4/14/2016
SURGICAL SITE INFECTIONS
(SSI) IN THE ASC
INVESTIGATION, FOLLOW‐UP
AND MITIGATING FUTURE RISKS
Lisa Booth, RN, LHRM, Infection Preventionist April 21, 2016
Learning Objectives
Upon completion of this unit, students should be
able to:
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Identify common SSI pathogens
Discuss SSI investigation techniques
Discuss SSI prevention strategies
Identify common sterile processing findings
Discuss risks of SSI related to medical equipment, devices and supplies
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Operating Theatre
SSIs‐How Many is Too Many?
One Infection is One Too Many
TARGETING ZERO HAIs
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SSI Statistics
NHSN 2015
• Estimated 8,205 deaths/year
• Estimated 11% of all deaths in ICU
• Most frequent cause (20%) of unplanned readmissions after surgery
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$13.2 billion in additional costs per year
• Estimated 11 additional days of hospitalization for each SSI per patient
SSI Rates in the ASC
Agency for Healthcare Research & Quality (AHRQ) 2014
30 Day Infection Rate is approximately 0.48%
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HISTORICAL PERSPECTIVE
Florence Nightingale
“The very first requirement in a hospital is that it should do the sick no harm”
1820‐1910
• Pioneer of modern Nursing
• Reformer Sanitation Methods
• Determined poor living conditions were leading cause of deaths of soldiers in army hospital
• Early Statistician‐ gathered data during Crimean War
Ignaz Semmelweis
Father of Handwashing
“WASH YOUR HANDS”
Late 1840’s
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High infant mortality rates noted in obstetrical hospital
Ordered medical students to wash hands
Dramatically decreased infant mortality rates
Met with enormous resistance
Ostracized in the medical community
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SSI Pathogen Sources
Exogenous
Surgical team members
 Soiled attire
 Break in aseptic technique
 Inadequate hand hygiene
• Physical Environment & Ventilation in OR
• Equipment, devices, materials in the OR
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Endogenous
Patient Flora
 Skin
 Mucous membranes
 GI tract
• Seeding focus of infection
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Common SSI Pathogen Sources
PATHOGENS
SOURCES/INFO
Staphylococcus  Normalflora(patient&staff)
aureus
 Healthcareenvironment(surfaces,equipment)
 Highest inOrthopedicSSIs
 Leadingcauseofbacterialdiseaseinhumans
 IncreasingnumbersofMRSAinfections
Coagulase‐
 Normalfloraofskinandmucousmembranes
negative
(patient&staff)
staphylococci
 Healthcareenvironment(surfaces,equipment)
 Immunocompromised patients
 Presenceofanindwellingmedicaldevice
 S.Epidermidisismostcommon speciesinSSIs
Enterococcus  Foundinhuman&animalintestines
spp.
 NormalFlora(patient&staff)
 Healthcareenvironment(surfaces,equipment)
 E.faecalis&E.faeciummostcommon
 IncreasingnumbersofVREinfections(E.
faecium)
Common SSI Pathogen Sources
PATHOGENS
Escherichia
coli
Pseudomonas
aeruginosa
SOURCES/INFO
 Foundinhuman&animalintestines
 Normalflora(patient&staff)
 Healthcareenvironment(surfaces,
equipment)
 Contaminatedwater source
• Most frequent cause of UTIs
 Mostcommoninhabitantofsoilandwater
 Sourceisoftenexogenous(outsidethehost)
 Normalintestinalandskinflora(patient&
staff)
 Survivesinmoistenvironments
 Healthcareenvironment(surfaces,
equipment,sinks,drains,whirlpools,RT
equipment)
 Immunocompromisedpatients
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How do Pathogens Contaminate Wounds ?
