Today’s Webinar will begin at
11:00 PST
4/12/12
Welcome from Barb DeBaun, RN, MSN, CIC
Introduction
Please do not put your phone on hold; use
the mute function or *6
Please type questions or comments into
text box
Interactive question session
If time permits, we will open up the phone
lines at the conclusion of the presentation
Introducing Sue Barnes, RN,
BSN, CIC
4
Beyond SCIP – SSI Prevention
Sue Barnes RN, BSN, CIC
National Program Leader
Infection Prevention & Control
Kaiser Permanente
5
Objectives
1. Discuss strategies to optimize 4
specific SCIP measures, beyond
regulatory compliance
2. Discuss 11 products and practices
above and beyond SCIP – i.e. “plus”
measures
3. Provide resources and references
relative to “plus” measures
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7
SCIP Measures
http://intranet.uchicago.edu/quality/SCIP_files/page0001.htm
 SCIP INF 1 Prophylactic antibiotic received within one hour prior
to surgical incision
 SCIP INF 2 Prophylactic antibiotic selection for surgical patients
 SCIP INF 3 Prophylactic antibiotics discontinued within 24 hours
after surgery end time (48 hours for cardiac patients)
 SCIP INF 4 Cardiac surgery patients with controlled 6 a.m. post op
serum glucose (200 mg/dL)
 SCIP INF 6 Surgical patients with appropriate hair removal
 SCIP INF 7 Colorectal surgical patients with immediate
postoperative normothermia
 SCIP INF 9 Urinary catheter removed on post op day 1
 SCIP INF 10 Surgery patients with perioperative temperature
management
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9
3 grams Ancef for Bariatric Patients
1. Freeman JT, Anderson DJ, Hartwig MG, Sexton DJ.
“Surgical site infections following bariatric surgery in
community hospitals: a weighty concern?” Obes Surg.
2011 Jul;21(7):836-40.
2. Pevzner L, Swank M, Krepel C, Wing DA, Chan K,
Edmiston CE Jr. “Effects of maternal obesity on tissue
concentrations of prophylactic cefazolin during
cesarean delivery”. Obstet Gynecol. 2011
Apr;117(4):877-82.
3. Roe JL, Fuentes JM, Mullins ME. “Under dosing of
common antibiotics for obese patients in the ED”. Am
J Emerg Med. 2011 Dec 12. [Epub ahead of print]
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SAFE Pre-op Hair Removal
 Removal outside of OR or clipper with
vacuum
 Pre op patient teaching no leg shaving
 Disposable clipper head or reprocess b/w
patients
1. Adisa AO, Lawal OO, Adejuyigbe O. “Evaluation of two methods
of preoperative hair removal and their relationship to
postoperative wound infection”. J Infect Dev Ctries. 2011 Oct
13;5(10):717-22.
2. Broekman ML, van Beijnum J, Peul WC, Regli L. “Neurosurgery
and shaving: what's the evidence?” J Neurosurg. 2011
Oct;115(4):670-8. Epub 2011 Jul 1.
3. Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N,
Demartines N. “Measures to prevent surgical site infections: what
surgeons (should) do”. World J Surg. 2011 Feb;35(2):280-8.
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Unless your patient looks like this,
consider NOT clipping hair
Mangram AJ et al. Guideline for prevention of surgical site infection, 1999.
Hospital Infection Control Practices Advisory Committee. Infect Control Hosp
Epidemiol 1999; 20:250‐278; quiz 279‐280.
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Normothermia
1. Esnaola NF, Cole DJ. “Perioperative normothermia
during major surgery: is it important?” Adv Surg.
2011;45:249-63.
2. Hart SR, Bordes B, Hart J, Corsino D, Harmon D.
“Unintended perioperative hypothermia”. Ochsner J.
2011 Fall;11(3):259-70.
3. Moola S, Lockwood C. “Effectiveness of strategies for
the management and/or prevention of hypothermia
within the adult perioperative environment”. Int J Evid
Based Healthc. 2011 Dec;9(4):337-45.
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Glucose Control = minimizing extremes
1. Chi A, Lissauer ME, Kirchoffner J, Scalea TM, Johnson SB. “Effect
of glycemic state on hospital mortality in critically ill surgical
patients”. Am Surg. 2011 Nov;77(11):1483-9.
2. Martinez EA, Chavez-Valdez R, Holt NF, Grogan KL, Khalifeh KW,
Slater T, Winner LE, Moyer J, Lehmann CU. “Successful
implementation of a perioperative glycemic control protocol in
cardiac surgery: barrier analysis and intervention using lean six
sigma”. Anesthesiol Res Pract. 2011;2011:565069. Epub 2011 Sep
6.
