Today’s Webinar will begin at 11:00 PST
12/18/12
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, CIC
4
SSI Prevention - How Are We Doing?
Direct OR Observations
Sue Barnes, RN, BSN, CIC
National IP Leader, Kaiser Permanente
IP Before Holiday Break
6
Overview and objectives
OVERVIEW: This session will describe how inpatient and outpatient
surgery centers are doing relative to surgical infection prevention based on
a small number of direct case observations. Prevention in all phases of
the surgical journey will be addressed: pre-operative, intra-operative and
Post-operative. The uncharted arena of surgical technique and infection risk
will also be considered.
OBJECTIVES
1. Share project overview
2. Review observed compliance with standard infection prevention efforts,
share best practices and challenge areas
3. Share my ongoing dialogue with surgeons and periop staff – what do
they know that we don’t know about surgical procedures and infection
risk?
Project overview
Preparation
•
•
•
Request permission to observe cases from surgeon colleagues
Schedule with OR managers – inform local IP – request time for debrief
View UTube video clips of procedures
Observations
•
•
Use checklist to guide observations – take notes: best practices, questions,
opportunities for improvement
Ask surgeons and periop staff their perspective regarding aspects of surgical
procedure, technique and SSI risk – their concerns
After the case
•
•
•
Debrief post op with OR manager and IP (separately or together at their
convenience)
Sent thank you to surgeon, team and their supervisors with summary of best
practices
Sent private list of challenge areas – “your eyes only” to surgeon, IP and OR
manager – professional courtesy
My next steps
•
4 cases observed to date (general, OB/GYN, cardiac, plastics). I plan to continue
next year with other high risk procedures including: bariatric, ortho, eye, spine
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)
9
1. Pre Op:
Questions posed
• Hair removal
• Skin prep
• Hand scrub
2. Intra Op:
• Aseptic technique
• Antibiotic weight based dosing and
re-dosing
• Irrigation
• What are you concerned about?
3. Post Op:
• Skin closure
• Patient education
• Drains, dressings
10
Observation focus
1. Anesthesia: Foley on floor? Scrub the hub?
Mask over nose and mouth? Hair coverage?
2. Aseptic technique movement front to front,
hands above waist, sterile field
3. Attire full hair coverage (including chest), long
sleeves, mask
4. Environment OR room design and cleaning,
clutter, supplies covered/behind closed doors,
equipment, instruments
5. Hand degermer outside/inside OR rooms
6. Scrub sinks brushless scrub, no refillable bottles
7. Traffic in OR rooms during case.
11
Lap hysterectomy + hernia repair
Breast reduction
Laparoscopic colectomy
CABG
My primary take away
Also
A couple of these moments
18
Pre-operative
Surgical hand scrub
With brush: CHG or PVI
Brushless: Alcohol +/- CHG
Jarral OA, McCormack DJ, Ibrahim S, Shipolini AR. Should surgeons scrub with chlorhexidine or iodine prior
to surgery? Interac Cardiovas Thorac Surg. 2011 Jun;12(6):1017-21.
Lai KW, Foo TL, Low W Naidu G. Surgical hand antisepsis-a pilot study comparing povidone iodine hand
scrub and alcohol-based chlorhexidine gluconate hand rub. Ann Acad Med Singapore 2012 Jan;41(1):12-6.
Pre-operative antibiotics
Ho VP, Barie PS,Stein SL, Trencheva K, Milsom JW, Lee SW, Sonoda T Antibiotic regimen and the timing of
prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery.
Surg Infect 2011 Aug;12(4):255-60.
Bowater RJ, Stirling SA, Lilford RJ Is antibiotic prophylaxis in surgery a generally effective intervention?
Testing a generic hypothesis over a set of meta-analyses. Ann Surg. 2009 Apr;249(4):551-6.
Glucose control
Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative
glycemic control in general surgery: a report from the surgical care and outcomes assessment
program. Ann Surg. 2013 Jan;257(1):8-14.
Normothermia
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
Lista F, Doherty CD, Backstein RM, Ahmad J. The impact of perioperative warming in an outpatient aesthetic
surgery setting. Aesthet Surg J. 2012 Jul;32(5):613-20.
Skin Antisepsis
Yeung LL, Grewal S, Bullock A, Lai HH, Brandes SB. A comparison of chlorhexidine-alcohol
versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a
randomized controlled trial. J Urol. 2013 Jan;189(1):136-40.
24
MRSA Decolonization high risk cases
Vonberg RP, Gastmeier P. Prevention of surgical site infections in bone and joint procedures.
Curr Infect Dis Rep 2012 Oct;14(5):576-84.
