Transcript Care of Postop Dressings by Nursing Staff

Establish a Culture of Safety:
Working Toward Zero
Surgical Site Infections
Maureen Spencer, RN, M.Ed, CIC
Infection Preventionist Consultant
Email: [email protected]
www.workingtowardzero.com
www.creativehandhygiene.com
Despite current preventive measures,
SSIs remain a significant problem

In the US, at least 780,000 SSIs occur each
year1
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SSIs account for about 37% of all hospitalacquired infections for surgical patients1
 SSIs
1.
2.
occur in up to 5% of surgical patients2
WHO Guidelines for Safe Surgery 2009.
Cheadle WG. Risk factors for surgical site infection. Surg Infect. 2006;7: s7-s11.
2
Mortality risk is high among patients
with SSIs

A patient with an SSI is:
 5x
more likely to be readmitted after
discharge1
 2x more likely to spend time in intensive care1
 2x more likely to die after surgery1

The mortality risk is higher when SSI is
due to MRSA
A
patient with MRSA is 12x more likely to die
after surgery2
1.
2.
WHO Guidelines for Safe Surgery 2009.
Engemann JJ et al. Clin Infect Dis. 2003;36:592-598.
3
SSIs are costly and are a financial
burden on the healthcare system
1.
2.
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The average cost of treating one SSI is
between $11,000 and $35,0001

The average cost of treating one MRSArelated SSI is
more than $60,0002

In total, SSIs have been estimated to cost
the US healthcare system up to $10
billion/yr1
Scott RD. Centers for Disease Control and Prevention. March 2009.
Anderson DJ et al. PLoS One. 2009 Dec 15;4(12):e8305.
4
Changing demographics are increasing
patients’ risk for SSIs

1.
2.
3.
4.
A patient with even ONE of these risk factors is at greater
risk of developing an SSI.1-4
 Older (>70 yrs old)
 Obese (BMI > 25)
 Smoker
 Diabetes or poor glucose control
 Undergoing abdominal surgery
 Prolonged surgery required (>2 hrs)
 Longer hospital stay
 ≥3 discharge diagnoses
Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134.
SHEA, APIC, CDC, SIS Consensus paper. Infect Control Hosp Epidemiol 1992;13:599-605.
Cheadle WG. Surg Infect. 2006;7: s7-s11.
Konishi T, Watanabe T, Kishimoto J, Nagawa H. Ann Surg. 2006 Nov;244(5):758-63.
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6
SSI Risk Factors –
Procedures/Techniques
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Duration of operation
Duration of surgical scrub
Preoperative shaving,
skin preparation
Inadequate OR ventilation
Inadequate sterilization of
instruments
Surgical technique
Tissue kept moist with saline
heals better
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Poor hemostasis
Failure to obliterate dead
space
Tissue trauma
Skin antisepsis
Antimicrobial prophylaxis
Surgical drains
Tissue allowed to air dry
do not heal as well
Mangram AJ et al. Am J Infect Control. 1999;27:97-134
Orthopedic Surgical Site Infection

