PREVENTION OF SURGICAL SITE INFECTION

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PREVENTION OF SURGICAL SITE INFECTION Montreal, March 29 2011 Chantal Bellerose P.

1 PREVENTION OF SURGICAL SITE INFECTION Montreal, March Chantal Bellerose P. Dt., BScHN, M.Sc. Adm Claude Laflamme MD, FRCPC, MHSC(c) Sandra Savery BScN, M.Sc.Adm

2 Disclosure Financial disclosure: Faculty member Safer Healthcare Now

3 Objectives Review current EBBP used to decrease Surgical Site Infections Recognize the main barriers encounter in Quality Improvement and learn about their mitigation strategies Share ideas and tools used to reduce Surgical Site Infections

4 Background Institute of Medicine (1999) - To Err Is Human - Building a Safer Health System Estimated 98,000 Americans die each year as a consequence of health care errors Canadian Hospitals Adverse Events (AE) Study (2004) Estimated up to 24,000 preventable deaths in Canada each year Estimated 70,000 preventable adverse events

5 Background Other studies have shown: 1 in 9 acquire infection in hospital 1 in 9 given the wrong medication More deaths occur due to adverse events than from breast cancer, vehicle crashes and HIV combined Canada is no different than other countries

6 Normalization of Deviance

7 Safer Health Care Now (SSI) FOCUS: Prophylactic Antibiotics Maintaining Normothermia Appropriate Hair removal Glucose Control for diabetic patients Skin prep

8 Surgical Site Infection Second most common type of adverse events occurring in hospitalized patients (Brennan. N Engl J Med. 1991;324: ). The rate of surgical site infection averages between 2% and 3% for clean cases 40% to 60% of these infections are preventable by implementing EBBP

9 Impact of SSI 2007 CDC report others ~1.7 million health care related infections a year Causing 99,000 deaths blood stream infections 14% 17% 32% UTI 15% 22% pneumonia SSI Cost of each SSI: LOS 10.6 days cost $27,288 US 60% more likelihood for ICU adm. 5X more likelihood for readm. to hosp 2X mortality rate Bretzler, D.W., Houck, P.M., et al. The American Journal of Surgery, 189 (2005) 9

10 It is no surprise that SSI have made the 2010 Joint Commission National Patient Safety Goals for the second consecutive year

11 SSI Rate (%) Quarterly SSI Rates for Elective Colorectal Surgery SSI% Target Quarters

12 Clean Surgery patients with SSI

13 SSI: Modifiable Risks Glucose control Preoperative CHG shower Appropriate hair removal Hand hygiene Skin antisepsis Antimicrobial prophylaxis Normothermia 1. Mangram AJ, et al. The hospital infection control practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4): Million lives. Institute for Healthcare Improvement. Available at: Accessed on February 8, 2007.

% surgical patients given pre-op ABx within 60 min* ( Goal 95% )

14 Prophylactic Antibiotics The right drug The right dose At the right time* For the right duration Performance measure (target): % surgical patients given pre-op ABx within 60 min* ( Goal 95% ) % surgical patients having ABx, discontinued within 24 hrs ( Goal 95% )

15 SSI (%) Perioperative Prophylactic Antibiotics Hours from incision Classen. NEJM. 1992;328:281.

16 Steinberg JP, et al. Ann Surg 2009;250:

17 Prophylaxis Weight Based Dosing Gap in the literature Dated evidence that antibiotic prophylaxis weight-based dosing for cefazolin and vancomycin lowers SSI rates among obese surgical patients 1 Not enough evidence to make recommendation 1. Forse et al. Surgery 1989; 106:

18 Prophylaxis Dosing Consider the upper range of doses for large patients Gastroplasty: SSI rates 16.5% vs 5.6% 1 Repeat doses for long operations (> 4 hours) Cardiac surgery: SSI rates 16% vs 7% 2 1 Forse, R; Karam, B; Maclean, D; Cristou, N. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery, 1989, 106: Zanetti et al., Emerg Infect Dis, 2001

19 Canada Healthcare Facility Cefazolin Vancomycin Fraser Health Authority, Vancouver, British Columbia Edmonton and Area Acute Care Facilities, Alberta Health Services, Alberta Grace Hospital, Winnipeg Regional Health Authority, Winnipeg, Manitoba University Health Network, Toronto, Ontario North York General Hospital, Toronto, Ontario Sunnybrook Health Sciences, Toronto, Ontario Jewish General Hospital, Montréal, Quebec St. Clare s Mercy Hospital, St. John s, NL Horizon Health Network, Moncton, NB 1g IV if 80kg 2g IV if >80kg 1g IV if 100kg 2g IV >100kg 1g IV if <80kg 2 g IV if 80kg 1g IV <70kg 2g IV if 70kg 1g IV if 80kg 2g IV if >80kg 2g for everyone 2g for everyone 1g IV if 80kg 2g IV if >80kg 1g IV if 100kg 2g IV >100kg Not Available Vancomycin 1g for everyone 1g IV if 75kg 1.25g IV if 76-94kg 1.5g IV if 95kg Not Available No weight-based modifications Not Available Weight modifications based on renal insufficiency Not Available Not Available

