Presented by:
Kathleen Kohut, RN, MS, CIC, CNOR
System Director of Infection Prevention
Cone Health, Greensboro, NC

3M
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AMN Healthcare
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The Compass Group
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BE Smith Consulting
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Johns Hopkins Hospital
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NCH Healthcare System
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APIC
1.
2.
3.
4.
5.
Discuss the five basics of SSI prevention
Describe the use of glycemic control, nasal
decolonization, and normothermia initiatives
for the reduction of SSIs.
Name the 2 most common mechanisms for
wound contamination
Name 3 SCIP Measures
Discuss two opportunities for practice
improvement
Current National SSI Initiatives include:
The Joint Commission National Patient Safety
Goal NPSG.07.05.01 included in 2009
CMS Public reporting requirements for SSIs
 2012 - Colon Resections and Abd Hysterectomies
▪ Nationally
1.
Antibiotic Prophylaxis ( Inf- 1,2,3)
 Drug, Timing, Dosing, Discontinuation
2.
3.
4.
5.
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Hair Removal (Inf- 6)
Glycemic Control (Inf – 4)
Foley Catheter removal POD1 or POD2 (Inf- 9)
“Normothermia” (Inf 10)
Expanded in June 2011
All surgical patients
http://www.jointcommission.org/specifications_manual_for_national_hospital_in
patient_quality_measures.aspx
http://www.jointcommission.org/assets/1/6/Surgical%20Care%20Improvement%
20Project.pdf
SSI is an unfortunate possibility (it says so right on the consent
form)
Challenge-change the culture of tolerance to one of intolerance to SSI
The Business Case- maximization of OR volume to increase revenue
Challenge- improve efficiencies without compromising infection prevention
Tradition
Challenge- re-examine practices from a fresh perspective to find new
opportunities
Lack of research
Challenge- conduct research and publish to create a solid body of evidence
Five Focus Areas:
1.
2.
3.
4.
5.
Patient Preparation
Aseptic Technique
ABX Prophylaxis
Hair Removal
Skin Antisepsis

Losing weight, quitting smoking

Glucose Management

Nasal Decolonization

Normothermia – pre-warming

The stress response induced by surgical
procedures increases blood glucose levels

Non-diabetics may also experience
hyperglycemia during this critical
perioperative period
CDC(2011). http://www.cdc.gov/diabetes/pubs/factsheet11.htm; accessed on May
10, 2013.
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>25 million Americans diagnosed with
diabetes
> 7 million are undiagnosed
79 million considered pre-diabetic
30-35% of cardiac patients are
diabetics
http://www.cdc.gov/diabetes/pubs/factsheet11.htm

SCIP INF 4: Cardiac surgery patients with
controlled 6 a.m. postoperative serum glucose.

All Patients should be managed with a target of
<200
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The first 24 hours is critical
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The OR cannot be a black hole
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Between 25-30% of all patients are colonized
at any given time and another 60% carry it
intermittently.
Carriers are at higher risk
S. aureus causes 25-35% of all HAIs
20% of all surgical pts acquire some type of
HAI during their postoperative course
Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus
Infections. N Engl J Med 2002; 346(24): 1871-7.

85% of S. aureus infections were endogenous in SSI
study populations
Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti
Chemotherapy 2008; 61:254-261.

MRSA SSI rates decreased from .23% to .09% (5,094 pts)
with MRSA eradication program
Pofahl, WE, et al. Active Surveillance Screening of MRSA and Eradication of the Carrier State Decreases SurgicalSite Infections Caused by MRSA. J Am Coll Surg 2009;208:981-988.

SCIP Measure Inf-10
 Includes all SCIP surgical patients (June 2011)
▪ Total Knee, Hip, Vascular, Cardiac, ABD Hyst, Colon Resect
 Requires one temperature > 96.8º F(36º C) 30 min.
before or 15 min after anesthesia end time.
 Start with pre-warming
Principles were developed to reduce the
risk of wound contamination.
Risk of SSI =
Dose of Bacterial
Contamination X Virulence
Resistance of Host (patient)
Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254
Exogenous sources
1.

Cleanliness of environment, lack of proper
airflow, shedding by the Surgical Team
Endogenous sources
2.
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Patient’s own skin/hair
Infection at a remote site
People = Shedding
4000-10,000 particles per minute
(Berry & Kohn’s, Operating Room Technique, 11th ed., p. 252)
Carried by wind currents to the sterile field
which results in wound contamination.
1.
2.
3.
4.
5.
6.
Patient
Surgical Team
Ancillary Personnel
Sales Reps
Students
Passersby

Requires the control of the amount of traffic and the
traffic patterns themselves
 Essential personnel only
 One foot (min) perimeter around sterile field
 Sterile fields should be a destination, not a thoroughfare
 Limit students and observers
▪ The right of the student to learn vs. the right of the patient to
receive safe patient care
 Utilize alternative methods of communication
Sherertz, et al. “Cloud” HCWs. Emerging Infect Dis. 2001;7(2): 241-44.
Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6):
1169-1183.
People + Wind + (-) Aseptic Technique
> ABX + Skin Prep =
Wound Contamination = SSI
Patient Opportunities

Pre-op showering program
-At least 2 showers with CHG
Hat and clean gown/linen for patient transport
 Hair removal only when necessary

