PREVENTION OF SURGICAL
SITE INFECTION
Refueling Your Quality Engine
Winnipeg
March 3 & 4, 2011
Risk Factors for SSI
Patient
Operation
Post-op care
Age
Antimicrobial prophylaxis
Wound care
Nutritional status
Blood Glucose
Discharge
Diabetes
Normothermia
Smoking
Hair Removal
Obesity
Antiseptic technique
Steroid use
Surgical technique
Prolonged pre-op LOS
Wound classification
Length of surgery
Blood transfusion
OR Ventilation
Traffic Control
Prophylactic Antibiotics
Appropriate Use Of Antibiotics
 The right drug
 The right dose
 At the right time*
 For the right duration
Performance measure (target):
 % surgical patients given pre-op ABx within 60 min*
( Goal ≥ 95% )
 % surgical patients having ABx , discontinued within
24 hrs ( Goal ≥ 95% )
Duration Concerns
 There is a lack of evidence that antibiotics given
after the end of the operation prevent SSIs.
 There is evidence that unnecessary or prolonged
use of antibiotics promotes antibiotic resistance1
1. Bratzler & Houck. Clinical infectious Diseases 2004; 38: 1706-15
SHN! Recommendation
1
 Based on the evidence, the Safer Healthcare Now! faculty
recommend that prophylactic antibiotics be completely
absorbed within 60 minutes of first incision, and should
be repeated for surgeries lasting longer than the half-life
of the antibiotic (4 hours for cephalosporins).
 Antibiotics administered for cardiac, thoracic,
orthopaedic and vascular patients should be discontinued
within 24 hours of the end of surgery, whereas noncomplex and uncomplicated surgeries require no further
administration of antibiotics following surgery.
1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010
Prophylaxis Dosing
 Consider the upper range of doses for large
patients
- Gastroplasty: SSI rates 16.5% vs 5.6%1
 Repeat doses for long operations (> 4 hours)
- Cardiac surgery: SSI rates 16% vs 7%2
1Forse,
R; Karam, B; Maclean, D; Cristou, N. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery, 1989, 106: 750-7
et al., Emerg Infect Dis, 2001
2Zanetti
Weight Based Dosing in Canada:
Evidence into Practice
Healthcare Facility
Cefazolin
Vancomycin
Fraser Health Authority, Vancouver,
British Columbia
1g IV if ≤80kg
2g IV if >80kg
Not Available
Edmonton and Area Acute Care
Facilities, Alberta Health Services,
Alberta
Grace Hospital, Winnipeg Regional
Health Authority, Winnipeg,
Manitoba
1g IV if ≤100kg
2g IV >100kg
Vancomycin 1g for everyone
1g IV if <80kg
2 g IV if ≥80kg
1g IV if ≤75kg
1.25g IV if 76-94kg
1.5g IV if ≥95kg
University Health Network, Toronto,
Ontario
1g IV <70kg
2g IV if ≥70kg
Not Available
North York General Hospital,
Toronto, Ontario
1g IV if ≤80kg
2g IV if >80kg
No weight-based modifications
Sunnybrook Health Sciences,
Toronto, Ontario
2g for everyone
Not Available
Jewish General Hospital, Montréal,
Quebec
2g for everyone
Weight modifications based on renal
sufficiency
St. Clare’s Mercy Hospital, St.
John’s, NL
1g IV if ≤80kg
2g IV if >80kg
Not Available
Horizon Health Network, Moncton,
NB
1g IV if ≤100kg
2g IV >100kg
Not Available
SHN! Recommendation
 Based on the evidence, SHN Faculty recommends that
prophylactic antibiotic administration be started and
completed within 60 min. of first incision for
c-sections instead of after cord-clamping.
 Faculty recommend that prophylactic antibiotic
infusion be started and completed within 60 min. (120
min. for Vancomycin) prior to application of
tourniquet to maximize antibiotic efficacy.
Change Ideas
Use pre-printed or computerized standing orders specifying choice of antibiotic,
dose, timing, and discontinuation.
Change operating room drug stocks to include only standard doses and
standard drugs, reflecting locally agreed upon guidelines.
Incoporate pre-mixed antibiotics for use by OR staff.
Reassign antibiotic administration responsibilities to anesthesia or holding area
nurse to improve timeliness.
Incorporate the use of the surgical safety checklist so that “Antibiotic absorbed”
is addressed in the time out.
Hair Removal
SHN! Recommendation
1
 Based on the evidence, the Safer Healthcare Now! SSI
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faculty recommend that patients be educated not to
shave in the vicinity of the incision for one week
preoperatively.
