3M Learning Connection 5/7/2013 3M Infection Prevention Solutions Learning Connection Beyond SCIP: Leading the Way to SSI Reduction Dianne Rawson, RN, MA Hugo, MN May 14, 2013 2012. All Rights Reserved. House Keeping Questions From the GoToWebinar page: Click on the orange box with a white arrow to expand your control panel (upper right-hand corner of your screen). Type a question in the question box and click send. 3M 2013. All Rights Reserved House Keeping Continuing Education Each 1 hour web meeting qualifies for 1 contact hour for nursing. 3M Health Care Provider is approved by the California Board of Registered Nurses CEP 5770. Post webinar email Link to Course Evaluation CE Certificate Included Forward email to Others in Attendance 1
Disclosure Dianne Rawson, RN, MA Hugo, MN Director Perioperative Services University of Minnesota Learner Objectives List the process variables related to reducing the risk of surgical site infection Discuss the importance of nasal carriage of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) as they relate to surgical site infections List three means of reducing the bacterial load on skin prior to surgery and the supporting guidelines Discuss the importance of following manufacturer s directions for use to achieve efficacy of surgical patient preps Outline the importance of creating a sterile surface during the draping process Surgical Site Infections (SSIs) Surgical site infections are a common complication of many surgical procedures This results in postoperative patient morbidity, mortality, increased length of hospital stay and enormous additional costs to hospitals and healthcare Surgical site infections is estimated at 750,000 to one million SSIs in the US each year This results in 3.7 million extra hospital days at a cost of more than $1.6 billion in hospital charges In 2002, it was estimated that out of 300,000 SSIs in the United States approximately 8,205 deaths occur annually 2
Types of Surgical Site Infections Patient Factors: Preexisting Medical Conditions Diabetes Mellitus (DM) Obesity Malnutrition Tobacco Use Preexisting Remote Body Site Infection Surgical Care Improvement Project (SCIP): Core Measure Set Related to Surgical Infection SCIP Inf-1 SCIP Inf-2 SCIP Inf-3 SCIP Inf-4 SCIP Inf-6 Prophylaxis antibiotic received within one hour prior to surgical incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) Cardiac surgery patients with controlled 6 am postoperative serum glucose (<200 mg/dl) Surgical patients with appropriate hair removal SCIP Inf-10 Surgery patients with perioperative temperature management 3
SCIP Inf-1 Prophylactic antibiotic must be given within 1 hours prior to incision or 2 hours if Vancomycin/Fluoroquinolone Optimal time for administration of parenteral antibiotics is 30-60 minutes prior to incision Proper timing is essential for achieving bactericidal tissue and proper serum levels to reduce the risk of infection Studies confirm that when prophylaxis is given >2 hrs prior to initial incision or after initial incision the risk of infection increases SCIP Inf-2 Administration of appropriate prophylactic antibiotic Antibiotic must be safe, cost-effective, and broad spectrum Prophylactic antibiotic regimen selection: Surgical Procedures CABG, Other Cardiac or Vascular Hip/Knee Arthroplasty Colon Hysterectomy Approved Antibiotic Cefazolin, Cefuroxime, or Vancomycin Cefazolin, Cefuroxime, or Vancomycin Cefotetan, Cefoxitin, Amicillin/Sulbactam, Entapenem, or Cefazolin, Cefuoxime, or Metronidazole Cefetetan, Cefazolin, Cefurozime, or Amicillin/Sulbactam SCIP Inf-3 Prophylactic antibiotics should be discontinued within 24 hr after surgery end time and 48 hr for cardiac patients Intraoperative re-dosing may be necessary when length of operation exceeds four hours or an antimicrobial with short half-life is used 40-60% of SSIs are preventable with proper use of prophylactic antibiotics Overuse, under use, improper timing, and misuse of antibiotics occurs in 25-50% of operations 16% of C. diff infections in surgical patients can be attributed to inappropriate prophylaxis use alone Health care professionals should follow all recommendations for antibiotic timing, selection, and durations to prevent SSIs and development of antibioticresistant pathogens 4
3M Learning Connection 5/7/2013 SCIP Inf-4 Cardiac surgery patients with controlled 6 am postoperative serums glucose Hyperglycemia reduces the body s natural resistance to infection by impairing leukocyte function Hyperglycemia in the immediate postoperative phase increases risk of infection for both diabetic and non-diabetic patients The higher the level of hyperglycemia, the higher the potential for infection in both patient populations Blood glucose control in both the perioperative phase and postoperative phase to reduce SSIs this will take a multidisciplinary team approach Perioperative Glucose Level Two mechanisms that impair host defenses causing increased risk for infection in both diabetic and non-diabetic surgical patients include: Decreased vascular circulation resulting in reduced tissue perfusion and impaired cellular function Reduced activity of cellular immunity functions Interventions: Anesthesia must check patient s finger stick glucose (FSG) preoperatively and implement insulin therapy as indicated by hyperglycemic