 Clippers, not in the OR
Association of periOperative Registered Nurses (AORN). Recommended Practices for
Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended
Practices 2013 ed., pp75-89.
Chlebicki MP, et al. Preoperative chlorhexidine shower or bath for prevention of
surgical site infection: A meta-analysis. Am J Infect Control 2013;41:167-73.
Newsmanager.commpartners.com/shea/issues/2013-04-02/1.html. Accessed 4/3/13.
Surgical Team
 Hand Hygiene
 Nocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998)
 Proper aseptic technique
 Properly worn hats, masks, clean OR scrubs,
jackets, minimal jewelry (AORN scrub attire)
If it takes 17 years to adopt new technology, our time is up!
Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet
1973; (Nov) 1157-59.
Institute of Medicine (IOM). (2001). Crossing the quality chasm. Crossing the quality chasm: A
newhealth system for the 21st century. Washington: National Academy Press.
THE JACKSON LABORATORY
BIOTECHNOLOGY COMPANY
COSTCO
Room Requirements
• Ventilation System
▪ (min 15- recommended- 20-25/hr, 3 fresh)
▪ Positive pressure
• Temperature (68-73° F)
• Humidity (20-60%)
Room Cleaning
• Between cases
• Terminal cleaning
• Types of construction materials
• Clutter
AORN, Recommended Practices for Perioperative Nursing: Patient & Worker Safety.
(2011 ed., p 219-221)
SCIP Measures - INF 1,2,3 and NPSG.07.05.01 (#7)
 Goal >95%
▪ Challenge the organization to 100%
 Proper dosage for obese population (BMI>30)
(Surg 1989;106:750)
 Redosing q 3 hours (Ann Surg 2009; 250:10)
• RCA or Med Error if missed
Bratzler, DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health-Syst. Pharm. 2013;70:195-283.
1.
SCIP measure (Inf-10)
2.
NPSG.07.05.01 (#8)
Goal
 Minimize as much as possible
 Clippers only
3.
Not addressed: Location of hair removal
The attributes of an appropriate surgical skin antiseptic
require:

The ability to significantly reduce microorganisms
(2 log-dry sites, 3 log-wet sites)
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Provide broad spectrum activity
Be fast acting
Have a persistent effect
All products with FDA approval meet this criteria
Association of periOperative Registered Nurses (AORN). Recommended
Practices for Perioperative Patient Skin Antisepsis. Perioperative
Standards and Recommended Practices 2013 ed., pp75-89.
1.
Procedure (location and type of incision site)
 May challenge the prep area with the presence of blood,
saline, friction from retractors, etc.
2.
Patient Safety

Consider not using alcohol based preps for head and neck
surgeries due to the highest risk of fire.

CDC SSI guideline states to “use an appropriate antiseptic”
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SHEA Compendium - “Optimal preparation and disinfection of the
operative site”
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AORN compares products but does not provide specific product
recommendations

NQF 2011 recommendation: “use solutions that contain
isopropyl alcohol as skin antiseptic preparation until other
alternatives have been proven as safe and effective, and allow
appropriate drying time per product guidelines.”
National Quality Forum:
http://www.qualityforum.org/News_And_Resources/Press_Releases/2011/NQF_Maintains_Endor
sement_of_Safe_Practice_to_Prevent_Surgical_Site_Infection.aspx

Limited research is available that compares
commonly used skin antiseptic agents with SSI
outcomes
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The majority of the literature compares microbial
counts
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Much more work must be done to create a body of
evidence to guide practice
Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in
Shoulder Surgery. J Bone Joint Surg AM 2009;91:1949053
 Microbial culture study of 150 patients comparing 3 methods
(Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™)
Swenson, et al. Preoperative skin preparation on postoperative
wound infection: a prospective study of three skin preparation
protocols. Infect Control Hosp Epidemiol 2009; 30:964-971
▪
SSI Outcome study of 3209 pts comparing 3 methods (Iodophor
Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™
Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for
Surgical-Site Antisepsis. N Engl J Med 2010; 362(1):18-26.
 Microbial culture study of 849 patients comparing 2 methods (Iodophor
Scrub/Paint vs. Chlorhexidine-alcohol)
Savage, JW et al. Efficacy of Surgical Preparation Solutions in Lumbar Spine
Surgery. J Bone Joint Surg Am. 2012;94:490-4

Efficacy study comparing ChloraPrep® to DuraPrep™ preop, post prep, and
post-op
Mechanism of actions:
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Denatures (kills) proteins
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Bactericidal
Fungicidal
Virucidal
Does not kill spores
Has no persistent effect
Association of periOperative Registered Nurses
(AORN). Recommended Practices for
Perioperative Patient Skin Antisepsis.
Perioperative Standards and Recommended
Practices 2013 ed., pp75-89.

Follow manufacturer’s directions
 Read the labels!

Utilize proper aseptic technique during
application & gloves to contain shedding
Create relationships between IP, OR, SPD,
Pre-op, Surgeons (and their offices):
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Learn how they do their work
Learn how you can help each other
Choose process measures together
Its about partnering not policing

Provide process data on an ongoing
basis
 Maintains focus
▪ IUS rates
▪ Compliance with surgical attire

Review outcome data regularly
 SSI Rates

SSIs are preventable and there is much work
to be done

The tools for success include SCIP measures,
NPSG.07.05.01, process and outcome data and the
operating room basics to:
1. Educate
2. Measure
3. Communicate