• Direct Contact: Transfer from hands of caregivers or from equipment
• Airborne Dispersal: Micro‐organisms deposited from surrounding air
• Self‐Contamination: Migration from the patient’s skin or GI tract
National Institute of Allergy and
Infectious Diseases (NIAID)
Chain of Infection
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SSI Investigation Scenario 1
Cluster of Pseudomonas Cases
• Case 1: Knee arthroscopy with debridement
 DOS: March 20
 Infection Reported: March 31
 Organism Cultured from Wound‐ Pseudomonas
• Case 2: Shoulder arthroscopy with debridement
 DOS: March 23
 Infection Reported: March 31
 Organism Cultured from Wound‐ Pseudomonas
SSI Investigation Scenario 1
Common Findings
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Same organism isolated
Same surgeon
Both orthopedic cases used a scope
Same type of instrumentation used
Same circulating nurse
Same surgical site prep solution
Same surgical suite
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SSI Investigation Scenario 1
Pseudomonas Areuginosa
Sources/Info
Commonly found in soil and water
Present in normal intestinal & skin flora
Ability to survive in moist environments
Spread on the hands of healthcare workers or by contaminated or improperly cleaned equipment
• Easily found in healthcare environment in  Sinks; Drains
 Soap solutions; Disinfectants
 Medical equipment & devices
 Dialysis fluids
 Whirlpools
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CDC/ Janice Haney Carr
SSI Investigation Scenario 1
Immediate Actions‐ Top Priority
• Notify Infection Preventionist
• Identify the scope or scopes used for each procedure and take them out of commission
• Re‐clean and reprocess all arthroscopic endoscopes following manufacturer’s information for use (IFU)
• Re‐clean and reprocess all instrumentation used for arthroscopic procedures according to IFU
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SSI Investigation Scenario 1
Immediate Investigative Actions • Discuss situation with staff and physicians and emphasize hand hygiene & aseptic technique
• Review manufacturer’s IFU for cleaning scope and shaver handpiece with employees responsible for reprocessing. Ensure each step is precisely followed
• Observe cleaning of scope based on manufacturer’s IFU
• Check and remove sink aerators in the decontamination and clean processing rooms
• Review and observe surgical site prep process
SSI Investigation Scenario 1
Investigative Findings
Scope Cleaning Process
• Detergent solution should be changed after each instrument washing
• Disposable brushes used to clean shaver handpiece should be discarded after each use
• Shaver hand piece switch should be in the “on” position prior to cleaning and sterilization
• Shaver attachment should be soaked in both enzymatic and detergent solution for 15 minutes
• Clean and reprocess shaver handpiece with strict adherence to manufacturer’s recommendations (IFU)
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SSI Investigation Scenario 1
Shaver Handpiece
SSI Investigation Scenario 1
Investigative Findings Sink Faucet Aerator
Debris noted in aerator of sink located in clean processing room
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SSI Investigation Scenario 1
Investigative Findings Sink Faucet Aerator Information
• Aerator’s are found on the tip of a faucet to create a no‐splash stream and deliver mixture of water and air
• Controversial as to the benefits of removal of aerator to prevent dirt and debris build‐up
• Can culture aerator to determine microbial growth
• Cultured for routine Legionella testing in high‐risk environments and in Legionella investigation
Decision to culture or not to culture in this investigation
SSI Investigation Scenario 1
Documented Literature Outbreak
of Pseudomonas SSIs
Outbreak of Pseudomonas aeruginosa Surgical Site Infections after Arthroscopic Procedures: Texas, 2009
• Seven organ/space SSI’s after arthroscopic procedures within 15 day period
• Isolated organism Pseudomonas aeruginosa
• Endoscopic evaluation revealed retained tissues in both the inflow and outflow cannula and shaver handpiece
• No additional cases after changes in instrument reprocessing
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FDA Alert‐ Arthroscopic Shavers
July 7, 2009
“FDA informed healthcare professionals of instances in which pieces of tissue have remained within arthroscopic shavers .………. even after the cleaning process was believed to have been completed according to the manufacturer’s instructions.”
“FDA encourages facilities that use any of these types of devices to evaluate the adequacy of their cleaning procedures……….”
