Infection prevention in the OR: A close examination of interventions

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1 Infection prevention in the OR: A close examination of interventions Kim Delahanty BSN, PHN, MBA/HCM, CIC, FAPIC kboyntondelahanty@ucsd.edu 1

2 Objectives Describe the clinical and economic impact of SSIs on patients and health care facilities. Provide an outline of the evidence based methodology currently employed by the, SHEA (Society for Healthcare Epidemiology of America)and CDC and the Hospital Infection Control Practices Advisory Committee (HICPAC) for developing guidelines. Give a brief overview of infection prevention measures in the surgical suite: surgical attire, traffic control, instrument sterilization, disinfection of the environment, monitoring of the air handling system. Understand the evidence related to and protocols for processimprovement measures. Understand why it is critical for IPs and OR staff to work together Impact of Health Care Associated Infections 2002 data from CDC National Nosocomial Infections Surveillance Systems Estimated number of HAIs: 1.7 million Estimated number of deaths associated with the HAI: 98,987 Pneumonia: 35,967 Bloodstream: 30,665 Urinary tract: 13,088 Surgical site: 8,205 Other sites: 11,062 Overall annual direct medical costs range from $28.4 to $33.8 billion (adjusted to 2007 dollars) SSI take into account $11,087 to $29,443 per event. With Morbidity and Mortality 2.6% Klevaround ens RM. Public Health Rep. 2007, 122(2):160 6, Scott DR, CDC, March

Cleaning equipment Correct antibiotic prophylaxis choice, timing, and discontinuation for selected surgeries Definition: NHSN Operative Procedure A procedure that 1.

3 How can most HAIs be prevented? Adherence to recommended infection control practices: Hand hygiene Sterile techniques Standard, contact, droplet, and airborne precautions Cleaning patients Cleaning environment Cleaning equipment Correct antibiotic prophylaxis choice, timing, and discontinuation for selected surgeries Definition: NHSN Operative Procedure A procedure that 1.is performed on a patient who is an NHSN inpatient or an NHSN outpatient 2.takes place during an operation where a surgeon makes a skin or mucous membrane incision (including the laparoscopic approach) and primarily closes the incision before the patient leaves the operating room 3.is represented by an NHSN Operative Procedure Code 3

4 2015 NHSN SSI Changes SSI PATOS is required on events only (infection Present At Time Of Surgery) Must be documented prior to surgery If continuing infection (i.e. hip or gut) there can not be a period of wellness between last surgery and this one. Must be to the same depth as previous infection Always go deep Previous infection does not need to meet NHSN definition but infection or abscess evidence does need to be noted In 2016 PATOS will be excluded from SIR! 4

5 Joint Events You must look to see if the code for a previously existing infection is associated with the admission. If yes then enter yes revision was associated with a previous infection. DO NOT use NHSN SSI definition for this This is for all joint surgeries not just events Diabetes NHSN has added another option for users to answer the question of diabetes on the denominator for procedure form. NHSN users can chose to use assignment of the discharge ICD 9 CM codes in the 250 to range to answer YES to this diabetes field question. The 2014 definition is also still in place as a choice to answer this field. 5

6 Inpatient Vs Outpatient For 2015, the NHSN SSI protocol will refer to inpatient and outpatient operative procedures, rather than operative procedures that are performed on inpatients or outpatients. Please disregard earlier guidance to identify OR areas/suites as inpatient or outpatient. 6

7 Inpatient Definition NHSN Inpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and the date of discharge are different calendar days. Outpatient Definition NHSN Outpatient Operative Procedure: An NHSN operative procedure performed on a patient whose date of admission to the healthcare facility and date of discharge are the same calendar day. 7

8 Post discharge SSI Surveillance Methods Surgeon and/or patient surveys by mail or phone Review of postoperative clinic records Line list of all readmission with diagnosis Line list of ED admissions with diagnosis ICD 9 CM Discharge/Procedure codes* *Infect Control Hosp Epidemiol Dec;34(12): doi: / Epub 2013 Oct 28. SSI Process Measures Immediate Use Steam Sterilization Rate (IUSS) Previously called Flash Sterilization SCIP (Surgical Care Improvement Project) measures Hand Hygiene Compliance Rate Occurrence Reports OR rounding 8

