Transcript FIC Slides SSI Prevent_Fund_2015Hoover

PREVENTION OF SURGICAL
SITE INFECTIONS (SSI)
MSIPC Fundamentals of Infection Prevention & Control
October 2015
Karen Hoover, RN
Infection Prevention Coordinator
St. Mary’s of Michigan, Saginaw
SSI: A Complication of Surgical Care
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> 51.4 million surgical procedures/year in US
31% of all HAI’s due to SSI, second only to UTI
> 91,000 readmissions for SSI Rx
1 million additional inpatient days
1.6 billion excess costs
Associated mortality rate of 3%
Cost… Pay for performance …patient safety
CDC’s Guideline for Prevention of Surgical Site Infection,
1999.8
• Jan 2014 CDC
Common Surgeries/Procedures
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719,000/year
498,000
395,000
332,000
1.3 million
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Ambulatory
1.3 million cataracts
923,000 Lens implants
499,000 Endoscopies of lg. intestine + 1.1 million of sm. intestine
735,000 Injections of spine
Approx. 40% have more than 1 procedure
Total knee
Hysterectomy
CABG
Total Hip
Cesarean sections
CDC http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm (2010)
CDC www.cdc.gov/nchs/data/nhsr/nhsr011.pdf
Risk Factors for SSI: identification &
opportunities for intervention
• Risk factor: variable with significant, independent association
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with development of SSI
Patient: age, nutrition, diabetes, smoking, obesity,
immunocompromised, pre-op LOS, micro-flora, other infection
SSI prevention measure: action(s) to reduce SSI risk, antibiotic
prophylaxis, skin prep/antisepsis
Operation: patient & peri-op personnel, duration, ATB re-dosing,
surgical asepsis, traffic flow, surgical technique (robotic), hair
removal, immediate use sterilization, glove/instrument change
Environmental: cleaning, disinfectant contact time, UV light,
OR environment-HVAC
Risk of SSI after receipt of blood products 3.5%
Principles for Prevention of SSI
• Minimize access of bacteria to the surgical site
• Measures to neutralize that do gain access to site
• Reduce that which is conducive to infection
• Enhance the host defenses - look at risk factors
• Follow established guidelines
Pathogenesis of Surgical Site
Infection (SSI)
• Dose x virulence
Resistance of Host
= risk of SSI
• > 105 / gm tissue risk; with
foreign body only 100/gm is
needed to cause SSI
• Pathogens:
Endogenous – flora normally
contained
Exogenous – healthcare
personnel, environment,
devices/materials used
Key Concepts on Source of SSI
Pathogen: OR personnel or patient?
• Every surgical site has bacteria
by the end of the procedure!
• Four Clinical variables determine
infection:
• Inoculum of bacteria
• Virulence of bacteria
• Microenvironment
• Host defenses
Endogenous – flora normally
contained
Distribution of Pathogens Causing SSIs
S. aureus
20%
Coag.-neg Staph.
14%
Enterococci
12%
P. aeruginosa
8%
E. coli
8%
Enterobacter spp.
7%
Other gram neg.
8%
B. fragilis
2%
Mangram AJ. AJIC 1999;27:97-134
Risk Classification for SSI:
• CLASS I/CLEAN WOUNDS--an
uninfected surgical wound in
which no inflammation is
encountered and the
respiratory, alimentary,
genital, or uninfected urinary
tracts are not entered.
• CLASS III/CONTAMINATED
WOUNDS--open, fresh, accidental wounds.
In addition, surgical procedures in which a major
break in sterile technique occurs (eg, open
cardiac massage) or there is gross spillage from
the gastrointestinal tract and incisions in which
acute, nonpurulent inflammation is encountered
are included in this category.