SSI Investigation Scenario 1
Conclusion
As with the majority of surgical site infections, it is unlikely that a definite cause can be identified with a 100% certainty, but it appears that inconsistent decontamination and cleaning processes related to the shaver handpiece most likely contributed to this cluster of pseudomonas infections
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#1 TJC Cited Deficiency Related to Infection Control in 2015
The Organization reduces the risk of infection with medical equipment, devices and supplies
Common Findings during SPD Survey
• Staff not consistently following manufacturer’s IFU for cleaning and sterilization found
during equipment tracers
• Disposable brushes used to clean devices must be discarded after each use
• Reusable brushes must be cleaned after each use
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Common Findings during SPD Survey
• Elevated IUSS rates
• Loaner Equipment must be cleaned at the receiving facility according to manufacturer’s IFU
• Daily monitoring of Temp and RH in decontamination, sterile processing and sterile storage rooms
• Instruments waiting to be cleaned must be sprayed with enzymatic solution as soon as possible after use
• PM records for Sterilizers must be readily available
• Daily temperature log and monitoring for high‐level disinfectant solution that is present in a cleaning receptacle
Common Findings during SPD Survey
• Instruments packaged for sterilization must be in the open position
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Common Findings during SPD Survey
• Quality controls on Cidex OPA strips as per manufacturer’s IFU with each new container opened
• GI Endoscopes must be hung vertically in a vented cabinet without
touching the sides of the cabinet
• There must be a clear separation (3 feet) between the dirty and clean areas in Endoscopy work room
Common Findings during SPD Survey
• No chemical indicator
in peel packs
• Improper measurement of enzymatic and detergent
solution mixture as per manufacturer’s IFU
• Detailed Competencies must be completed on‐
hire and annually
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Common Findings during SPD Survey
Room Pressurization Variances
Decontamination/Dirty Room‐ should be negative
Sterilization/Clean Room‐ should be positive
Operating Room‐ should be positive
Equipment Storage Room‐ should be positive
• Quick pressurization test technique
• Routine engineering checks
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Common Findings during SPD Survey
Rigid sterilization containers • Debris and rust on containers
• Complex devices
• Multiple seals, filters, retentions plates & valves
• Should be routinely inspected
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Rigid Containers vs. Wrapped Trays‐
Bacterial Ingress (AJIC December 2015)
Sterility Maintenance Study: Dynamic evaluation of sterilized rigid containers and wrapped instrument trays to prevent bacterial ingress CONCLUSION:
• 111 rigid containers tested, only 14 had no bacterial ingress
• 161 wrapped trays tested (100%) had no bacterial ingress
• Sterilization wrap products provide greater protection against airborne bacterial ingress compared with rigid containers
• Some rigid containers had high levels of bacterial ingress
• Barrier efficacy of rigid containers may diminish over time
• Need greater level of attention to ensure the performance of rigid containers as they age
• Review manufacturer’s usable life recommendation‐ some are 10 years.
CDC & FDA HEALTH ADVISORY‐ September 2015
Public health need to properly maintain, clean, and disinfect or sterilize reusable medical devices.
Summary
Recent infection control lapses due to non‐
compliance with recommended reprocessing procedures highlight a critical gap in patient safety. Recommendations
Healthcare facilities should arrange for a healthcare professional with expertise in device reprocessing to immediately assess their reprocessing procedures. This assessment should ensure that reprocessing is done correctly………reprocessing personnel to follow all steps recommended by the device manufacturer. 18
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FDA Issues Safety Alert for Duodenoscopes (ERCP Endoscopes)
February 2015
• The complex design of endoscopic retrograde cholangiopancreatography (ERCP) endoscopes (also called duodenoscopes) may impede effective reprocessing.