9 Process measures Should be part of your report to your ICC Not just a report, should be able to be used to drive improvement What is the most commonly IUSS ed items they should be on top of your purchase list Who isn t washing their hands, surgeons? Nurses? When aren t they washing their hands incorporate that into your infection prevention annual training (yes you need to do that!) For SCIP measures are you evaluating who is failing to administer abx on time? Is that in their recredentialing file? Surgical Site Definitions Clinical Based on individual physician judgment Dependent on risk to the patient of being wrong and likelihood of the event Based on temporal experiences of physician Epidemiological Reproducible Clear Indisputable Highly correlated with clinical diagnosis Understandable Not dependent on outside variables Useful for preventing future SSIs 9

10 Definitions of Surgical Site Infection Closure on closure Modification of the SSI Primary Closure and Non primary Closure Definitions Primary Closure is defined as closure of the skin level during the original surgery, regardless of the presence of wires, wicks, drains, or other devices or objects extruding through the incision. This category includes surgeries where the skin is closed by some means. Thus, if any portion of the incision is closed at the skin level, by any manner, a designation of primary closure should be assigned to the surgery. We do surveillance on both primary closed and open surgeries. They are risk adjusted depending on the closure 10

11 11

12 Closure example An example of a surgery with non primary closure would be a laparotomy in which the incision was closed to the level of the deep tissue layers, sometimes called fascial layers or deep fascia, but the skin level was left open. Another example would be an open abdomen case in which the abdomen is left completely open after the surgery. Wounds with non primary closure may or may not be described as "packed with gauze or other material, and may or may not be covered with plastic, wound vacs, or other synthetic devices or materials. Infections are defined by where the occur Superficial Incisional can be operative related but also can be a post operative care issue Deep incisional More likely to be related to the operative procedure than post operative wound care Organ/Space SSI Most likely to be related to be related to the operative procedure than post operative wound care 12

Superficial Incisional SSI SIP and SIS Superficial incisional primary (SIP) A superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or

13 Superficial Incisional SSI SIP and SIS Superficial incisional primary (SIP) A superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., augmented site for cosmetic surgery that has a donor site) Superficial incisional secondary (SIS) A superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site [buttocks] incision for cosmetic surgery) 13

14 Deep Incisional SSI 14

15 Organ/Space SSI Organ/Space SSI 15

16 If a patient has several NHSN operations prior to an SSI, report the operation that was performed most closely in time to the infection date. Example: Patient underwent a COLO on 2/12/14. Three days later, he went back to surgery to repair a leaking anastamosis (OTH). He developed an intraabdominal abscess on 3/18/14. This SSI is attributed to the second procedure (OTH), not the COLO. If more than one operation is done through a single incision First, attempt to determine the procedure that is thought to be associated with the infection. Example: If the patient had a CBGC and CARD done at the same time and develops a vegetative valve, then the SSI will be linked to the CARD. Then, if it s not clear or if the infection site being reported is not an SSI, use the NHSN Principal Operative Procedure Selection Lists to select which operative procedure to report. 16

Table 5. NHSN Principal Operative Procedure Categ01y Selection Lists The following lists are derived from the operative procedures listed in Table 1.

17 Table 5. NHSN Principal Operative Procedure Categ01y Selection Lists The following lists are derived from the operative procedures listed in Table 1. The categor the highest risk of SSI are listed before those with lower risks. Priority Code Abdominal Operations 1 LTP Liver transplant 2 COLO Colon surgery 3 BILI Bile duct, liver or pancreatic surgery 4 SB Small bowel surge1y s REC Rectal surge1y 6 KTP Kidney transplant 7 GAST Gastric smge1y 8 AAA Abdominal aortic aneurysm repair 9 HYST Abdominal hysterectomy 10 CSEC Cesarean section 11 XLAP Laparotomy 12 APPY Appendix surge1y 13 HER Hemion-Iiaphy 14 NEPH Kidney surgery 15 VHYS Vaginal Hysterectomy 16 SPLE Spleen surge1y 17 CHOL Gall bladder surgery 18 OVRY Ovarian surgery Priority Code Thoracic Operations 1 HTP Heart transplant 2 CBGB Coronaiy aite1y bypass graft with donor incision(s) 3 CBGC Coronaiy aiie1y bypass graft, chest incision only 4 CARD Cardiac smge1y 5 THOR Thoracic surgery Reporting SSIs Complete a Surgical Site Infection (SSI) form for each patient found to have an SSI using the definitions. 17

Specific Type: IAB Criteria 2: 2. Patient has abscess or other evidence of intra abdominal infection seen during a surgical operation or histopathologic examination.