• Class IV/Dirty-Infected
• CLASS II/CLEAN-
Old traumatic wounds with retained
CONTAMINATED WOUNDS--a
devitalized tissue and those that involve
surgical wound in which the
existing clinical infection or perforated
respiratory, alimentary, genital, or viscera. This definition suggests that the
urinary tracts are entered under
controlled conditions and without organisms causing postoperative
infection were present in the operative
unusual contamination.
field before the operation.
http://www.cdc.gov/hicpac/SSI/table7-8-9-10-SSI.html
Smoking & Surgery: Bad combination
• Randomized, controlled trial: 48
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smokers(S) vs 30 never smoked (NS)
228 wounds evaluated
SSI rate 12% S vs 2 % in NS
SSI rate significantly less for S if
abstain for 4wks (27% vs.1.1%)
Wound rupture: 12% S vs. 0% NS
Smokers nearly 40% more likely to die
(within 30 days)
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When to stop … 30 days? …
2-6months? …at least 1 yr?
http://health.clevelandclinic.org/2013/08/facing-surgery-kick-cigarettes-now
Preoperative Patient Shower with
Antimicrobial Soap
• Bacterial counts on skin
are 9-fold lower after
shower - chlorhexidine
• CDC SSI Guidelines:
Require patients to bathe
with antiseptic on at least
the night before their
operation
• CHG cloth use night
before & day of surgery
Intranasal De-colonization & Prevention of SSI
• Orthopedic &
cardiothoracic patients significant reduction in
SSI among treated1-3
• However these were
retrospective & used
historical controls
• Another randomized trial
in ortho.surg found less
S. aureus nasal carriage
but no signif. Reduction
in SSI rate4
Mupirocin decolonization of nasal
Staphylococcus aureus prior to surgery
decreases surgical site infections,
however, treatment requires 5 days,
compliance is low and resistance occurs.
Preventing Surgical Site Infection:
System-level success
[Usry GH, et al. AJIC 2002;30:434-6.]
Sternal SSI Rates/100 Procedures
Intervention:
Intranasal mupirocin
48 hrs prior to through 5
days post op
Results:
94% of patients Rx
Rate of SSI dropped by:
53% overall
55% for deep sternal
3
2.5
2
Rate
Per
100
CABGs
Baseline
Interven
1.5
1
0.5
0
Overall
Superficial
New Study (2015):
Povidone-Iodine Solution 5%
• Assurance - Reduces bacterial counts
in the nares, including S. aureus by
99.5%, so you know you're helping
address another variable in the fight
against surgical site infections
Control - Works within one hour
• One at a time, the foam-tipped
applicators are saturated with the
appropriate solution using a vigorous
stirring motion for at least 10 seconds.
The subject’s nostrils are prepped for 30
seconds each using separate
applicators. This process was then
repeated using two additional
applicators for a total application time of
1 minute per nare (2 minutes total).
Surgical Care Improvement Project (SCIP)
• Antibiotic Timing -
<60min
• Antibiotic Selection –
type/body location
of procedure
- dosing for body wt.
- duration of procedure
- PCN allergy?
- cost of antibiotic
Surgical Care Improvement Project (SCIP)
within 24 hours surgery end time
Stop ATB 24 Hours of OR end time …48 for Cardiac Surgery
Blood sugar <200 POD 1 & 2
S Controlled @ < 200 by 6STTTTTTGKLBLK a.m. POD 1 & 2
Appropriate Hair removal
…no razors
DVT Prophylaxis
Beta-blocker given before OR and after unless contraindicated
ICD (Int. Compression Device), TED’s, Heparin, Warfarin
Foley cath …remove by POD 2 or physician note why not
Centers for Medicare & Medicaid
Services (CMS) Actions
• Payment reforms for inpatient hospital services in 2008:
• …ensure that Medicare no longer pays for the additional costs of
certain preventable conditions (including certain infections)
acquired in the hospital…
1) Serious preventable events: Object left in during surgery; air
embolism; Delivering ABO-incompatible blood or blood
products
2) catheter-associated urinary tract infections
3) pressure ulcers
4) Vascular catheter associated infection
5) Mediastinitis after CABG surgery
6) Patient falls
7) VAE
8) Influenza vaccination rates
9) Future: MRSA, S. aureus BSI, CDAD (C. diff)
Impact of SSI Occurring After Discharge
* Many/Most SSI not identified until after discharge
•Cost for care with SSI were 2.9 times greater
•19.5% of readmits & 18% of ER visit …some at other facilities
•Post discharge SSIs can impair physical & mental health
•Surveillance (PDS) is inconsistent …phone/paper …honest
•Education - ? enough/consistent/updated
•Host defense – acute and chronic medical conditions
•Effective management to minimize consequences
http://www.hfma.org/Content.aspx?id=28199 Feb 2015
Pt.
