Published on November 1, 2016
1. SSI Prevention: Bundle Amber Wood, MSN, RN, CNOR, CIC, FAPIC
2. • Discuss evidence-based practices to prevent surgical site infections (SSI) • Develop a plan for implementing a SSI bundle Objectives
3. How to Build a Bundle
4. No two bundles are the same…
5. Gap Analysis • New • Improve Procedure Specific Compliance Your Bundle Risk Assessment
6. Implementation Science • Behavior (Human Factors) • Change management • Leadership Support • Resources (Equipment, Staff) • Teamwork & Communication • TeamSTEPPS (AHRQ) • CUSP/SUSP (Johns Hopkins)
7. Atul Gawande http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine#t-1128716
8. Bundle Elements
9. Core Practices (not procedure-specific)
10. • Only when indicated • Select agent based on clinical practice guidelines • Time the dose to be in tissue at time of incision • Within 1 hour • Dosing • Weight based • Re-dosing Antimicrobial Prophylaxis Order Sets, Time Out CDC HICPAC Draft Guideline for Prevention of SSI SHEA Compendium SSI Guideline
11. • Maintain normothermia (35.5°C) perioperatively • Before, during, and after surgery • Best method unresolved • Active & Passive • Patient assessment • Temperature monitoring • Selection of method Normothermia CDC HICPAC Draft Guideline for Prevention of SSI, SHEA Compendium SSI Guideline, AORN Guideline for Prevention of Unplanned Patient Hypothermia Pre-warming, Products
12. General anesthesia with endotracheal intubation • Increase FiO2 • Intraop and post-extubation Tissue oxygen delivery also needs… • Normothermia • Adequate volume replacement Oxygenation Anesthesia Champion CDC HICPAC Draft Guideline for Prevention of SSI SHEA Compendium SSI Guideline
13. • Target blood glucose levels <200 mg/dL • SHEA: <180 mg/dL • All patients • Diabetic and non-diabetic Glycemic Control Order sets, Equipment CDC HICPAC Draft Guideline for Prevention of SSI SHEA Compendium SSI Guideline
14. • Patient bathing • At home & preop holding • CHG liquid & cloths • Staphylococcus aureus screening & decolonization • MRSA & MSSA • SHEA Compendium: High-risk procedures (ortho, cardiac) Bathing & Decolonization Patient Reminders (electronic) SHEA Compendium SSI Guideline
15. • Patient bathing may reduce the microbial flora • Limitations/Gaps • Optimal bathing procedures • Antiseptics vs soaps (ie, plain, antimicrobial) • Whole body or only the surgical site • Optimal timing before surgery • Optimal number of baths or showers • Benefits outweigh harms Evidence Review AORN Guideline for Preoperative Patient Skin Antisepsis
16. I.a. The patient should be instructed to bathe or shower before surgery with either soap or a skin antiseptic on at least the night before or the day of surgery. [1: Strong Evidence] I.b. A multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists should develop a mechanism for evaluating and selecting products for preoperative patient bathing. [2: Moderate Evidence] AORN Recommendations AORN Guideline for Preoperative Patient Skin Antisepsis
17. • S. aureus screening prior to surgery • MSSA & MRSA • CHG baths for 5 days prior to surgery • Ten (10) dose mupirocin regimen • Use vancomycin in MRSA positive and some high risk patients who cannot be screened • Continue current SCIP Measures Institute for Healthcare Improvement (IHI) PROJECT JOINTS “Project Joints, Joining Organizations in Tackling SSI’s”; sponsored by the Institute for Healthcare Improvement (IHI); Kathy D. Duncan, Institute for Healthcare Improvement Faculty, Presented at the AFMC Quality Conference on May 10, 2011.
18. • Alcohol-based skin antiseptic • Hair removal with clippers vs razor Skin Antisepsis & Hair Removal Preferred Antiseptic Technique (IFU) SHEA Compendium SSI Guideline
19. • Remove soil • Rapidly and persistently remove transient microorganisms at the surgical site • Reduce resident microorganisms to subpathogenic levels • Minimal skin and tissue irritation Effective Skin Antisepsis AORN Guideline for Preoperative Patient Skin Antisepsis
20. • Organization level & Patient care team • FDA-Approved antiseptic • Alcohol-based antiseptics may be more effective than aqueous- based antiseptics when not contraindicated Selection Maiwald M, Chan ES-Y. The Forgotten Role of Alcohol: A Systematic Review and Meta-Analysis of the Clinical Efficacy and Perceived Role of Chlorhexidine in Skin Antisepsis. PLoS ONE. 2012;7(9).