No hair removal prior to surgery is optimal.
If hair removal is necessary, clippers should be used
outside of the OR and within 2 hours of surgery.
Do not use razors in the vicinity of the surgical area.
Patients should shower after clipping due to increased risk
of bacterial contamination of the surgical site.
1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010
Change Ideas
 Develop a letter for surgeon’s offices to provide to
their patients that includes a reminder about not
shaving for one week prior to surgery
 Indicate that the clipping of any hair will be done in
the hospital on the day of surgery
Perioperative Normothermia
Consequences of Mild Hypothermia
 Increases duration of hospitalization
 Increases intra-operative blood loss
 Increases adverse cardiac event
 Increases patient shivering in PACU
 Promotes metabolic acidosis
 Increases SSI rates1
1. Melling et al. 2001 Lancet, 358: 876-80
SHN! Recommendation
1
 Based on the evidence, the Safer
Healthcare Now! SSI faculty recommend
that measures are taken to ensure that
surgical patient core temperature
remain between 36.0⁰C and 38⁰C
preoperatively, intraoperatively, and in
PACU.
1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010
Change Ideas
 Pre operative warming utilizing forced warm air blankets
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for 30+ min pre-op
Continue active warming in the OR (include warmed IV
fluid and lavage for abd. cases)
Increase the ambient temperature in the operating room
to 20⁰C
Hats and booties on patients during surgery
PACU warming to discharge as needed
Do this routinely on all procedures slated 60 min. +
Blood Glucose Control
Recent Research
 Strict vs. conventional blood glucose control
 2009 consensus statement on glycemic control from
American Association of Clinical Endocrinologists and
American Diabetes Association report BG should be
maintained between 7.8 and 10 mmol/L for most
critically ill patients
SHN! Recommendation
1
 Based on the evidence, The Safer
Healthcare Now! SSI faculty recommend
that preoperative blood glucose levels be
checked on all surgical patients. Teams
are encouraged to apply glucose control
to surgical populations as directed by
your local organization.
1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010
Change Ideas
 Pre-op blood sugar analysis to pick up on undiagnosed
diabetics
 Referral to endocrinology or initiate treatment prior to
slated date
Skin Prep
Prevention Strategies and Skin Antisepsis
The Ideal Skin Antimicrobial
 The “ideal” antimicrobial agent for skin should
have the following properties:
- Broad spectrum
- Rapid bactericidal activity
- Persistence or residual properties on the skin
- Effective in the presence of organic matter
- Non-irritating or have low allergic and/or toxic responses
- None or minimal systemic absorption
Current Approaches: Prevention of SSIs
Multiple studies have shown that CHG and CHG/alcohol
solutions display these important properties:
CHG plus 70% isopropyl alcohol (IPA) has demonstrated
efficacy against a wide range of bacteria, including P.
aeruginosa, S. aureus, and antibiotic-resistant bacteria.
CHG/IPA exhibits a rapid onset of action, persists for up to
24 hours, and has increased efficacy with repeated
applications.
Chlorhexidine is not inactivated in the presence of blood,
which neutralizes the effects of iodine and PCMX and dilutes
the effects of alcohol.
Florman et al. Current Approaches for the Prevention of SSIs. Am J Infect Dis. 3(1):51-61, 2007.
Safety
 CHG 2%/70% IPA solution is flammable
 CHG-alcohol skin prep solution should not be used
around eyes, ears, and mouth, or come in direct
contact with neural tissue
SHN! Recommendation
1
 Based on the evidence, the Safer Healthcare Now! SSI faculty
recommends that the skin should be cleansed before surgery
with a chorhexidine–based solution, preferably with no rinse
disposable chlorhexidine gluconate impregnated wash cloths.
 The antiseptic of choice for skin prep should be alcohol based
chlorhexidine antiseptic solutions instead of povidone-iodine.
 Following application of chlorhexidine-alcohol skin prep
solution, surgical teams should complete the time out of the
surgical checklist to allow time for the skin prep to dry.
1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010
SHN! Recommendation
1
 To maximize its efficacy, CHG-alcohol skin prep should not be
washed off for at least 6 hours following surgery.
 In order to prevent a fire hazard, It is imperative that CHG-
alcohol skin prep be allowed to air dry for at least 3 minutes, or
longer if there is excessive hair insitu.
 Povidone-iodine should be used as a skin preparation in
emergent cases where there is not enough time to allow CHGalcohol solution to completely dry before incision.
 Chlorhexidine-based solutions must not be used for procedures
involving the ear, eye, mouth or neural tissue.
1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010
 http://www.youtube.com/watch?v=4IG8ItaTTzY