J
DOB
Surg
5/22/63 3/7
Class Room
Procedure Description
1
OR 12 DECOMPRESSIVE LAMINECTOMY L4-5, L5-S1, NEURO FORAMOTOMY L4-5, L5-S1
J
4/8/54
3/7
1
OR 12 KNEE ARTHROSCOPY LEFT
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J
7/29/59 3/30
1
OR 12 KNEE ARTHROSCOPY RIGHT, PARTIAL MENISCECTOMY,
J
6/20/62 3/14
1
OR 12 KNEE ARTHROSCOPY LEFT, PARTIAL MENISECTOMY, PARTIAL CHONDROPLASTY
J
11/19/68 3/21
1
OR 12 KNEE ARTHROSCOPY RIGHT, PARTIAL CHONDROPLASTY, RELEASE PLICA
J
1/28/32 3/28
1
OR 12 KNEE TOTAL ARTHROPLASTY LEFT
J
8/31/91 3/28
1
OR 12 left KNEE ARTHROSCOPY with fixation of osteochondyle fx, debridement of
J
8/18/40 3/21
1
OR 12 LEFT TOTAL HIP REPLACEMENT
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9/10/30 3/11
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OR 10 OPEN REDUCTION, PINNING RIGHT FEMORAL NECK
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1/29/05 3/15
1
OR 8
J
9/16/60 3/14
1
OR 12 RELEASE OF ACHILLES TENDON RIGHT
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2/24/32
3/7
1
OR 12 REMOVAL OF FOREIGN BODY RIGHT THIGH ANTIBIOTIC BEADS
J
5/14/59 3/30
1
OR 12 REVISION LEFT TOTAL KNEE ARTHROPLASTY, EXTENSIVE SYNOVECTOMY
J
11/1/44 3/28
1
OR 12 REVISION, POLY LEFT KNEE, DEBRIDMENT, LATERAL RELEASE
J
1/13/25 3/21
1
OR 12 RIGHT KNEE ARTHROSCOPY, CHONDROPLASTY, PARTIAL MENISCECTOMY
J
12/1/38 3/28
1
OR 12 RIGHT OPEN QUADRICEPS REPAIR WITH AFLEX GRAFT
Stitch/
Superficial
Deep
Staple
Incisional
Incisional
REALINEMENT WITH PINNING AND CASTING LEFT ELBOW
Stitch/staple:
minimal inflammation and discharge confined to the points of suture penetration
Superficial Incisional:
Purlent drainage from the superficial incision; or pain or tenderness, localized swelling, redness, or
heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured
If from secondary incison (e.g., donor site [leg] incision for CABG), please note: Y- SIS
Deep incisional :
a. purulent drainage from the deep incision but not from the organ/space
b. incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured
a. purulent drainage from the deep incision but not from the organ/space
during reoperation, or by histopathologic or radiologic examination
ICD – 9 – CM codes
The Challenge of Surveillance of SSIs:
expanding universe of health care delivery
• Major trend towards
delivery in wide range of
settings
• Short lengths of stay +
inter-facility transfer is
common
• NEW: PACE (Program of
All-inclusive Care for the
Elderly) Home care for
55yr+ who met Medicaid’s
LTC eligibility with 24 hr call
line, respite care
• http://www.michigan.gov/mdch/0,4612,7-132-
2945_42542_42543_42549-87437--,00.html
Networking!
Ambulatory Surgery: Risk Free?
Cluster of Endoph-thalmitis after
cataract surg.