Orthopedic Total Joint Infections:
 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 THE
SURGEON
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Relative Economic Burden Associated with
HAIs
• SSI
Surgical Site Infections
• CLA-BSI
Central-Line Associated
Blood Stream Infections
• VAP
Ventilator Associated Pneumonia
• CA-UTI
Est. Annual # of
Infections
Direct Cost per
Patient (2007$)
Avg. Increased
Length of Stay
Attributable
Mortality
290,485
$34,670
~12 days
4%
$29,156
~10-24 days
26%
$28,508
~9-13 days
24%
$1,007
1 day
1%
~$30,000
~9.1 days
~4%
(~17% of HAIs)
248,678
(~14% of HAIs)
250,205
(~15% of HAIs)
561,667
Catheter-Associated
Urinary Tract Infections
(~32% of HAIs)
• Other / MDROs*
386,090
Multi-Drug Resistant Organisms (e.g.,(~22% of HAIs)
MRSA, C. difficile, VRE, etc.)
9
* NOTE: MDRO often cause other infection types (e.g., SSI, BSI, VAP, UTI); MDRO statistics reflect CDC estimates for methicillin-resistant Staphylococcus aureus
(MRSA) only.
SOURCES: Klevens, et al., “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Review, 2007; CDC: “The Direct Medical
Cost of HAIs in U.S. Hospitals and the Benefits of Prevention”, March 2009; Kirkland, et al., “The Impact of Surgical Site Infections”, Infect Control Hosp Epidemiol, 1999;
Arch Internal Med, 1988; Arch Internal Med, 1974; Infect Control Hosp Epidemiol, 2002; CareFusion MedMined Analysis, 2009 .
Pathogens survive on surfaces
Organism
Survival period
Clostridium difficile
35- >200 days.2,7,8
Methicillin resistant Staphylococcus aureus (MRSA)
14- >300 days.1,5,10
Vancomycin-resistant enterococcus (VRE)
58- >200 days.2,3,4
Escherichia coli
>150- 480 days.7,9
Acinetobacter
150- >300 days.7,11
Klebsiella
>10- 900 days.6,7
Salmonella typhimurium
10 days- 4.2 years.7
Mycobacterium tuberculosis
120 days.7
Candida albicans
120 days.7
Most viruses from the respiratory tract (eg: corona,
coxsackie, influenza, SARS, rhino virus)
Few days.7
Viruses from the gastrointestinal tract (eg: astrovirus, HAV,
polio- or rota virus)
Blood-borne viruses (eg: HBV or HIV)
1.
2.
3.
4.
5.
6.
Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5.
BIOQUELL trials, unpublished data.
Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2
Boyce. 2007. J Hosp Infect. 65:50-4.
Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200.
French et al. 2004. ICAAC.
60- 90 days.7
>7 days.5
7. Kramer et al. 2006. BMC Infect Dis. 6:130.
8. Otter and French. 2009. J Clin Microbiol. 47:205-7.
9. Smith et al. 1996. J Med. 27: 293-302.
10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4.
11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.
Why Better Environmental Cleaning?
Prior room occupancy increases risk
Study
Healthcare associated pathogen
Martinez 20031
VRE – cultured within room
VRE – prior room occupant
MRSA – prior room occupant
VRE – cultured within room
VRE – prior room occupant
VRE – prior room occupant in previous
two weeks
2.6x
1.6x
1.3x
1.9x
2.2x
C. difficile – prior room occupant
A. baumannii – prior room occupant
P. aeruginosa – prior room occupant
2.4x
3.8x
Huang 20062
Drees 20083
Shaughnessy 20084
Nseir 20105
1.
2.
3.
4.
5.
Martinez et al. Arch Intern Med 2003; 163: 1905-12.
Huang et al. Arch Intern Med 2006; 166: 1945-51.
Drees et al. Clin Infect Dis 2008; 46: 678-85.
Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.
Nseir et al. Clin Microbiol Infect 2010 (in press).
Likelihood of patient acquiring HAI
based on prior room occupancy
(comparing a previously ‘positive’
room with a previously ‘negative’
room)
2.0x
2.1x
New England Baptist Hospital
Boston, MA
Working Toward Zero Teams
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150-bed adult medical/surgical
hospital located in Mission Hill
area of Boston
Orthopaedic subspecialty
hospital & “Center of
Excellence”
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Acute inpatient discharges:
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75% Orthopedic
8% General Surgery
17% Medical
Orthopaedic Surgery ~
12,000/cases a year
>4700 total joints
 >1500 spine
 >3600 other (foot, shoulder, etc)
 > 3100 outpatient
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2
Orthopedic Service - Infection Rates - Date of Onset
1.5
1
0.5
0
2
Orthopedic Infection Rates - Date of Surgery
Antibacterial sutures
1.5
MRSA/MSSA Eradication Program
Chloroprep
Instituted incisional adhesives and
AMD Gauze
1
0.5
0
Increase in Lami infections due to locally
administered steroids
Increase in total knee infections – due to
improper use of needles for OR pain meds
Post-op hematomas being
investigated
Making the Case to
Cover Incisions
While Hospitalized
Post-op Skin Issues in Orthopedics
Anterior fusion with tape burns
Posterior fusion with contaminated steri-strips
Contaminated steri-strips
Staples increase infection rate
Obesity and Surgical Incision
 Incision collects fluid –
serum, blood - growth
medium for organisms
 Spine fusions -incisions
close to the buttocks or neck
 Heavy perspiration common
 Body fluid contamination
from bedpans/commodes
 Friction and sliding - skin
tears and blisters
 Itchy skin - due to pain
medications - skin
breakdown
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Due to Environmental Contaminants – Do Not
Recommend Incisions Opened to Air
Bacteria use blood (and sugar) as
a fuel source
Incisions are in exudative stage of
wound healing first 2-3 days
postop
Proliferative stage begins ~ day
3-4 and most patients are sent
home around that time
Incisions are best protected if
sealed – or covered with an
antimicrobial gauze, silver
dressing
Resident and PA Direct Observation Study:
ABD with Paper or Gauze Tape
Check residents and physician assistant dressing
technique
ABD pads may be stuffed in lab coat pockets during
rounds and gloves may not be worn for dressing
changes
Lack of hand hygiene before and after patient contact