• Recent medical publications and adverse event reports link multidrug‐resistant bacterial infections in patients who have undergone ERCP with reprocessed duodenoscopes
• Meticulously cleaning duodenoscopes prior to high‐
level disinfection should reduce the risk of transmitting infection
Duodenoscopes linked to CRE Resistant Bacteria
• National Attention: 2015 UCLA Medical Center Outbreak of CRE related to duodenoscopes used for ERCP procedures
• 7 infections, 2 deaths, 200 patients tested
• 2012‐2015, closed channel duodenoscopes linked to 25 different antibiotic resistant outbreaks world‐
wide; 250 people infected
• Elevator wire channel difficult to disinfect
• Manufacturers have recently implemented revised reprocessing instructions
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SSI Investigation Scenario 2
Cluster of Staphylococcus Aureus Cases
4 Staphylococcus Aureus SSIs within three week period
• Orthopedic, General, and Podiatry
Cases
• Most common organism responsible for surgical site infections
• Most common SSI scenario in ASC setting
SSI Investigation Scenario 2
Common Findings
Detailed Review of Cases Individually and Comparatively
Same organism isolated
Same OR room in 3 of the 4 cases
Same surgeon in 2 of the 4 cases
Same scrub tech in 2 out of the
4 cases
• Same circulator in 2 out of the 4 cases
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SSI Investigation Scenario 2
Staphylococcus Aureus Sources/Info
• STAFF: normal flora, improper practices
• PATIENT: normal flora, improper pre‐op/post‐
op practices
• ENVIRONMENT: healthcare surfaces, air
• EQUIPMENT/SUPPLIES: contamination or improper cleaning
SSI Investigation Scenario 2 Investigative Actions STAFF/PRACTICE AS A SOURCE‐ FOCUS:
EVALUATE ACCORDING TO EVIDENCED‐BASED PRACTICES
• Observe staff for any break in aseptic technique
focus on proper mask, head, and arm cover
placement • Ensure that proper surgical attire guidelines are followed at all times (AORN)
• Ensure proper surgical site prep technique • Ensure clipping and not shaving is used to prep site
• Ensure most effective surgical prep solution usage 21
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SSI Investigation Scenario 2 Investigative Actions STAFF/PRACTICE AS A SOURCE‐ FOCUS:
• Review pre‐op antibiotic administration & timing
• Review appropriateness of antibiotic selection based on surgical procedure • Review re‐administration of antibiotics during long cases
• Minimize traffic in and out of OR • Ensure no personal items in the OR
• Ensure proper hand hygiene
• Maintain normothermia
• Maintain blood glucose monitoring/control pre‐op and post‐op
SSI Investigation Scenario 2 Investigative Actions PATIENT AS A SOURCE‐ FOCUS
Ensure Detailed Preoperative and Postoperative Infection Prevention Education of Patient & Family • Protect site with sterile occlusive dressing for 24 to 48 hours post‐operatively
• Hand hygiene‐ wash hands before and after dressing changes and contact with site
• Proper surgical site incision care
• Signs & symptoms of infection
• Reporting of unusual signs & symptoms
• Night before showering with CHG as indicated
• Smoking cessation prior to surgery
• Glucose control pre and post procedure
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SSI Investigation Scenario 2 Investigative Actions ENVIRONMENT AS A SOURCE‐ FOCUS
• Pressurization in Operating Room, Sterile and Processing, Decontamination Areas
• Air Exchanges in Operating Room
‐15 exchanges per hour‐ older designed
‐20 exchanges per hour‐ newer designed
• Air flow across the foot of the OR table
‐25 to 35 feet per minute at diffuser
• Design of OR environment should flow from clean to dirty
• Terminal cleaning and cleaning between cases
SSI Investigation Scenario 2 Investigative Actions EQUIPMENT/SUPPLIES AS A SOURCE‐ FOCUS
The organization reduces the risk of infection associated with medical equipment, devices, and supplies
• Equipment tracking process
• Strict adherence to manufacturer’s IFUs
• Low level disinfection of equipment used between patients
• Follow AAMI (Association for Advancement of Medical Instrumentation) guidelines for sterile processing
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SSI Investigation Scenario 2
Findings and Conclusion
Staphylococcus auerus is the most frequent cause of surgical site infections. We were unable to identify a specific common causative factor in this investigation, but after review and implementation of an action plan based on mitigating all possible sources of transmission of the microorganism, there were no further clusters reported. Fungal Surgical Site Infections
• Can occur during renovation or construction because it stirs up the amount of dust and fungal spores in the air • Unlikely to occur in ASC environment BUT healthcare facilities are frequently renovating or under construction and have higher acuity of patients
• Immunocompromised patients are most susceptible
• Most likely culprit is aspergillus 24
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Infection Control Risk Assessment
ICRA
• ICRA (Infection Control Risk Assessment)‐
process to prevent infections during renovation or construction
• Infection preventionist should be involved in planning and approval of renovation and construction activities to recommend and ensure adherence to proper precautions
Infection Prevention & SPD
Working Together to Promote
Patient Safety
121st Combat Hospital, US Army, Seoul, South Korea
March 2016
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Cut to the Chase & Celebrate The Greatness of What We Do!