Acremonium kiliense
4 patients
Risk Factor: 1st case, Mondays
Humidified air in ventilation
likely source
Fridkin SK. Clin Infect Dis 1996
• Cluster of fungal
contamination of
saline breast implant
• Saline bottle stored
under waterdamaged ceiling &
• OR in negative
pressure
• Kainer MA. 40th IDSA
Steroid Injection Outbreak
(abstr)
CMS for Ambulatory Care
• 42 CFR Part 416 Medicare and Medicaid
Programs; Ambulatory Surgical Centers (ASC),
Conditions for Coverage:
• …require the ASC to designate a qualified
professional, such as a registered nurse, as the
infection control officer
• The infection control condition places
accountability on ASCs to prevent, control, and
• investigate infections and communicable diseases,
and take action that result in improvements…
Waterless Alcohol-based Hand Rub for Surgical
Hand Antisepsis
• Randomized trial, 4387
pts.
• Hand rub vs scrub with
antimicrobial soap +
water
• SSI rate in hand rub
(2.4%) vs scrub (2.5%)
not signif.
• Better compliance, less
skin irritation/dryness with
hand rub in personnel
Parienti JJ. JAMA 2002;
WHO
288:722-77
Possible SSI Prevention Measures
• Subcuticular suturing vs skin stapling technique,
CABG - 2 studies; no consistent results (Mullen JC. Can J Cardiol
1999;15:65- ; Chughtai T. Can J Cardiol 2000;16:1403-)
• Quill Suturing? …expensive
• Anemia & leukocyte-depleted red blood cell
transfusion - studies have had mixed results; more study
needed(Jensen LS. Transfusion 1995;35:719-; Titlestad IL. Int J Colorectal Dis
2001;16:147-;van de Watering LM. Circulation 1998;97:562-)
• Laminar Airflow & Orthopedic Surgery - Mixed results
& difficult to demonstrate clear cost effectiveness (Berbari EF.
Clin Infect Dis 1998;27:1247-)
• UV light vs Xenon gas
Possible SSI Prevention Measures
• Supplemental perioperative oxygen- randomized trial found
lower SSI with 80% O2 among 500 colorectal surgery pts.;however-high SSI
rate & risk index in control population - Need confirmation
(Grief R. N Engl J
Med 2000;342:161-7)
• Periop. normothermia - randomized trial of 200 patients,
colorectal surgery pts. = lower SSI rate with additional warming(forced air +
IV fluids) vs those with regular care; more investigation needed for wider
application (Kurz A. N Engl J Med 1996;334:1209-15)
• Changing Gloves/equipment - before closure(spillage)
• Invanz/Ertapenem – new studies suggesting not as effective
• More patients who received ertapenem developed Clostridium difficile infection
• http://dicon.medicine.duke.edu/sites/dicon.medicine.duke.edu/files/documents/October%202013%
20DICON%20newsletter--Avoiding%20Ertapenem.pdf
Category IA SSI Prevention
Recommendations
• Patient-focus:
• treat existing infections
first before OR
• avoid hair removal but if
needed use clippers
• Asepsis & technique:
• aseptic principles: IV,
inserting catheters,
administering medications
AJIC 1999;27:97-132
Category IB SSI Prevention
Recommendations
• Patient-focus:
• control serum blood glucose
• encourage tobacco
cessation
• preop shower
• clean skin incision site +
apply antiseptics
• Surgical Team:
• no artificial nails
• surgical hand antisepsis
AJIC 1999;27:97-132
Category IB SSI Prevention
Recommendations
• Intraoperative:
• Positive pressure in OR
• Min. 15 air changes/hour
• Filter supply air
• Keep OR doors closed as much as
possible
• sterilize surgical instruments; limit flash
sterilization
• Surgical Team:
• surgical mask, hair cover
• gown & sterile gloves
• Gentle handling of tissue
AJIC 1999;27:97-132
Category IB SSI Prevention
Recommendations
• Surveillance:
• Use CDC definitions
• Apply risk index
• Periodically calculate risk stratified SSI
rates
• Report SSI rates to surgical personnel
• Use standard case finding methods
AJIC 1999;27:97-132
Surgical Site Infection Criteria
• Superficial incisional SSI
• Infection occurs within 30 days after any NHSN operative procedure and
• involves only skin and subcutaneous tissue of the incision and
• patient has at least one of the following:
• a. purulent drainage from the superficial incision.