18 Specific Type: IAB Criteria 2: 2. Patient has abscess or other evidence of intra abdominal infection seen during a surgical operation or histopathologic examination. Culturing Gut Spills or leaking anastomsis This practice makes no sense since it is unlikely that only one organism spilled out of the gut. Most likely polymicrobic and reflective of the gut biome This is why radiographic review of cases is important Cases may be drained by interventional radiology rather than a return to surgery. 18

19 Day 1: HYST performed. Patient screened for MRSA upon admission to ICU per protocol. Day 2: Patient is very confused. Temperature normal. Wound condition good. Day 3: Results of the admission screening cultures of the nose and groin are positive for MRSA. The following entry is found in the chart: Patient removed the dressing several times. Recurrent confused condition. Wound edges very red and taut. Patient non compliance with wound care If it occurs in your facility you count the SSI If documented outside of your facility you do not count the case 19

20 How are the durations for the individual procedures determined? If more than one NHSN operative procedure is performed through the same incision, record the combined duration of all procedures, which is the time from skin incision to primary closure. What s New? 2016 NHSN Surveillance Definition Updates *SSI = surgical site infection 20

Surgical Site Infections (SSI) NHSN uses ICD 10 PCS and CPT codes. Transition complete from ICD 9. ICD 10 PCS Guidance was provided for spinal level and approach for FUSN procedures.

Note: (+) culture is obtained if the patient meets SSI criterion b. Addition of Appendix 1 Contains a list of all NHSN operative procedure groups.

21 Surgical Site Infections (SSI) NHSN uses ICD 10 PCS and CPT codes. Transition complete from ICD 9. ICD 10 PCS Guidance was provided for spinal level and approach for FUSN procedures. Updated supporting materials. SSI criteria continued Superficial SSI criterion c Updated to reflect a symptomatic patient whose incision opened but for whom no culture was obtained. Note: (+) culture is obtained if the patient meets SSI criterion b. Addition of Appendix 1 Contains a list of all NHSN operative procedure groups. Site specific SSIs are available as events for each group. nual_current

22 What else can reduce SSIs? CHG baths pre surgery Reduce traffic in OR Maintain positive pressure in ORs But not temperature or humidity Proper surgical scrub in OR NO surgical scrub brushes CHG skin prep Maintain asepsis!!!!!!!!!!!!! No artificial nails or jewelry! Proper Cleaning Cleaning the OR 22

All rights reserved. Other things to look at SPD Was it sterilized? Is it free of bioburden?

23 End of Procedure Cleaning in the OR or Procedural Room Adapted with permission from Perioperative Standards and Recommended Practices. Copyright 2014, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO All rights reserved. Other things to look at SPD Was it sterilized? Is it free of bioburden? Does it have blind spots? Was IUSS used? Post operative care Reaching out to SNFs (do the dressing changes match the surgeon s home instructions? 23

24 Changing practice Improving outcomes Science + Expert consensus HICPAC Guidelines Pragmatic lessons and tools Compendium guidance 24

25 online.org/prioritytopics/compendiumofstrategiestopreventhais.aspx Rationale for the Compendium Hospitals are straining to accommodate an increasing number of infection prevention initiatives, regulatory obligations, and requirements for collecting and reporting performance measures Create a set of documents that hospitals can use to help prioritize their HAI prevention efforts Help all stakeholders to work together to implement and sustain strategies to improve patient care 25

26 The Compendium process Implementation focused Collaborative effort involving experts in infection prevention and control Written in partnership with implementation focused organizations online.org/prioritytopics/compendiumofstrategiestopreventhais.aspx Section Leads and Panel members Involved organizations with content expertise Pediatric ID Society The Joint Commission APIC CDC Society for Critical Care Medicine Society for Hospital Medicine Institute for Healthcare Improvement Surgical Infection Society 26

