Preventing Surgical Site Infections with the SHEA Bundle Where we are vs. Where we hope to be San Diego APIC Chapter September, 2016 Angela Vassallo, MPH, MS, CIC, FAPIC Director, Infection Prevention/Epidemiology Providence Saint John s Health Center, Santa Monica, CA President-Elect, CA APIC
Today Changes in SSI Surveillance in the past 5 years Infection Prevention projects in the OR Surgical Attire excitement according to AORN and ACS OR cleaning and disinfection NHSN/CDC criteria for SSI s and meaningful use of data The SSI Prevention Bundle (SHEA, 2014) Also, I have no conflicts of interest! 2
Learning Objectives 1. Understand the components of the SSI Prevention Bundle 2. Determine where your organization is in implementing the SSI Prevention Bundle 3. Identify key opportunities for improvement in your program s SSI Prevention Bundle process
SSI Surveillance changes over the past 5 years
Old School Surgery Committee presentations with SSIs as Rates Monthly letters to surgeons to return with SSI info Little involvement with Surgery Staff in SSI Prevention Surgical prep: Chloraprep vs Betadine Surgical denominator data Excel spreadsheet from the OR Director Download from Ace (Remember that?) Targeted SSI surveillance based upon committee recommendations Hips/Knees Laminectomies C-Sections
New school SSI data is now public through CDPH: https://www.cdph.ca.gov/programs/hai/pages/surgicalsiteinfecti ons-report.aspx Letter to Surgeons? Are they aware of their public data? 2011 CDPH mandate to report SSIs from 29 selected procedures through NHSN Was IP staffing increased at this time to account for this new reporting mandate? Did your facility switch from reporting Rates to SIRs in committees? How long did it take to educate everyone? NHSN SSI definition changes in 2013 IP no longer tracks implantables for one year. Really? 30 to 90 days max? What? Surgical Denominator data is no longer just a number 32 data points per surgical patient with specific directions for extra fields to be left empty on an Excel spreadsheet And, you can still have BAD DATA per NHSN!
Infection Prevention involvement in the OR is multi-faceted.
SSI Prevention or NOT? Hair Shaving vs. Clipping Where is this done in Preop, Patient s home, OR suite? Skin Prep Betadine, Chloraprep, Duraprep, Merlin, etc. Cleaning/Disinfection of the OR Contact time of disinfectants vs. room turn-over time Staff Certification (EVS staff vs. Surgical Tech staff) OR Environment Cleaning Toolkit (AORN and EcoLab) New technology: UV, Hydrogen Peroxide vapor/mist, ATP Who cleans the iphones and ipads that are taken into the OR? What is your stance on personal bags in the OR (fabric vs hard surfaces vs plastic bags)?
SSI Prevention or NOT? Sterile Processing Dr. Rutala s 14 Steps for assessing disease transmission after breaches in disinfection and sterilization (www.disinfectionandsterilization.org) Biological Indicator monitoring What indicator is your SPD using and when (with each load, daily, weekly)? Is this data reported to the Infection Prevention Committee, the Surgery Committee or EOC? Flash vs. Immediate Use Early release of implants? Does anyone ever drop things on the floor in the OR during a procedure (accidentally, of course)? Do they tell Infection Prevention about it when they do?
SSI Prevention or NOT? Hand Hygiene Who monitors OR staff? Do the monitors understand flow in the OR? Do circulators gel in and gel out? Anesthesia Does IP attend the Anesthesia Committee and vice versa? Sentinel Event 52: Safe injection practices Any education done on this issue? Surgical Attire Does OR leadership enforce a surgical attire policy? Do staff still wear cloth caps (under bouffants)? Do staff wear their own OR shoes and transport patients from OR to ICU? Do staff wear booties in the café over their OR shoes? Does staff wear jewelry? Do staff tuck in scrub tops and wear cover jackets? Temp and humidity monitoring Does Engineering call OR and/or IP when out of range?