results Surgeon must continue glucose control for at least 48 hrs after surgery Nursing staff must monitor, calibrate, and control normoglycemia during inpatient stay SCIP Inf-6 Surgical Patients should have appropriate hair removal According to the CDC, preoperative shaving the night before or morning of surgery is associated with a significantly higher risk for SSIs than depilatory agents or no hair removal According to AORN, hair at surgical site should be left in place, not removed whenever possible Process measure improvements include: Provide patient education against performing his/her own hair removal Instructing clinical staff about appropriate methods/timing of hair removal Remove razors from OR and supply areas Establish a protocol for how/when to remove hair in affected areas Avoid shaving heart surgery patients for EKGs conducted shortly before surgery Hair removal should take place outside the OR suite 5
SCIP Inf-10 Surgery patients with perioperative temperature management Emphasizes importance of maintaining normothermia to reduce surgical site infections Specifies that active warming should be used intraoperatively or the patient should have at least one temperature 36.0 C within 30 minutes immediately before and 15 minutes after anesthesia end time Mild hypothermia is known to increase adverse consequences including: Surgical site infections Adverse cardiac events Increased blood loss Alteration in medication metabolism Prolonged lengths of stay in the hospital and PACU Perioperative Hypothermia Interventions: Preoperative Active: forced-air warming gowns and blankets and conductive warming blankets Passive: maintain ambient temperature perioperative area at or above 24 C/75 F Intraoperative Active: warm IV fluids, forced air warmers, warmed blankets, hot water mattresses, and thermal pads Passive: maintain ambient room temperature of OR between 20-25 C (68-77 F) Postoperative Maintain the same thermal care implemented preoperatively Assess patient s thermal comfort level Observe for signs and symptoms of hypothermia Beyond SCIP: Process Focused Interventions: Preoperative Measures to Reduce Bacteria on the Body Preop Wipes/Showers Reducing Colonization in the Nares Intraoperative Measures to Reduce Bacteria on the Body Patient Preoperative Skin Antisepsis Creating a Sterile Surface 6
Distribution of Top Ranking Pathogens (January 2006 - October 2007) Pathogens SSI Staphylococcus aureus 30.01% Coagulase Negative Staph (CNS) 13.74% Enterococcus spp. 11.21% Pseudomonas aeruginosa 5.55% Eschericia coli 9.55% Acinetobacter baumannii 0.60% Enterobacter spp. 4.17% Candida spp. 2.07% Abstract for SHEA 18th Annual Scientific Meeting Antimicrobial Resistant Pathogens Associated with Healthcare-Acquired Infections (HAIs) Reported to the CDC's National Healthcare Safety Network (NHSN), 2006-2007. http://www.cdc.gov/ncidod/dhqp/shea_abstract1.html Preoperative Wipes or Showers Reduces the bacterial burden on the patient s skin prior to surgical incision Practical problems: patient compliance, patient s ability to bath/shower, and consistency in method of preparation 2% CHG impregnated cloth proven more effective than 4% CHG liquid detergent in multiple studies Patient information regarding CHG Inactivated by soaps and shampoos Keep out of eyes and ears Do not use lotions, powders, or creams after application Preoperative Wipes or Showers Current Guidelines: CDC SSI Guideline Require the patients shower/bath with an antiseptic agent at least the night before surgery AORN Unless contraindicated, Patients should be instructed or assisted to perform two preoperative showers/baths with CHG SHEA/IDSA Preoperative bathing with chlorhexidinecontaining products (Unresolved Issue) 7
Nasal Carriage of S. aureus and MRSA Staphylococcus species account for nearly 50% of infections with MRSA representing 13.7% 30% of the population carries S. aureus in their nose and 1% carries MRSA Has been strongly implicated as a predictor of SSI Nasal carriers have a three-fold increase risk for nosocomial S. aureus bacteremia compared to non-carriers A 2008 study found that S. aureus is the main cause of surgical site infection after major heart surgery, with the patient s endogenous flora as the principle source Approximately 80% of invasive nosocomial S. Aureus infections are caused by the patient s own clonal nasal flora Evidence shows that hospital personnel have a S. aureus colonization rate of 20-35% Preoperative Reduction of Nasal Colonization Current Guidelines: CDC SSI Guideline No recommendation to preoperatively apply mupirocin to nares to prevent SSI. (Unresolved issue) SHEA/IDSA Routine screening for MRSA or routine attempts to decolonize surgical patients with an antistaphylococcal agent in the preoperative setting. (Unresolved issue) STS Routine mupirocin administration is recommended for all patients undergoing cardiac surgical procedures in the absence of documented negative testing for staphylococcal colonization Preoperative Reduction of Nasal Colonization Interventions: Develop protocol for reducing nasal colonization May include: Preop patient screening Preop treatment with mupirocin nasal ointment Preop nasal prep to reduce bacteria in nares with 5% povidone iodine Create a process that flags patients who test positive for MRSA to ensure use of Vancomycin 8