27 NOT a guideline Review of relevant literature Heavy focus on published guidelines and systematic reviews/meta analyses Grading the quality of evidence Grade High Definition Highly confident that the true effect lies close to that of the estimated size and direction of the effect (e.g., wide range of studies and no major limitations, little variation between studies) Moderate The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different (e.g., only a few studies and some have limitations but not major flaws, variation between studies) Low The true effect may be substantially different from the estimated size and direction of the effect (e.g., supporting studies have major flaws, important variation between studies, no rigorous studies, only expert consensus) 27

Recommended strategies Two levels of recommendations based on balancing of potential benefits and risks Basic Practices: Recommended for all acute care hospitals Special

28 Recommended strategies Two levels of recommendations based on balancing of potential benefits and risks Basic Practices: Recommended for all acute care hospitals Special Approaches: Strategies to consider if basic practices are in place but there s still a problem based on risk assessment or surveillance data BASIC PRACTICES TO PREVENT SSI 28

29 Multi level review Many organizations and societies contributed Many organizations and societies invited to review the drafts and to consider endorsement or support Reviewed and cleared by the CDC Approved by the SHEA Guidelines Committee and IDSA Standards and Practice Guidelines Committee Approved by the Boards of the major partnering organizations Perioperative antimicrobial prophylaxis HICPAC Administer preoperative antimicrobial agent(s) only when indicated, based on published clinical practice guidelines and timed such that a bactericidal concentration of the agent is established in the serum and tissues when the incision is made (IB) Compendium Administer antimicrobial prophylaxis according to evidence based standards and guidelines (Basic Practice; Quality of evidence=high) 29

Updated perioperative antimicrobial prophylaxis guidelines Available at: http://www.idsociety.

30 Updated perioperative antimicrobial prophylaxis guidelines Available at: Perioperative antimicrobial prophylaxis HICPAC In clean and cleancontaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain (IA) Compendium Discontinue antimicrobial prophylaxis within 24 hours after surgery 30

31 Perioperative antimicrobial prophylaxis HICPAC No further refinement of timing can be made for preoperative antimicrobial agent, based on clinical outcomes (No recommendations/ Unresolved issue) Compendium Begin administration within 1 hour before incision to maximize tissue concentration. Two hours are allowed for the administration of vancomycin and fluoroquinolones Perioperative antimicrobial prophylaxis HICPAC Our search did not identify RCT evaluating weightadjusted AMP dosing and its impact on the risk of SSI (No recommendation/ Unresolved issue) Compendium Adjust dosing on the basis of patient weight (examples: pediatric patients, vancomycin, gentamicin, morbidly obese patients) 31

32 Perioperative antimicrobial prophylaxis HICPAC Our search did not identify sufficient RCT evidence to evaluate intraoperative redosing of parenteral prophylactic antimicrobial agents for the prevention of SSI (No recommendation/ Unresolved issue) Compendium Redose prophylactic antimicrobial agents for long procedures (intervals of ~every 2 half lives) and in cases with excessive blood loss during the procedure Redose prophylactic antibiotics for long procedures 6% Surgical siteinfectionrate 5% 4% 3% 2% 1% Redose No redose 0% On time Not on time Timing of initial antimicrobial prophylaxis dose Steinberg JP, et al. Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg 2009; 250:10 32

33 Perioperative antimicrobial prophylaxis HICPAC Does not address Compendium Use a combination of parenteral antimicrobial agents and oral antimicrobials to reduce the risk of SSI following colorectal procedures Strategies to consider: Oral antibiotics and mechanical bowel prep for colorectal surgery Two interrelated issues: Mechanical bowel prep Fleet enema Polyethylene glycol Phospho soda Magnesium citrate Oral antimicrobial prophylaxis Neomycin + erythomycin Neomycin + metronidazole 33

34 Impact of mechanical bowel prep on SSI risk No difference Guenaga KF, et al. Cochrane Database Syst Rev, 2011 Despite this, how often is a bowel prep used? Englesbe, et al. Ann Surg 2010;252:

Oral antibiotics with mechanical bowel preparation propensity matched analysis 15% No Oral Antibiotics Oral Antibiotics Percent of patients 10% 5% * * * * P <0.