3. Pichardo-Lowden A, Gabbay RA. “Management of Hyperglycemia
During the Perioperative Period”. Curr Diab Rep. 2011 Nov 12.
[Epub ahead of print]
4. Stawicki S, Schuster D, Liu J, Kamal J, Erdal S, Gerlach A,
Whitmill M, Lindsey D, Murphy C, Steinberg S, Cook C. “The
glucogram: A new quantitative tool for glycemic analysis in the
surgical intensive care unit”. Int J Crit Illn Inj Sci. 2011 Jan;1(1):512.
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“Plus” Measures for SSI Prevention
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Attire - Surgical
 Eliminate or cover cloth
skull cap when in surgery
 Double gloving
 Change sterile gloves
before closing
 Permit ONLY scrubs
laundered by hospital
 Red caps for visitors
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Attire - Surgical
 Double Gloving: Phillips S. “The comparison of double gloving
to single gloving in the theatre environment.” J Perioper
Pract. 2011 Jan;21(1):10-5.
 Changing gloves: Epstein NE. “Preoperative, intraoperative,
and postoperative measures to further reduce spinal infections.”
Surg Neurol Int. 2011 Feb 21;2:17.
 Hair coverage :Frey K, Ross T. eds. Surgical Technology for the
Surgical Technologist: A Positive Care Approach. 3rd ed. Clifton
Park, NY: Delmar Cengage; 2008.
 Scrubs: Belkin NL. Home laundering of soiled surgical scrubs.
American Journal of Infection Control. 2001; 29: 58-64.
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Blood – Minimizing Transfusions
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Blood - Minimizing Transfusions
1.
2.
3.
4.
Young H. Et al. “Statewide collaboration to evaluate the effects of
blood loss and transfusion on surgical site infection after
hysterectomy”. ICHE Jan 2012, Vol. 33, No 1 pp 90-93.
Schwarzkopf R et al. “Effects of Perioperative Blood Product Use
on Surgical Site Infection Following Thoracic and Lumbar Spinal
Surgery”. Spine. 2010;35(3):340-346.
Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection:
the incidence, timing, and predisposing factors. Clin Orthop Relat
Res. 2008; 466(7):1710-1715.
Talbot TR et al. “Perioperative Blood Transfusion Is Predictive of
Poststernotomy Surgical Site Infection: Marker for Morbidity or True
Immunosuppressant?” Clinical Infectious Diseases 2004;
38:1378–82
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Drains, Drapes, Dressings
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Drains, Drapes and Dressings
1.
2.
3.
4.
DRESSING - Epstein NE. “Preoperative, intraoperative, and
postoperative measures to further reduce spinal infections.” Surg
Neurol Int. 2011 Feb 21;2:17.
DRESSING - Krieger BR, Davis DM, Sanchez JE, Mateka JJ,
Nfonsam VN, Frattini JC, Marcet JE. “The use of silver nylon dressing
in preventing surgical site infections following colon and rectal
surgery”. Dis Colon Rectum. 2011 Aug;54(8):1014-9.
DRAINS - Rao SB, Vasquez G, Harrop J, Maltenfort M, Stein N,
Kaliyadan G, Klibert F, Epstein R, Sharan A, Vaccaro A, Flomenberg
P. “Risk factors for surgical site infections following spinal fusion
procedures: a case-control study”. Clin Infect Dis. 2011 Oct;53(7):68692.
DRAPE - Kramer A, Assadian O, Lademann J. “Prevention of
postoperative wound infections by covering the surgical field with
iodine-impregnated incision drape (Ioban 2)”. GMS Krankenhhyg
Interdiszip. 2010 Sep 21;5(2).
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Hand Scrub – Brushless & Dual Agent
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Hand Scrub - Brushless & Dual Agent
 Olson LK et al. “Prospective, randomized in vivo
comparison of a dual-active waterless antiseptic versus
two alcohol-only waterless antiseptics for surgical hand
antisepsis”. American Journal of Infection Control
Volume 40, Issue 2, March 2012, Pages 155–159.
 Usavadee Asdornwised “An Evaluation of Brush,
Brushless, and Waterless Surgical Hand Scrubs among
Health Care Workers in Operating Rooms at a University
Hospital in Thailand “. J Nurs Sci Vol.29 No.3 JulySeptember 2011.
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Irrigation: Intra-operative
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Irrigation: Intra-operative
1. COPIOUS IRRIGATION - Watanabe M, Sakai D, Matsuyama
D, Yamamoto Y, Sato M, Mochida J. “Risk factors for surgical
site infection following spine surgery: efficacy of
intraoperative saline irrigation”. J Neurosurg Spine. 2010
May;12(5):540-6.