Randomized Trial: Mupirocin vs. Povidone-Iodine (PI) for SSI Reduction Compared nasal mupirocin ointment with povidone-iodine solution for prevention of SSI after arthroplasty and spine fusion surgeries Nasal mupirocin ointment was administered for five days, or One dose of the PI was given prior to surgery In addition to two applications of topical CHG before surgery Results: Deep SSI due to S. aureus and all pathogens was lower in the PI group compared to the mupirocin group Rate of side effects (adverse events) was also lower in the PI group Conclusion: PI, as a nasal antiseptic, is an alternative for clinicians to consider over mupirocin to reduce the risk of S. aureus SSI for orthopedic surgery patients without the potential for acquiring antimicrobial resistance. Ref: Michael S. Phillips, MD, et al, New York University Presented at IDSA/SHEA Conference in San Diego, October 20, 2012 Preoperative Skin Antisepsis Three major types: iodine/iodophor, chlorhexidine, and alcohol-based preparations Interventions: Implement evidence-based intervention practices including hand washing prior to application of skin preparation agents AORN recommends antiseptic selection should be based on: Patient allergies The surgical site prepped Patient s record of skin irritation from specific antiseptic agents Contraindications to specific antiseptic agents The presence of organic matter including blood Neonatal status Large, open wounds A review of the manufacturer s written information Surgeon preference Preoperative Skin Antisepsis Current Guidelines: CDC SSI Guideline use an appropriate antiseptic agent for skin preparation AORN preoperative skin antiseptic agents that have been FDA-approved or cleared and approved by health care organization s infection control personnel should be used for all preoperative skin preparations SHEA/IDSA wash and clean skin around incision site; use an appropriate antiseptic agent NQF: Safe Practice #22 preoperatively, use solutions that contain isopropyl alcohol solution as skin antiseptic preparation, allow appropriate drying time per product guidelines FDA requires products for preoperative skin preparation to be fast acting and persistent 9
Why follow the Manufacturer s Directions for Use? Efficacy of Prep is based on following Directions for Use Paint vs. Scrub Application Warnings: Flammability of Alcohol Preps Allow to dry completely before draping Remove solution soaked materials Wick any pooled solution Include in time-out (prep is dry) Warnings: Do not Use Statements All preps have warnings and contraindications Patients can have allergies or irritation Preps cannot be used universally on all areas of the body Creating a Sterile Surface Skin bacteria are the leading cause of SSI Preps only disinfect the skin Still bacteria left on the skin after the prep Incise drapes provide a sterile surface to the wound edge and immobilize bacteria not killed by skin prep Most of the incise drapes are breathable and allow for moisture- vapor transmission thru the film Iodophor impregnated adhesive incise drapes kill bacteria that contact the adhesive Creating a Sterile Surface Adhesion most effective when skin is prepped with an alcohol-iodine povacrylex and allowed to dry completely One study showed a six-fold increase in infection when the incise drape lifted at the edge of skin compared to operations with no lifting of incise drape ECRI Institute in their 2009 Clinical Guide to Surgical Fire Prevention: Recommends the use of incise drapes, if possible, to help isolate the head, face, neck and upper-chest incisions from the oxygen-enriched atmosphere and from flammable vapors beneath the drapes. The incise drape can help prevent gas communication channels between the under-drape space and the surgical site. 10
Aseptic Draping Practices AORN Recommended Practices for Selection and Use of Gowns and Drapes Provide appropriate barriers to microorganisms, particulate matter, and fluids Be appropriate to methods of sterilization Maintain adequate integrity and durability Withstand physical conditions Resist tears, punctures, fiber strains, and abrasions Be free of toxic ingredients Be low linting Have positive cost: benefit ratios Have an acceptable quality level Be used and processed according to manufacturer s written instructions NQF Safe Practice #22 Take actions to prevent surgical-site infections by implementing evidence-based intervention practices SUMMARY Not all SSIs are preventable but a significant number can be avoided The SCIP initiative targets complications that account for a significant proportion of preventable SSI morbidity, as well as reduces costs associated with SSI complications Including: appropriate and timely prophylactic antibiotics, appropriate hair removal, tight glucose control in diabetic patients, and maintaining patient normothermia Adjunctive process interventions including preoperative wipes/showers, reducing nasal colonization, antiseptic skin preparation, and using incise drapes offer added opportunities to bundle SSI reduction measures Healthcare leaders and all perioperative team members within each facility need to take an active role in consistently executing best practice bundles for reducing SSI to improve patient outcomes. 11
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