35 Oral antibiotics with mechanical bowel preparation propensity matched analysis 15% No Oral Antibiotics Oral Antibiotics Percent of patients 10% 5% * * * * P <0.05 0% Deep Incisional Organ Space Superficial Incisional Overall SSI Englesbe, et al. Ann Surg 2010;252: Impact oral antibiotic prophylaxis on SSI risk 60% reduction in SSI risk Deierhoi RJ, et al. J Am Coll Surg 2013;217:763 35

36 Impact oral antibiotic prophylaxis on SSI risk 40% reduction in SSI risk Nelson, et al. Cochrane Database Syst Rev, 2014 Bottom line: Mechanical bowel prep and oral antimicrobial prophylaxis Difficult to tease out the impact of mechanical bowel prep and oral antibiotic prophylaxis in these studies Adding preoperative oral antibiotic prophylaxis (in addition to perioperative IV prophylaxis) decreases SSI risk when mechanical bowel prep is used Further studies are needed 36

37 Glycemic control HICPAC Implement perioperative glycemic control and use blood glucose target levels of <200 mg/dl in diabetic and non diabetic patients Compendium Control blood glucose during the immediate postoperative period ( 180 mg/dl) Normothermia HICPAC Maintain perioperative normothermia (IA) Compendium Maintain normothermia during the perioperative period (Basic Practice: Quality of evidence=high) 37

38 HICPAC Supplemental oxygenation For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, administer increased FiO2 both intraoperatively and post extubation in the immediate postoperative period. (IA) Compendium Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation (Basic Practice; Quality of evidence=high) HICPAC Perform intraoperative skin preparation with an alcohol based antiseptic agent, unless contraindicated (IA) Preoperative skin prep Compendium Use alcohol containing preoperative skin preparatory agents if no contraindication exists (Basic Practice; Quality of evidence=high) 38

practices to improve surgical patient safety Haynes AB, et

39 Additional Compendium Basic Practices: Surgical safety checklist Use a checklist to ensure adherence to best practices to improve surgical patient safety Haynes AB, et al. NEJM 2009;360:

40 Haynes AB, et al. NEJM 2009;360:491 Additional Compendium Basic Practices: SSI surveillance Perform surveillance for SSI Measure and provide feedback to providers regarding rates of compliance with process and outcome measures 40

41 Additional Compendium Basic Practices: Education Educate healthcare personnel about strategies to prevent SSIs Educate patients and their families, as appropriate A 7 S BUNDLE APPROACH TO PREVENTING SURGICAL SITE INFECTIONS 41

42 Mortality risk is high among patients with SSIs A patient with an SSI is: 5x more likely to be readmitted after discharge 1 2x more likely to spend time in intensive care 1 2x more likely to die after surgery 1 The mortality risk is higher when SSI is due to MRSA A patient with MRSA is 12x more likely to die after surgery 2 1. WHO Guidelines for Safe Surgery Engemann JJ et al. Clin Infect Dis. 2003;36: S Bundle to Prevent SSI SAFETY assuring surgery is done is a safe environment, using a wound protector in colon surgery,, good surgical technique SCREEN screening for risk factors and presence of MRSA & MSSA and decolonizing colonized patients before surgery SHOWERS patients cleanse their body the night before and morning of surgery with CHLORHEXIDINE (CHG) SKIN PREP applying a surgical skin prep with alcohol based antiseptics such as CHG or Iodophor SOLUTION irrigating surgical tissues prior to closure to remove exogenous contaminants with CHG for residual activity post op SUTURES closing tissues and incision with antimicrobial sutures SKIN CLOSURE sealing the incision with a topic adhesive or covering it with an antimicrobial dressing to prevent exogenous contamination post op 42

CHALLENGES WITH THE 7 S BUNDLE Getting More Surgeons to Use Abdominal

Incision Sites from Bacterial Invasion SURGICAL INFECTIONS Volume 11,

Site Infection in Open Elective Colorectal Surgery: A Randomized Clinical

43 CHALLENGES WITH THE 7 S BUNDLE Getting More Surgeons to Use Abdominal Wound Protector/Retractor Horiuchi et al: A Wound Protector Shields Incision Sites from Bacterial Invasion SURGICAL INFECTIONS Volume 11, Number 6, 2010 Reid et al: Barrier Wound Protection Decreases Surgical Site Infection in Open Elective Colorectal Surgery: A Randomized Clinical Trial DISEASES OF THE COLON & RECTUM VOLUME 53: 10 (2010) 43