References
• Jorgensen, James. H. and Michael A. Pfaller, (2004), A Clinician’s Dictionary of Pathogenic Microorganisms, Washington, DC: ASM Press
• Florence Nightingale. (2014, January 17). New World Encyclopedia, . Retrieved 16:07, April 1, 2016 from http://www.newworldencyclopedia.org/p/index.php?title=Florence_Nightingale&ol
did=977727
• CDC, Surgical Site Infection (SSI) Toolkit, Activity C: ELC Prevention Collaberatives. www.cdc.gov/hai/pdfs/toolkits/SSI_toolkit021710SIBT_revisedpdf
• Hopper, W., Moss, R. (2010). Common Breaks in Sterile Technique: Clinical Perspectives and Perioperative Implications. AORN, Volume 91, No. 3, 350‐357.
• AHRQ Study Shows Low Rates of Serious Infections Following Ambulatory Surgery. February 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/press‐releases/2014/ssi_study.html
• Ahmed, M., Mustapha, M., Gousuddin, M. Kuar, S. Root cause anaylsis in surgical site infections (SSIs). (2012). International Journal of Pharmaceutical Science Invention, Volume 1, Issue 1, December 2012, 11‐15.
• CDC, Hospitalized Patients and Fungal Infections.
www.cdc.gov/fungal/infections/hospitalized.html
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References
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GAYATHREE NAIK, SRINIVASR DESHPANDE. A STUDY ON SURGICAL SITE INFECTIONS CAUSED BY STAPHYLOCOCCUS AUREUS, WITH A SPECIAL SEARCH FOR METHICILLIN‐RESISTANT ISOLATES. Journal of Clinical and Diagnostic Research [serial online] 2011 June [cited: 2016 Apr 1]; 5:502‐508. Available from http://www.jcdr.net/back_issues.asp? issn=0973‐
709x&year=2011&month=June&volume=5&issue=3&page=502‐508&id=1382
John, J., Davidson, R., Low, D. “Staphylococcus epidermidis and other Coagulase‐
Negative Staphylococci.” Antimicrobe.
www.antimicrobe.org/news/b234/asp
Neely, A., Maley, M. “Survival of Enterococci and Staphylococci on Hospital Fabrics and Plastics.” (2000) Journal of Clinical Microbiology, pages 724‐726.
CDC, Pseudomonas aeruginosa in Healthcare Settings‐
HAIwww.cdc.gov/hai/organisms/pseudomonas.html
Tosh, P., Disbot, M., Duffy, J., Boom, M., Heseltine, G., Gould, C., Berrios‐Torres, S. (2011). Outbreak of Pseudomonas aeruginosa Surgical Site Infections after Arthroscopic Procedures: Texas, 2009. Infection Control Hospital Epidemiology,
Dec;32(12), 1179‐86.
www.ncbi.nlm.nih.gov/pubmed/22080656
References
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FDA, Arthroscopic Shavers Ongoing Safety Review, 07/07/2009.www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsfor
Human…
CDC, Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices www.emergency.cdc.gov/han/han00382.asp
Markel, Howard PBS NewsHour, “In 1850, Ignaz Semmelweis saved lives withthree simple words: wash your hands.” Web. 15 May 2015.http://www.pbs.org/news/hour/updates/ignaz‐semmelweis‐doctor‐
prescribed‐hand‐washing/
John, J., Davidson, R., Low, D. “Staphylococcus epidermidis and other Coagulase‐
Negative Staphylococci.” Antimicrobe.
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