2. CHG - Han Y, Giannitsios D, Duke K, Steffen T, Burman M.
“Biomechanical analysis of chlorhexidine power irrigation to
disinfect contaminated anterior cruciate ligament grafts”. Am J
Sports Med. 2011 Jul;39(7):1528-33.
3. PULSATILE - Nikfarjam M, Kimchi ET, Gusani NJ, Avella DM,
Shereef S, Staveley-O'Carroll KF. “Reduction of surgical site
infections by use of pulsatile lavage irrigation after prolonged
intra-abdominal surgical procedures”. Am J Surg. 2009
Sep;198(3):381-6.
4. OPHTHALMOLOGY - Fernandes M, Pathengay A. “Reduction of
anterior chamber contamination rate after cataract surgery by
intraoperative surface irrigation with 0.25% povidone-iodine”. Am
J Ophthalmol. 2011 Aug;152(2):320; author reply 320-1.
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OR Observations
“Almost no matter what experimental conditions were imposed, increases
in output occurred….The investigators had obviously influenced the
subjects’ behavior merely by studying that behavior, and this phenomenon
has become known as the Hawthorne effect.” (Kelly Shaver, Principles of
Social Psychology, 2nd ed., Winthrop, 1981)
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Oxygen - Supplemental
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O2 - Supplemental
 Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr.
“Perioperative supplemental oxygen therapy and
surgical site infection: a meta-analysis of randomized
controlled trials.” Arch Surg. 2009 Apr;144(4):359-66;
discussion 366-7.
 James T. Lee, MD, PhD “Supplemental Oxygen and
Risk of Surgical Site Infection”JAMA
2004;291(16):1957-1958.
 Hopf H, Hunt T, Rosen N. “Supplemental Oxygen and
Risk of Surgical Site Infection”.
JAMA. 2004;291(16):1956.
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Skin Antisepsis
Estimates of costs/mortality associated with infections
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Skin Antisepsis
1. SKIN - Lee I, Agarwal RK, Lee BY, Fishman NO, Umscheid CA.
“Systematic review and cost analysis comparing use of chlorhexidine with
use of iodine for preoperative skin antisepsis to prevent surgical site
infection”. Infect Control Hosp Epidemiol. 2010 Dec;31(12):1219-29.
2. SKIN- Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM,
Connor DL, Lee I, Muder RR, Lee BY Economic value of dispensing homebased preoperative chlorhexidine bathing cloths to prevent surgical site
infection. Infect Control Hosp Epidemiol. 2011 May;32(5):465-71.
3. NASAL - Pofahl WE, Ramsey KM, Nobles DL, Cochran MK, Goettler C.
“Importance of methicillin-resistant Staphylococcus aureus eradication in
carriers to prevent postoperative methicillin-resistant Staphylococcus
aureus surgical site infection”. Am Surg. 2011 Jan;77(1):27-31.
4. ORAL - Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol
BA. “Prevention of nosocomial infections after cardiac surgery by
decontamination of the nasopharynx and oropharynx with chlorhexidine; a
prospective, randomised study”. Ned Tijdschr Geneeskd. 2008 Mar
29;152(13):760-7.
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Skin Antisepsis: Pre-op bathing
with CHG cloths
Also used as pre-op skin prep for
emergency C-sections
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Skin Closure
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Skin Closure
1. Fraeman KH, Reynolds MW, Vaughn BB, Hart JC. “Patient
outcomes associated with 2-octyl cyanoacrylate topical skin
adhesive in coronary artery bypass graft surgery”. Surg Infect
(Larchmt). 2011 Aug;12(4):307-16.
2. Singer AJ, Chale S, Giardano P, Hocker M, Cairns C,
Hamilton R, Nadkarni M, Mills AM, Hollander JE. “Evaluation
of a novel wound closure device: a multicenter randomized
controlled trial”. Acad Emerg Med. 2011 Oct;18(10):1060-4.
3. Iyer A, Gilfillan I, Thakur S, Sharma S. “Reduction of surgical
site infection using a microbial sealant: a randomized trial”. J
Thorac Cardiovasc Surg. 2011 Aug;142(2):438-42..
4. Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ.
“Randomized trial of antimicrobial-coated sutures to prevent
surgical site infection after breast cancer surgery”.Surg Infect
(Larchmt). 2011 Dec;12(6):469-74.
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Reducing Traffic in the OR
36
Reducing OR Traffic
1.
2.
3.
Dunbar MJ, Richardson G. “Minimizing infection risk:
fortune favors the prepared mind.”Orthopedics. 2011 Sep
9;34(9):e467-9.