Surgical Attire Rationale Although there is no direct link between nonsterile surgical attire and the impact on surgical site infections, it seems prudent to minimize a patient s exposure to a surgical team member s skin, mucous membranes, or hair. Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017
Surgical Attire It is recommended that perioperative personnel in the semi-restricted and restricted areas wear facility-approved, clean, freshly laundered, or disposable surgical attire, including shoes, head coverings, masks, jackets, and ID badges. Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination and to assist with traffic control and should change back into street clothes if they need to leave the facility or travel between buildings to prevent contaminating the surgical attire through contact with the external environment. Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017
America College of Surgeons August, 2016 The ACS guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence. They are as follows: Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure. Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled. Masks should not be worn dangling at any time. Operating room (OR) scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up over them. OR scrubs should not be worn at any time outside of the hospital perimeter. OR scrubs should be changed at least daily. During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections. Earrings and jewelry worn on the head or neck where they might fall into or contaminate the sterile field should all be removed or appropriately covered during procedures The ACS encourages clean appropriate professional attire (not scrubs) to be worn during all patient encounters outside of the OR. 13 Retrieved on 8-17-16 from: https://www.facs.org/about-acs/statements/87-surgical-attire
American College of Surgeons August, 2016 The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case. Religious beliefs regarding headwear should be respected without compromising patient safety. Many different health care providers (surgeons, anesthesiologists, CRNAs, laboratory technicians, aids, and so on) wear scrubs in the OR setting. The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any health care provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel. The ACS emphasizes patient quality and safety and prides itself on leading in an everchanging and increasingly complex health care environment. As stewards of our profession, we must retain emphasis on key principles of our culture, including proper attire, since attention to such detail will help uphold the public perception of surgeons as highly trustworthy, attentive, professional, and compassionate. This statement will be published October 2016 in the Bulletin of the American College of Surgeons. 14 Retrieved on 8-17-16 from: https://www.facs.org/about-acs/statements/87-surgical-attire
Cleaning the Periop Environment and EVS Staff Training
Cleaning guide for the OR/Procedure Room
Cleaning in the OR/Procedure Room
Cleaning order in Preop and Postop
Cleaning in the Preop and Postop
NHSN Criteria for SSIs and Meaningful Data Presentation Does anyone really understand what Infection Prevention does?
NHSN SSI criteria, 2012 3 Types of SSI s: 1) Superficial SSI -Infection occurs within 30 days -Involves only skin or subcutaneous tissue 2) Deep Incisional SSI -Infection occurs within 30 days if no implant left in place or within 1 year if implant is in place -Involves deep soft tissue (i.e.. fascial & muscle layers) 3) Organ/Space SSI -Infection occurs within 30 days if no implant left in place or within 1 year if implant is in place -Involves any part of the anatomy opened/manipulated with drainage from the organ/space or abscess involving organ/space
NHSN SSI criteria, 2013 No longer tracking implantable devices for one year 30 to 90 days review max 14 Procedure types require 90-day monitoring period: Breast, Cardiac Surgery excluding CABGs, CABG with both chest & donor incision sites, and CABG with chest incision only, Craniotomy, Spinal fusion, Hip, Knee, Open reduction of fracture, Herniorrhaphy, Pacemaker, Refusion, Peripheral Vascular, & Ventricular shunt All other procedures require 30-day monitoring period regardless of presence of an implant
What is the SIR? Standardized Infection Ratio ( SIR ) CDC recommends that hospitals use a SIR to measure their progress as it is a more accurate measurement than a RATE. It compares the actual number of HAIs reported with the baseline U.S. experience. It adjusts for several risk factors that have been found to be significantly associated with differences in infection incidence. SIR uses ONE as the benchmark.
Number of cases SSI from 2007-2012 Healthcare-Associated Infection (HAIs) Housewide 40 35 34 30 25 CDPH Mandates SSI Reporting for a total of 29 operative procedures effective 4/1/2011 20 15 13 17 10 10 9 12 5 0 2007 2008 2009 2010 2011 2012 Total per Year 10 13 9 12 17 34 2007 SSI Targets: CABG Disk/Laminectomy Spinal fusion Hip & Knee Prothesis 2008 SSI Targets: CABG Disk/Laminectomy Spinal fusion Hip & Knee Prothesis 2009 SSI Targets: CABG Disk/Laminectomy Spinal fusion Hip & Knee Prothesis 2010 SSI Targets: CABG Disk/Laminectomy Spinal fusion Hip & Knee Prothesis 2011 & 2012 SSI Targets: All procedures
Surgical Site Infections (SSI s) SIR, 2012 2012 Quarters # actual infections / # expected infections SIR / 95% Confidence Interval 1 4 / 20.4 0.196 / 0.053-0.501 2 4 / 20.7 0.193 / 0.053-0.495 3 7 / 20.3 0.344 / 0.138-0.709 4 11 / 21.5 0.512 / 0.256-0.916 Total 26 / 83 0.313 / 0.205-0.459 In 2012, the SIR was 0.31, which is <1. This signifies fewer infections than expected. This is good!