Eliminating Skull Caps and Assuring Hair is Covered Normal individuals

Approximately 10% of skin squames carry viable microorganisms and it s

individuals shed approximately 1 million microorganisms AORN Recommended

lint surgical head cover or hood that confines all hair and covers scalp

The head cover or hood should be designed to minimize microbial

Skullcaps may fail to contain the side hair above and in front of the

44 Eliminating Skull Caps and Assuring Hair is Covered Normal individuals shed more than 10 million particles from their skin every day. Approximately 10% of skin squames carry viable microorganisms and it s estimated that from their bodies each day. individuals shed approximately 1 million microorganisms AORN Recommended practices for surgical attire section IV.a. states that: a clean, low lint surgical head cover or hood that confines all hair and covers scalp skin should be worn. The head cover or hood should be designed to minimize microbial dispersal. Skullcaps may fail to contain the side hair above and in front of the ears and hair at the nape of the neck. Boyce, Evidence in Support of Covering the Hair of OR Personnel AORN Journal Jan 2014 Surgical Attire Arms Covered During Surgery New scrub with arm sleeve AORN Journal January 2012 Vol 95 No 1 44

Use of Antimicrobial Sutures Bacterial colonization of the suture Like all foreign bodies, sutures can be colonized by bacteria: Implants provide nidus for

Contamination Colonization Biofilm Formation 1.Ward KH et al. J Med Microbiol. 1992;36: 406 413. 2.Kathju S et al Surg infect. 2009;10:457 461 3.

45 Use of Antimicrobial Sutures Bacterial colonization of the suture Like all foreign bodies, sutures can be colonized by bacteria: Implants provide nidus for attachment of bacteria1 Bacterial colonization can lead to biofilm formation1 Biofilm formation increases the difficulty of treating an infection2 Contamination Colonization Biofilm Formation 1.Ward KH et al. J Med Microbiol. 1992;36: Kathju S et al Surg infect. 2009;10: Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27: On an implant, such as a suture, it takes only 100 staphylococci per gram of tissue for an SSI to develop3 45

days Traditional suture 5 day zoneof inhibition 10 day zone ofinhibition Antimicrobial suture Spencer et al: Reducing the Risk of Orthopedic Infections: The

46 Antibacterial Suture Challenge Studied the zone of inhibition around the suture A pure culture 0.5 MacFarland Broth of S. aureus was prepared on a culture plate An antibacterial suture was aseptically cut, planted on the culture plate, and incubated for 24 hrs held at 5 and 10 days Traditional suture 5 day zoneof inhibition 10 day zone ofinhibition Antimicrobial suture Spencer et al: Reducing the Risk of Orthopedic Infections: The Role of Innovative Suture Technology NAON 2010 Annual Congress May 15 19, 2010 Wang et al: British Journal of Surgery, 2013 Edmiston et al: Surgery 2013;154: > 30% reduction in SSIs 46

Antibiotic Irrigation Cocktails versus CHG prepared IrriSept

05% Irrigation Solution IrriSept Meets American College of Emergency

Proprietary SplatterGuard protects healthcare workers, patients and

05% has demonstrated antimicrobial efficacy and persistence in

47 Antibiotic Irrigation Cocktails versus CHG prepared IrriSept Chlorhexidine 0.05% Irrigation Solution IrriSept Meets American College of Emergency Physicians (ACEP) guidelines for wound irrigation volume and pressure Proprietary SplatterGuard protects healthcare workers, patients and the environment from biohazard contamination Chlorhexidine Gluconate 0.05% has demonstrated antimicrobial efficacy and persistence in laboratory testing The mechanical action effectively loosens and removes wound debris Safe for mucous membranes approved by FDA 47

