptic technique during application & gloves to contain shedding 13

14 Skin Antisepsis Process Measures 1. Monitoring application methodology 2. Observing aseptic technique during application 3. Utilization of safety precautions Facilitating Process Improvements Create relationships with the Operating Room Personnel: Learn how they do their work You can be their advocates attire, cleanliness, policies, product selections Example: waterless surgical hand scrubs educate, standardize, ritualize Need alcohol and an antimicrobial NPSG Educate- about SSI prevention strategies CBT s, staff mtgs, etc. 2. Measure Make regular observations of aseptic technique Utilize data to implement change 3. Communicate Provide the data to the HCP 14

15 Process Improvements Choose process measures together Its about partnering not policing Provide data on an ongoing basis Create interest, stay focused Summary SSIs arepreventable and there is much work to be done NPSG will help get us there 1. Educate 2. Measure 3. Communicate 15