• b. organisms isolated from an aseptically-obtained culture of fluid or tissue from the
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superficial incision.
c. superficial incision that is deliberately opened by a surgeon and is culturepositive or not cultured
and patient has at least one of the following signs or symptoms: pain or
tenderness; localized swelling;
redness; or heat. A culture negative finding does not meet this criterion.
d. diagnosis of a superficial incisional SSI by the surgeon or attending
physician or other designee (see reporting instructions).
Two specific types of superficial incisional SSIs
• Superficial Incisional Primary (SIP)
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., C-section incision or chest incision for CABG)
• Superficial Incisional Secondary (SIS)
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 incision for CBGB)
• Do not report a stitch abscess, stab wound or pin site infection as SSI
• Diagnosis of “cellulitis”, by itself, does not meet criterion for superficial
incisional SSI.
Deep incisional SSI
• Infection occurs within 30 (most) or 90 days (implant) after the NHSN operative
procedure and involves deep soft tissues of the incision (e.g., fascial and muscle
layers) and patient has at least one of the following:
• a. purulent drainage from the deep incision.
• b. a deep incision that spontaneously dehisces or is deliberately opened by a surgeon
and is culture-positive or not cultured and patient has at least one of the following
S/S:
-fever (>38°C); localized pain or tenderness.
• c. an abscess or other evidence of infection involving the deep incision
• d. diagnosis of a deep incisional SSI by a surgeon or attending physician
or other designee
Organ/Space SSI
• Infection occurs within 30 or 90 days after the NHSN operative
procedure and
infection involves any part of the body, excluding the skin incision,
fascia, or muscle layers, that is opened or manipulated during the
operative procedure and
patient has at least one of the following:
• a. purulent drainage from a drain that is placed into the organ/space
• b. organisms isolated from an aseptically-obtained culture of
fluid or tissue in the organ/space
• c. an abscess or other evidence of infection involving the
organ/space
Special Comments:
• Occasionally an organ/space infection drains through the incision
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and is considered a complication of the incision. Therefore, classify it
as a deep incisional SSI.
• Report mediastinitis following cardiac surgery that is accompanied
byosteomyelitis as SSI-MED rather than SSI-BONE.
• If meningitis (MEN) and a brain abscess (IC) are present together
after operation, report as SSI-IC.
• Report CSF shunt infection as SSI-MEN if it occurs within 90 days
of placement; if later or after manipulation/access, it is
considered CNS-MEN
Report spinal abscess with meningitis as SSI-MEN following spinal
surgery.
Environmental Infection Control
Guidelines, 2003
• HVAC:
• Positive pressure ventilation
• Filtration
• Environmental Cleaning
• Preventing water-
associated illness
• Preventive maintenance
MMWR 2003;52:RR-10
A Surgeon’s Perspective on Prevention of SSI
“The most critical factors in the prevention of
postoperative infections, although difficult to
quantify, are the sound judgment and proper
technique of the surgeon and surgical team,
as well as the general health and disease
state of the patient”
-Nichols RL. Emerg Infect Dis 2001;7(No.2):220-4.
How to Display SSI data:
• Target …state in IP Plan
• Just %? …what if 1 of 2 procedures develop SSI?
• Denominator & numerator?
• Graphs
• Previous year …2 years?
• Scorecards
• Compare with NNIS vs Standard Infection Ratio (SIR)
• Special Investigations
• High volume surgery
• Surgeon specific?
• “Tell them/show them what they need to see”
Sample of displaying SSI’s:
2013
Surgery
Jan
2014
Feb
Total hip
# done
Apr
May
Jun
Jul
Aug
Sep
1
10
12
SSI rate/month
7
12
11
10
17
19
8
14.3%
Total knee
# done
Mar
Oct
Nov
1
1
13
10
12
SSI rate/month
16
16
18
18
21
15
19
20
1
# done
4
SSI rate/month 25.0%
21
8
14
4.8%
4
1
3
33.3%
3
1
141
11
Feb
Mar
Apr
210
9
9
10
20
1.4%
17
19
5.9%
2
4
2
0
3
2
3
38
5.3%
Jun
Jul
Aug
8
Sep
Oct
Nov
Dec
1
8
5
16
12.5%
1
24
May
1
3
1
4
Jan
2.1% 9.1%
1
12.5%
Vascular
12
7.7% 10.0%
2
20
Dec Total
14
3
19
7
8
7.1%
1
1
1
16
23
20
6.3%
4.3%
5.0%
12
5
22
20
19
8.3%
5
4
2
2
50.0%
232
2.16%
1
4
124
2.42%
1
20
Total
1
6
0
2
1
4
3
4
37
2.7%
Post discharge Data Surveillance:
Patient Name
DOB
Surgery
Class
Room
Procedure Description
Name of hospital
_________________
Education: New surgeons/Annually (definitions)
Skin/staple related? …don’t count
Incisional … skin or sub-Q , drainage, dehisence, I&D
Any cultures?