Why CHG Irrigation: Environmental Contaminants from the Operating Room and

Closure leave in for 1 minute then rinse for 1 minute CHG Irrigant leaves a

Orthopedic Implants Hip or Knee aspiration If positive irrigation and

spacers Revisions at future date Long term IV antibiotics in community or

48 Why CHG Irrigation: Environmental Contaminants from the Operating Room and in the Tissues Should be Flushed out Before Closure Irrigate Tissues Before Closure leave in for 1 minute then rinse for 1 minute CHG Irrigant leaves a 2 week antimicrobial action in the tissue Special Risk Population: Orthopedic Implants Hip or Knee aspiration If positive irrigation and debridement Removal of hardware may be necessary Insertion of antibiotic spacers Revisions at future date Long term IV antibiotics in community or rehab Future worry about the joint In other words DEVASTATING FOR THE PATIENT AND SURGEON 73 48

49 Skin Adhesive Care of the Incision Most surgical patients are discharged within first 1 4 days when incisions is just starting the wound healing process Topical Incisional Adhesive Borderand Healing 6 Weeks Post op and Beyond 49

Orthopedic Total Joints Hip: Sealed with

50 Topical Skin Adhesive on Total Knee Clinical Use of Incisionial Adhesive in Orthopedic Total Joints Hip: Sealed with adhesive covered with gauze and transparent dressing for incision protection Knee: Sealed with incisional adhesive, covered with Telfa and a transparent dressing for incision protection Healed incision 50

51 Which Would You Prefer??? Topical Incisional Adhesive (TSA) Octyl Cyanoacrylate OTHER OPTIONS WHEN ADHESIVES ARE NOT USED 51

Ethicon Take Aim was conducted at six facilities to support corporate UHS initiatives Program objective Help providers implement evidence-based practices to address risks for SSIs* and BSIs**

52 Ethicon Take Aim was conducted at six facilities to support corporate UHS initiatives Program objective Help providers implement evidence-based practices to address risks for SSIs* and BSIs** Innovative approach Risk assessments to identify gaps in policies Staff training to reduce variation in practices Patient education to engage patients in care Broad Impact For patients Protect against known risks for infection For UHS Standardize practices across facilities Drive compliance with corporate polices Improve utilization of Ethicon devices Evidence supported portfolio * SSIs = Surgical Site infections ** BSIs = Bloodstream infections The components of Take Aim align closely with the Joint Commission NPSG and Educate staff and licensed independent practitioners - Educate patients, and their families, as needed - Implement policies and procedures to reduce risk of SSIs - Conduct periodic risk assessments - Select evidence-based SSI measures - Monitor compliance with guidelines - Evaluate effectiveness of efforts 52

UHS corporate identified the specific facilities and Take Aim components to be

infection prevention procedures - BIOPATCH Point Prevalence - Wound Closure

in clinical practices and improve compliance with facility policies - Prof. Ed.

53 UHS corporate identified the specific facilities and Take Aim components to be included in the pilot Risk assessments Identify potential gaps in current infection prevention procedures - BIOPATCH Point Prevalence - Wound Closure Point Prevalence - BSI and SSI gap assessment Staff training Reduce variation in clinical practices and improve compliance with facility policies - Prof. Ed. speaker event Many Risk Factors Influence SSI One thing could lead to the failure 53

#1: Way to STOP the Spread of Diseases: Hand Hygiene Proper hand hygiene is the single most

Alcohol basedgel,soap&h2o if visibly soiled or C Diff cases, and friction!

It is critical for patient safety in the operating room that infection prevention and the OR team

54 #1: Way to STOP the Spread of Diseases: Hand Hygiene Proper hand hygiene is the single most effective way to prevent infection! Alcohol basedgel,soap&h2o if visibly soiled or C Diff cases, and friction! Conclusions Infection Control Programs have been evolving to adapt to changing needs. It is critical for patient safety in the operating room that infection prevention and the OR team to work together and understand each others role in patient safety. Use of checklists in the operating room have shown to improve patient safety. NHSN is an ever changing landscape that needs constant review. 54

SURGICAL SITE INFECTIONS: SURVEILLANCE & PREVENTION

SURGICAL SITE INFECTIONS: SURVEILLANCE & PREVENTION Facts There were an estimated 157,500 surgical site infections associated with inpatient surgeries in 2011. SSIs were the most common healthcare-associated