LA COUNTY: 100 HOSPITALS compared to SAINT JOHN S SIR for Hips & Colons 2012 # actual infections (actual # procedures performed) SIR / 95% Confidence Interval HIP LA COUNTY 2012 57 (9292) 0.6 / 0.46-0.8 HIP SJHC 2012 4 (970) 0.4 / 0.12-1.14 COLON LA COUNTY 2012 108 (6102) 0.6 / 0.5-0.7 COLON SJHC 2012 4 (233) 0.3 / 0.08-0.80
Focus: Breast Surgeries, 2015 10 Breast SSIs 390 Breast Surgeries = my gut says something s not right
2015 Breast SSI s Surgery WC ASA Prep Surg eon Removal of infected tissue expander (12/16/14) Resection of left chest wall d/t recurrent breast CA (2/23/15) Left breast reconstruction with tissue expander (9/30/15) B/L mastectomies (12/14/15) Dirty Clean Clean Clean II II II II Povidone Scrub Povidone Iodine Chloraprep Povidone Scrub Surgeon A Surgeon C Surgeon D Surgeon E SSI Type Orgs NHSN report Deep (Purulent fluid drainage) Superficial (Positive culture) Superficial (fluid drainage MD diagnosis as SSI) Superficial (Cellulitis of left breast: MD diagnosis as SSI) E. Coli, Proteus Mirabilis Coag negative Staph Not cultured No growth Yes (SSI: 1/29/15) Yes (SSI: 3/4/15) Yes (SSI: 10/19/15) Yes (SSI: 12/22/15)
2015 Breast SSI s continued Surgery WC ASA Prep Surgeon SSI Type Orgs NHSN report B/L nipple sparing mastectomies (12/17/14) Clean I Povidone Scrub Surgeon B Superficial (Removal of Tissue Expander: MD diagnosis as SSI) No growth Yes (SSI: 1/2/15) B/L nipple sparing mastectomies (4/22/15) B/L nipple sparing mastectomies (5/20/15) Clean I Povidone Scrub Surgeon B Superficial (Infected left breast tissue expander: MD diagnosis as SSI) Clean II Betadine Surgeon B Superficial (Cellulitis of right breast: MD diagnosis as SSI) No growth No growth Yes (SSI: 5/14/15) Yes (SSI: 5/25/15) B/L nipple sparing mastectomies (7/8/15) Clean II Chloraprep Surgeon B Breast Abscess/Mastitis (Removal of infected left breast tissue expander) Pseudomonas aeruginosa Yes (SSI: 8/17/15) B/L nipple sparing mastectomies (9/9/15) Clean III Povidone Scrub Surgeon B Breast Abscess/Mastitis (drainage and removal of silicone implants and alloderm) Serratia marcescens Yes (SSI: 9/16/15)
Anderson DJ, Podgorny K, Berrios-Torres, SI, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 SHEA Update, Infection Control and Hospital Epidemiology, 2014 June; 35(6), 605-627. Pre-op Skin Prep Surgical Staff EVS Infection Prevention Preop patient bathing with Hibiclens (CHG) Blood Glucose control Primary rec: Alcohol-based prep Such as, Chloraprep, Duraprep, etc. Secondary rec: Chlorhexidine based prep Contraindicated for mucous membranes & any procedure above neck Consistent surgical attire COVER cloth caps Jewelry dangling Masks Scrub technique Consistent throughout Periop Ecolab soap & Avagard waterless Nail scrubbers Validate EVS staff for training to clean OR suites Approved disinfectants & correct contact time Communicate evidence-based guidelines to Surgery = MDs & staff Targeted SSI education: Surgeons w/ high SSIs Surgical services with high SSIs Hair removal NOT in OR Clippers only Surgical Safety Checklist Careful documentation procedure data (WC, coding) Cleaning frequency of specific locations in OR suite & use of UV Communicate SSI data to Surgery = MDs & staff (in addition to committees)
References Anderson DJ, Podgorny K, Berrios-Torres, SI, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 SHEA Update, Infection Control and Hospital Epidemiology, 2014 June; 35(6), 605-627. Association for the Healthcare Environment of the American Hospital Association. Practice Guidance for Healthcare Environmental Cleaning. 2nd ed. Chicago, IL: American Hospital Association; 2012. Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017 Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2014:255-276. Sehulster LM, Chinn RYW, Arduino MJ, et al. Guidelines for Environmental Infection Control in Health-Care Facilities. Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004. http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf Accessed January 13, 2014. American College of Surgeons website review of August, 2016 surgical attire statement: https://www.facs.org/about-acs/statements/87-surgical-attire
Thank you! Angela Vassallo, MPH, MS, CIC, FAPIC Director, Infection Prevention/Epidemiology Providence Saint John s Health Center 2121 Santa Monica Blvd. Santa Monica, CA 90404 Office: 310.829.8161 EFax: 310. 264.7271 angela.vassallo@providence.org 2016 President-Elect, CA APIC http://community.apic.org/thecaliforniaapiccoordinatingcouncil/home 33