20 Duration Single Dose Prophylaxis Single dose antibiotic prophylaxis is likely sufficient in preventing infections for most non-complex and uncomplicated surgical cases 1-4 No evidence that this is true for all major surgeries 24 hour antibiotic prophylaxis regimens still widely practiced for cardiac, thoracic, orthopedic, and vascular surgery Current guidelines (CDC, NICE, WHO, SHEA) not emphatic in recommending single dose prophylaxis Equal or superior to 24 hour antibiotic prophylaxis? Risk of antibiotic resistance 1. DiPiro et al. Am J Surg 1986; 152: Song & Glenny Br J Surg 1998; 85: Andrews et al. Archives of Facial Plastic Surgery 2006; 8: Takahashi et al. Journal of infection & Chemotheapy 2005; 11:

21 Recommendations Prophylactic antibiotics need to be completely absorbed within 60 minutes of first incision, and should be repeated for surgeries lasting longer than the half-life of the antibiotic (4 hours for cephalosporins). Antibiotics administered for cardiac, thoracic, orthopaedic and vascular patients should be discontinued within 24 hours of the end of surgery, whereas non-complex and uncomplicated surgeries require no further administration of antibiotics following surgery.

22 Normothermia

23 Perioperative hypothermia GA alters central thermoregulation Thermoregulatory responses are triggered after 2-3ºC of hypothermia (±34ºC) Core temperature decreases by 1ºC within 30 minutes of induction Heat production decreases by 5%/ºC in the absence of shivering Enhanced heat loss

25 Physiopathology Hypothermia Impairs neutrophils function Vasoconstriction Tissue hypoxia

26 Minimizing hypothermia Prewarming: Decreases core-to-peripheral temperature gradient

27 Recommendation Based on the evidence, the Safer Healthcare Now! SSI faculty recommend that measures are taken to ensure that surgical patient core temperature remain between 36.0⁰C and 38⁰C preoperatively, intraoperatively and in PACU.

28 Recommendations American College of Surgeons Vol. 209 No 4 October 2009

29 Recommendations Level one evidence Prewarming and Intraoperative warming should be used for abdominal procedures expected to last > 30 minutes

30 Glucose Control Recent research Strict vs. conventional blood glucose control 2009 Consensus statement on glycemic control from American Association of Clinical Endocrinologists and American Diabetes Association report BG should be maintained between 7.8 and 10mmol/L for most critically ill patients

31 Appropriate Hair Removal No hair removal or clipping Clipping time as close as possible to incision time Shaving shown to cause microscopic breakage in the epithelial barrier, leading to bacterial contamination of the wound Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:

S aureus 1. Mangram AJ, et al. The hospital infection control practices advisory committee.

32 2009 Cardinal Health SSI: Primary Risk Factors Endogenous microorganisms Skin-dwelling microorganisms Most common source S aureus most common isolate Exogenous microorganisms Surgical personnel OR environment All tools, instruments, and materials S aureus 1. Mangram AJ, et al. The hospital infection control practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4): WHO Guidelines for Safe Surgery. First Edition. 2008;72.

33 The Ideal Skin Antimicrobial The ideal antimicrobial agent for skin should have the following properties: Broad spectrum Rapid bactericidal activity Persistence or residual properties on the skin Effective in the presence of organic matter Non-irritating or have low allergic and/or toxic responses None or minimal systemic absorption

35 Skin Preparation

36 Proportion of Patients with SSI, According to Type of Infection (Intent to Treat Population) CHA PI Type of Infection N=409 n(%) N=440 n(%) Relative Risk (95% CI)* P Value Any surgical-site infection Superficial incisional infection Deep incisional infection 39 (9.5) 71 (16.1) 0.59 ( ) 17 (4.2) 38 (8.6) 0.48 ( ) 4 (1.0) 13 (3.0) 0.33 ( ) Organ-space infection 18 (4.4) 20 (4.5) 0.97 ( ) >0.99 * Relative risks are for CHA as compared with PI. The 95% confidence intervals were calculated with the use of asymptotic standard-error estimates. P values are based on Fisher s exact test.

Antimicrobial Prophylaxis in the Surgical Patient. M. J. Osgood

Antimicrobial Prophylaxis in the Surgical Patient M. J. Osgood Outline Definitions surgical site infection (SSI) Risk factors Wound classification Microbiology of SSIs Strategies for prevention of SSIs