Readmit? Within 30 days vs NEW 2013: 90 days (implants)
SSI Surveillance & Prevention Intervention
• Feedback: surgeon/surgical personnel
SSI: Joint
or committee (s)
Arthroplasty, 94-99
10
8 given
• Result: Overall SSI rate/SIR for
(targeted) surgeries
6
4
2
0
• Action Plan: Quality Improvement
–
1994 1997
education, equipment, timing, etc. Yr
Deep
SSI
Superfic
. SSI
Summary Aspects of Surveillance
Program for Prevention of SSIs
• SSIs cause considerable morbidity and mortality
and are expensive complications to treat prevention therefore is cost effective
• Surveillance & Interventional Epidemiology is an
effective component of a facility’s patient
safety/performance improvement program
• Feedback of process & outcome data is helpful
but broad partnership involving multiple
disciplines is likely key to success
Skin & Soft Tissue Infections
• Changing Pattern of Community- Associated Skin
and Soft-Tissue Infection with methicillin-Resistant
Staphylococcus aureus (CA-MRSA)
• Almost three quarters of the soft-tissue infections were
caused by CA-MRSA (N=389 patients)
• King MD, et al. Ann Intern Med 2006; 144:309-317.
Example of Surgeon-Specific data:
Conclusions:
• SSI’s will always be with us
• MDRO’s will challenge us
• New techniques and technology will evolve
• Government agencies will change how we measure
quality performance (NHSN)
• Reimbursement can effect our process, advancing to
new equipment or products, how we stay in business
Sterile Processing
• From Acquisition to Reuse
Sterilization of Equipment
• Certified technicians
• Cleaning …ultrasonic (5 to 10 min) open instruments
…DRY/inspect
• Wrapping … trays
Sterilization
• - Steam 121oC (250oF) and 132oC (270oF). Manufacturers
recommendation.
Bowie-Dick test is used to detect air leaks and inadequate air removal
Biological monitor: Geobacillus stearothermophilus (formerly Bacillus stearothermophilus)
Monitored using a printout (or graphically) by measuring
temperature, the time at the temperature, and pressure
- Sterrad
• -Portable (table-top) steam sterilizers
• - Immediate use
• www.roboz.com/catalog%20pdfs/Sterilization_and_Maintenance.pdf quick chart
• www.cdc.gov/hicpac/Disinfection_Sterilization/13_0Sterilization.html
Correct loading /unloading
• Sufficient space must occur around the packages
• place items on edge and no chamber wall touching
• do not stack packages or cassettes one upon the other
• paper of one pouch next to the plastic of the adjacent pouch
• Basins, bowls or other devices on their sides
• running a load with both linens and medical instruments, place
the linen packs on the top shelf
• heavy medical items or large trays flat on the bottom shelves
• Some steam sterilizers have an automatic dry cycle
• opening the door about ½ inch after the pressure equalizes and
let items sit inside the chamber for 30 to 60 minutes
• Wet packages that exist at the end of steam-sterilization cycles
should not be handled
Steam Sterilizer recall
• Recalls due mechanical, chemical and biological
-Who you going to call?
• Retrieval of processed items
• Notify your sterilizer service representative
• Re-validated with three consecutive negative biological
monitors in three consecutive cycles
• AAMI recommends that sterilizers be biologically
monitored at least once a week, preferably daily, when
normal cycles are used, in each flash sterilization load
and in any load containing an implantable device.
• http://www.spdceus.com/recalls.htm for online info & quiz