Lynch RJ, Englesbe MJ, Sturm L, Bitar A, Budhiraj K, Kolla
S, Polyachenko Y, Duck MG, Campbell DA Jr.
“Measurement of foot traffic in the operating room:
implications for infection control”. Am J Med Qual. 2009
Jan-Feb;24(1):45-52.
Young RS, O'Regan DJ. “Cardiac surgical theatre traffic:
time for traffic calming measures?” Interact Cardiovasc
Thorac Surg. 2010 Apr;10(4):526-9.
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Wound edge protector
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Wound Edge Protector
1.
2.
3.
Green C, Molony D, Cashman J, Burke T, Masterson E.
“Another string.... but no bow”. Acta Orthop Belg. 2011
Apr;77(2):258-9.
Kadowaki Y, Kurokawa T, Tamura R, Okamoto T, Ishido N,
Mori T. “Lap-Protector and Circular Stapler Are Useful in
Cystogastrostomy for Large Pancreatic Pseudocyst with
Severe Infection”. Case Rep Gastroenterol. 2010 Jul
21;4(2):215-219.
Nakamura Y, Matsumoto S, Tajiri T, Uchida E. “A safe
technique for laparoscopic distal pancreatectomy involving a
large cystic tumor”. J Nihon Med Sch. 2011;78(6):374-8.
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RESOURCES:
1.
AORN/APIC ASC Toolkit/library contents
http://www.aboutinfectioncontrol.com/SubWebs/APIC/MAIN_Tool
kits.htm
2.
APIC Cost Calculator
http://www.apic.org/Content/NavigationMenu/PracticeGuidance/G
uidelinesStandards/TMIT_V1_CostCalculator02082011.xls
3.
APIC/SHEA Compendium http://www.sheaonline.org/GuidelinesResources/CompendiumofStrategiestoPrev
entHAIs.aspx
4.
KP Patient Story Video Clip
http://nursingpathways.kp.org/national/quality/infectioncontrol/tool
kit/index.html
5.
KP Infection Prevention “Plus Measures” Toolkit
http://nursingpathways.kp.org/national/quality/infectioncontrol/toolkit/inde
x.html
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Surgical Site Infection (SSI) Prevention
The following standard bundle of prevention measures (supported by category 1 level evidence) are recommended in:
 SHEA/APIC C ompendium: http://www.shea-online.org/about/compendium.cfm
 IHI How To Guide: http://www.IHI SSI Prevention How To Guide
1.
Appropriate use of antibiotics
2.
Appropriate use of prophy lactic antibiotics
3.
Appropriate hair removal
4.
C ontrolled 6 AM postoperative serum glucose in cardiac surgery patients
5.
Immediate postoperative normothermia for colorectal surgery patients
6.
Pre op antiseptic shower category (1B HIC PAC guidelines SSI Prevention)
If zero infections have not sustained, consider adding one or more of the following “PLUS” prevention measures (less than
category 1 level evidence): DOUBLE CLICK ON ICONS IN TA BLE BELOW TO OPEN EMBEDDED DOCUMENTS
Measure
1 . A ntibiotic prophylaxis:
A. For Bariatric surgery use 3 grams
ancef routinely instead of 2 preoperatively
2. A ntisepsis – skin and oral:
A. Surgical skin prep:
C hlorhexidine/alcohol (C hloraprep)
B. Pre op CHG (chlorhexidine) bathing
cloths
C . Decolonization MRSA - test and
decolonize + MRSA patients prior to
high risk procedures
References
A
A
Tools
N/A
N/A
A CHG skin prep:
http://www.chloraprep.c
om/
B CHG cloth product
info: http://www.Sage
C HG C loths
C Mupirocin: KP
pharmacy
3M Nasal A ntiseptic:
3M™Skin and Nasal
Antiseptic (Povidone-
Patient instructions
C HG C loths
3 gms ancef
references 2012.doc
CHG skin prep
2012.doc
CHG Cloths 2012.doc
B
C
Product Order Info
Decolonization
references 2012 .doc
C:\Documents and
Settings\DNSSAB\My Documents\My Documents\PDF Docs\PDF Docs\IHI\Plus Measures Toolkit\N
Decolonization
Guidelines
C:\Documents and
Settings\DNSSAB\My Documents\My Documents\Word Docs A-P\MRO\Guidelines\MRSA Decolonization Re
41
Thanks for your time!
Any Questions?
42
bdebaun@cynosurehealth.org
Next Beyond SCIP Webinar
May 17th: 12:30-1:30 PST
Pascal Fuchshuber, MD, PhD, FACS
The Power of NSQIP data to drive change
and improvement
45
Cynosure Quality Swap Meet
May 21, 2012
www.cynosurehealth.org
Thanks for joining us today