Bandage scissors often used between patients with no
cleaning
Discard bloody dressings in regular waste
Facility Approach: Standardization to an
Antimicrobial Dressing (AMD)
AMD secured with MeFix
tape and dated for
protection from exogenous
contamination
Standardization of
Post-operative
Dressings
Goal
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Primary goal is to cover all incisions with AMD
gauze dressing (antimicrobial)
Leave primary dressing in place for at least 2
days post-op or until the day of discharge to
create an occlusive environment for wound
healing
Nursing staff will assume responsibility for
dressing changes, assessments, and reporting
of complications to MD, PA, or NP
Initial Dressing Change
 Will
be completed as specified on
the orthopedic order sheet
Example: POD # 2
 Preferably dressing would be left in
place until day of discharge
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 Exception:
Significant strike
through (post-op drainage)
Alert the MD, PA, NP
 Initially reinforce and change
dressing in 24 hrs
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Subsequent Dressing Changes
 On
the morning of discharge
change the dressing and
record the condition of the
incision in the progress notes
 Notify the Attending MD if
available or resident, PA, or
NP of any significant findings
Report Significant Findings
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Notify the Attending MD:
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Evidence of wound
dehiscence
Drainage
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Sanguinous and Purulent
drainage
Moderate or Copious
amount of drainage
Incisional Complication
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Blisters
Erythema
Edema
Skin Tears
Warmth
Ecchymosis
Incisional Breakdown
Postop Dressing Care
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Sanitize hands
Wear clean gloves to remove primary
dressing
Sanitize bandage scissors with alcohol
between use
Discard old dressing in red bag if saturated
and dispose in soiled utility room
Apply a sterile dressing using Kendall’s AMD
gauze (antimicrobial dressing – purple
package)
Affix gauze with MeFix tape (hypoallergenic
self-adhesive fabric tape), Tegaderm, or Ace
Wrap as appropriate
MeFix Tape
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Pull the sides of the
tape to break open
the backing
Remove one side all
the way down the
piece of tape
Tape one side of the
gauze and then the
other
Do not stretch as you
apply to prevent
blisters
Hip Dressing
Typically the
original dressing
will be covered with
either Microfoam or
Tegaderm
Microfoam dressing
Tegaderm dressing
Dressing Treatments
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Hip Incisions
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Apply 2 - 4 AMD Gauze Over
Incision
Loosely secure with MeFix
tape to allow for swelling
Date and initial the dressing
If dressing is removed for a
brief inspection it may be resecured in place
If dressing removed entirely
by surgeon or other – reapply
as soon as possible
Dressing Treatments
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Knee Incisions
 AMD
gauze directly over
incision
 6 inch Ace wrap
dressing
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Applied distal to proximal and
should extend to mid-thigh level
above any suprapatellar pouch
swelling to avoid a tourniquet
affect just above the knee
Spine Service and Shoulders
AMD Island
dressing –
left on until
discharge
AMD sealed with
Tegaderm left on until
discharge
Rotator cuff (and
total shoulders) –
Dermabond is
being used or an
AMD gauze
covered by
tegaderm – left on
until discharge
Strike Through
Minimal strike-through drainage
 Leave dressing intact
 Change dressing as indicated on
orders
Significant strike-through drainage
 Notify MD, PA, or NP and reinforce
unless otherwise ordered
 Change dressing on Post-op Day1
Documentation:
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Daily Skin Assessment in Meditech
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Location
Description
Drainage
Periphery
Wound Edges
Amount of Exudate
Type of Exudate
Nursing Intervention
Comment: Incisional Complications
Progress Notes for any complications
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Specify who was notified and when
Specify treatment and plan for any incisional complications
Discharge Dressings
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Hip, Knee, Spine, and Shoulder Discharge Dressings
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Apply same dressing used in the hospital
Wounds Without Drainage
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Patient should be instructed to remove the dressing after 2 days. It can then be
left open to air.
 Once the dressing has been removed, the patient may shower after the 2 days
but should be instructed not to use washcloths or scrub the incision with any
soap.
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Wounds With Drainage
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VNA services required at home
Dressings may vary depending on amount of drainage
Wounds with Sutures or Staples
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Should be kept covered until the sutures or staples are removed
Cost Savings
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Discharge Supplies
 Patients
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Supply patient with 2 additional dressing changes at home
Shower drapes: (for patients without Tegaderm)
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2 per patient or more if appropriate
They can be cut in half
 Patients
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with Sutures or Staples:
with Steri Strips
Unless draining, patient will not need any supplies for home
Questions?