21. • Eye • 5% Povidone-iodine • Gynecologic • 10% Povidone-iodine • 4% CHG recommended in ACOG position statement • Orthopedic • Conflicting • Alcohol-based antiseptics Procedure Specific AORN Guideline for Preoperative Patient Skin Antisepsis
22. • All available FDA-approved products might be contraindicated • Allergy, Anatomical Location, Wound • Evaluate the risks and benefits of alternative solutions • Soaps (baby shampoo, castile soap) • Saline Contraindications AORN Guideline for Preoperative Patient Skin Antisepsis
23. • Isopropyl alcohol 70% NOT approved for preoperative patient skin antisepsis • Injections (eg, IV start) • Select an alcohol-based antiseptic product • Mixing is compounding (USP 797) • “Painting” is a fire risk (flammable and clear) • Multi-dose bottle • FDA advises single use containers • Alcohol is not sterile, Bacillus cereus Alcohol
24. • Leave the hair and choose an aqueous, water-based antiseptic OR • Clip the hair and choose an alcohol-based antiseptic Hairy Patients AORN Guideline for Preoperative Patient Skin Antisepsis
25. • Closing instruments • Change gloves at closing Sterile Technique Technique, Resources
26. • Dressings • Technique, antimicrobial dressings, skin adhesive • Postoperative wound care education Dressings & Wound Care Standardization, Patient Education
28. • Nasal antiseptic • Surgical Helmet Systems • Laminar Flow Total Joints Multiple APIC 2016 Posters
29. • Suture closure vs. staple • Vaginal prep with povidone-iodine • Placenta removal with traction vs. manual extraction Cesarean Birth Multiple APIC 2016 Posters
30. • Nasal antiseptic • CHG mouthwash • Disposable telemetry leads Cardiac Procedures Multiple APIC 2016 Posters
31. • Wound protectors (SHEA Compendium) • Bowel technique • Closing instruments • Change gown/gloves • Mechanical/chemical bowel prep • Triclosan coated suture (HICPAC Draft SSI Guideline) Colon Procedures Multiple APIC 2016 Posters
32. • Preop • Fasting & carbohydrate needs • Thromboembolism prophylaxis • Antimicrobial prophylaxis • Skin preparation • Intraop • Anesthetic protocol • Surgical access • Avoid nasogastric intubation • Normothermia • Fluid management • Postop • Nausea & vomiting • Eliminating drains • Remove urinary catheter • Prevent ileus • Multimodal analgesia • Nutrition • Glucose • Early ambulation ERAS: Enhanced Recovery After Surgery ERAS Society: http://erassociety.org/ Hohenberger H & Delahanty K. 2015. "Patient-Centered Care—Enhanced Recovery After Surgery and Population Health Management". AORN Journal. 102 (6): 578-583.
34. Temperature & Humidity Facilities Guideline Institute, 2014 AORN Guideline for a Safe Environment of Care, Part 2 Area Humidity Temperature Air Pressure OR 20% to 60% 68° F to 75° F 20° C to 24° C Positive Soiled/ Decontamination < 60% *72° F to 78° F 22° C to 26° C (May be too warm for personnel in PPE) Negative Clean/Sterile <60% 72° F to 78° F 22° C to 26° C Positive
35. https://www.aorn.org/guidelines/clinical-resources/position-statements Harmonization
36. • Keep doors closed • Entry and exit of patients/personnel • SSIs related to door openings Traffic AORN Guideline for a Safe Environment of Care, Part 2
37. • Preplanning • Preference cards • Confirming all supplies present before the incision • Sign on the door to restrict traffic • Communication without door opening • Locks (opened from the inside only) • Taking breaks • Education Decrease Door Openings
38. • High transmission risk Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904. • 25% mean cleaning rate for objects cleaned in the OR at 6 acute care hospitals Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93(3):358-364. Environmental Cleaning AORN Guideline for Environmental Cleaning
39. • Determine which items are high touch • Clean those items more frequently Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM,Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol. 2011;32(2):185- 187. High Touch Objects AORN Guideline for Environmental Cleaning
40. • Multidrug-resistant organisms • Enhanced cleaning may reduce MRSA and VRE contamination & risk of transmission from prior room occupant Datta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch Intern Med. 2011;171(6):491-494. Enhanced Environmental Cleaning Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2006.
41. Adapted with permission from Guidelines for Perioperative Practice. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved. AORN Guideline for Environmental Cleaning
42. http://www.aorn.org/toolkits/environmentalcleaning/ Toolkit
43. Surgical Attire AORN Guideline for Surgical Attire
44. • Home laundering vs. health care- accredited laundering • Evidence conflicting • Risk for pathogens being carried on the scrub attire if home laundering Laundering AORN Guideline for Surgical Attire
45. • 3 postoperative Gordonia bronchialis sternal infections after CABG • Nurse anesthetist colonized: scrub attire, axilla, hands, and purse • Roommate also colonized • Home washing machine likely reservoir • Biofilms • Recommended hospital laundered scrub attire • First to demonstrate a causal relationship between home laundering and human disease Case Report Wright SN, Gerry JS, Busowski MTet al. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012;33(12):1238–1241.
46. • Completely cover arms • Long-sleeved jacket or scrub top • Restricted areas • Skin prep • Packaging items in sterile processing Long Sleeves AORN Guideline for Surgical Attire
47. • Clean or single-use • Evidence does not support wearing cover apparel to protect scrub attire from contamination • Lab coats can be contaminated with large numbers of pathogens Cover Apparel AORN Guideline for Surgical Attire
48. • A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn. • Hair colonized with bacteria & hair sheds • Significantly more bacteria on the ears than foreheads and eyebrows Owers KL, James E, Bannister GC. Source of bacterial shedding in laminar flow theatres. J Hosp Infect. 2004;58(3):230–232. Hair!! AORN Guideline for Surgical Attire Boyce JM. 2014. "Evidence in support of covering the hair of OR personnel". AORN Journal. 99 (1): 4-8.
49. Evidence Tables https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-tables