Transcript Webinar 4: Checklist Modification/Customization

Surgical Site Infections:
Preparing Our Patients For Surgery
Our Last Call Together
• Three problems that sit at the core of surgical
site infections
– Doing reliably what we know needs to be done
– Teamwork and communication
– Always being vigilant about keeping the patient
safe
• The South Carolina Surgical Safety Checklist
as a drug
Preventing SSI’s
Pre-Incision
•
Patient
•
•
Glucose Control
Hyperoxia
•
•
Basics of Skin
Prep
• Showers
• Skin Wipes
Hair Removal
Weight Based
Dosing
MRSA Screening
Glucose Control
•
•
Antibiotic
Bowel Prep
•
•
•
•
•
Re-dosing
Operating Time
Use of Tourniquet
Surgical Technique
Wound protectors
•
•
•
•
Basics of Sterility
Instrument Sterility
Hand Hygiene
Temperature
Control
Teamwork
Culture
•
•
•
•
•
•
•
Basics of Sterility
Instrument Sterility
Hand Hygiene
OR Traffic
Temperature Control
Teamwork
Culture
•
•
Operation
Environment
Incision/Surgery
•
•
Post Op
•
•
Wound care
Dressings
•
Discontinue
antibiotics
Teamwork
Culture
•
•
Todays Topics
•
•
•
•
Chlorhexidine Wipes
Preoperative Bacterial Screening
Keeping Your Patient Warm
Alcohol-Based Skin Preps
Chlorhexidine Wipes:
Common Sense Science
• Bacteria on the skin is bad. Wiping the skin with chlorehexidine
could be good
• Started in the ICU when patients who bathed with chlorexidine
impregnated cloths on a daily basis developed fewer bloodstream
infections
• Patients are less likely to develop a SSI if they use wipes the night
and morning before their procedure1
• 50% overall reduction in SSI in orthopaedic surgery1
• Studies show that even if patients are not fully compliant wipes still
can have an impact2
1. Eiselt. Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical
Patients. Orthopaedic Nursing. 2009; 28: 141-145 .
2. Zywiel et al. Advance pre-operative chlorhexidine reduces the incidence of surgical infections in knee arthroplasty. International Orthopaedics. 2011; 35;
1001-1006.
Useful Resources
The Institute for
Healthcare
Improvement has
examples of patient
materials for preparing
skin before surgery
http://www.ihi.org/knowledge/Pages/Tools/PreparingYourSkinBeforeSurgeryPatientInstructionsSSI.aspx
Preoperative Bacterial Screening:
Common Sense Science
• Patients who carry Staphylococcus aureus
(SA) are more likely to develop a surgical
site infection
• Patients should be screened prior to
surgery
• Schedule the screening so there is enough
time to kill the bacteria
How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA: Institute for Healthcare Improvement; 2012.
(Available at www.ihi.org)
S. Aureus Nasal Carriage
Persistent carriers
Always carry one strain of S.
aureus
Intermittent carriers
Carry different strains of S.
aureus intermittently
Noncarriers
20%
60%
20%
Kluytmans. Clin Microbiol Rev 1997; 10:505
S. Aureus Nasal Carriage
Usual Prevalence
Population
Percentage
General population
20%
Health care workers
27%
Patients on admission
36%
Patients on insulin
56%
Hemodialysis patients
52%
Chronic renal failure
21%
I.V. drug users
55%
Kluytmans. Clin Microbiol Rev 1997; 10:505
Useful Resources
The Institute for
Healthcare
Improvement has
sample tools for
educating patients
http://www.ihi.org/knowledge/Pages/Tools.aspx
Keeping Your Patient Warm:
Common Sense Science
• Human beings are warm-blooded
• The body fights infection better when it is
warm
• The operating room is a cold place
• Keeping patients warm can be a challenge
• The best thing to do is to never let your
patient get cold
Redistribution Hypothermia
Core
37°C
Core
36°C
Periphery Periphery
31-35°C
33-35°C
Vasoconstricted
Anesthesia
Vasodilated
Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012 .
Perioperative Warming,
Intraoperative Temperature and
Complications
Periop
N=47
Standard
N=56
P Value
200 ml
400 ml
0.011
Any complication
32%
54%
0.027
SSI
13%
33%
0.09
Blood loss
Wong. Br J Surgery 2007; 94: 423-6
Temperature and SSI
Following Colectomy
SSI
Normo
(104)
Hypo
(96)
P Value
6
18
.009
Kurz. NEJM 1996;334:1209
Keep your patient warm
before they go to surgery
• It is like “money in the bank”
• Use warming blankets before they go into
the OR
• Think about putting a hat on your patient
Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012
How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012.
Keeping Your Patient Warm
in the O.R.
• Pre-warming and active warming in the OR
is much more important than the OR room
temperature
• Put warming blankets under and over your
patient on the operating table (if possible)
• Use warmed fluids for IVs
• Use warm irrigation on the field (if possible)
Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012
How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012.
Alcohol-Based Skin Preps:
Common Sense Science
• The combination of alcohol together with
another agent is probably better because
there are two things killing the bacteria
• An antibacterial prep that lasts on the skin is
better than one that doesn’t1
• If you don’t let the prep dry or wipe it off it
can’t work because it is not on the skin
anymore
1. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18-26.
2. Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infection
rates: A prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol.
No skin prep will be effective
if you don’t use it the way that
you are supposed to
• Let the prep completely dry prior to draping
• Avoid pooling of the skin prep
How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012
Take Home Messages
Pre-Incision
•
Patient
•
•
Glucose Control
Hyperoxia
•
•
Basics of Skin
Prep
• Showers
• Skin Wipes
Hair Removal
Weight Based
Dosing
MRSA Screening
Glucose Control
•
•
Antibiotic
Bowel Prep
•
•
•
•
•
Re-dosing
Operating Time
Use of Tourniquet
Surgical Technique
Wound protectors
•
•
•
•
Basics of Sterility
Instrument Sterility
Hand Hygiene
Temperature
Control
Teamwork
Culture
•
•
•
•
•
•
•
Basics of Sterility
Instrument Sterility
Hand Hygiene
OR Traffic
Temperature Control
Teamwork
Culture
•
•
Operation
Environment
Incision/Surgery
•
•
Post Op
•
•
Wound care
Dressings
•
Discontinue
antibiotics
Teamwork
Culture
•
•
Questions
Upcoming Calls
Thursday, June 13th 2:00-2:45
Preventing VTE’s in Surgical Patients
Thursday, June 27th 2:00-2:45
Other Ways of Preventing Venous
Thromboembolism
Office Hours:
Wednesday 2:00-3:00
Resources
Website:
www.safesurgery2015.org
Email:
[email protected]