Craft RO, Damjanovic B, Colwell AS. Evidence-based protocol for infection control in
immediate implant-based breast reconstruction. Ann Plast Surg. 2012 Oct;69(4):446-50.
25
Hair Removal
Grober ED, Domes T, Fanipour M, Copp JE. Preoperative Hair Removal on the Male
Genitalia: Clippers vs. Razors J. Sex Med 2012 Aug 21.
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev 2011 Nov 9;(11):CD004122.
26
CHG cloths for pre-op antiseptic bathing
Webster J, Osborne S. “Home-based preoperative chlorhexidine bathing cloths to
prevent surgical site infection” ICHE 2011 Oct;32(10):1047.
Intra-operative
Aseptic technique
Blanchard, Byron Burlingame, Bonnie Denholm, Sharon Giarrizzo-Wilson, Mary Ogg, and Sharon A.
Van Wicklin. Perioperative Standards and Recommended Practices. Vol. 1, 2012.
Traffic control intra-operatively
Al-Benna S. Infection control in operating theatres. J Periop Pract 2012
Oct;22(10):318-22.
Staff hair coverage
Alicia J. Mangram GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999 INFECTION
CONTROL AND HOSPITAL EPIDEMIOLOGY Vol. 20 No. 4 247. “Wear a cap or hood to fully cover hair
on the head and face when entering the operating room.” (CDC category IB).
Foley on floor - Anesthesia
Gould C et al. CDC HICPAC GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT
INFECTIONS 2009 “Do not rest the bag on the floor.” (Category IB) .
Scrub the hub - Anesthesia
Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated
bloodstream infections by implementation of a post insertion care bundle. AJIC. 2010
Aug;38(6):430-3.
Hand hygiene - Anesthesia
Henderson DM, et al. “A collaborative, systems-level approach to eliminating healthcareassociated MRSA, central-line-associated bloodstream infections, ventilator-associated
pneumonia, and respiratory virus infections.” J Healthc Qual . 2012 Sep-Oct;34(5):39-47.
34
Red cap: Version1: visitors
Version 2: patient pre-op checklist pending
Change gloves before closing
Partecke LI, Goerdt AM, Langner I, Jaeger B, Assadian O, Heidecke CD, Kramer A, Huebner NO.
Incidence of microperforation for surgical gloves depends on duration of wear. ICHE 2009
May;30(5):409-14.
Use of disposables – hard to clean items
Brown DQ. Disposable vs. reusable electrocardiography leads in development of and
cross-contamination by resistant bacteria. Crit Care Nurse. 2011 Jun;31(3):62-8.
Post-operative
Patient teaching – S & S Infection
Hari M, Rosenzweig M. Incidence of preventable postoperative readmissions
following pancreaticoduodenectomy: implications for patient education.
Oncol Nurs Forum. 2012 Jul;39(4):408-12.
39
High dusting, de-cluttering, cleaning OR
Munoz-Price LS, Birnbach DJ, Lubarsky DA, Arheart KL, Fajardo-Aquino Y, Rosalsky
M, Cleary T, Depascale D, Coro G, Namias N, Carling P. “Decreasing operating room
environmental pathogen contamination through improved cleaning practice.” ICHE
2012 Sep;33(9):897-904.
40
UV light as adjunct to manual cleaning
Boyce JM, Havill NL, Moore BA. “Terminal decontamination of patient rooms using an
automated mobile UV light unit”. ICHE. 2011 Aug;32(8):737-42.
Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet
radiation device for decontamination of Clostridium difficile and other healthcareassociated pathogens in hospital rooms. BMC Infect Dis. 2010 Jul 8;10:197.
Antimicrobial post-op dressing
Epstein NE. “Preoperative, intraoperative, and postoperative measures to further reduce
spinal infections.” Surg Neurol Int. 2011 Feb 21;2:17.
Krieger BR et al. “The use of silver nylon in preventing surgical site infections following colon
and rectal surgery”. Dis Colon Rectum. 2011 Aug;54(8):1014-9.
Antimicrobial dressing for pins and drains
Egol KA et al. “Treatment of external fixation pins about the wrist: a prospective,
randomized trial.” J Bone Joint Surg Am. 2006 Feb;88(2):349-54.
D/C instructions with surgeon cell #
Surgical technique and SSI risk:
Questions posed to and by
surgeons
Electronic devices that discharge air, or
are designed to blow air in OR – a risk?
Intra-operative Irrigation
Pour? Bulb syringe? Jet?
47
Intra-operative Irrigation
NS, RL, CHG, antibiotics?
What about the operative wound –
size of incision, dead space, exposed
adipose tissue?
What’s the benefit of the wound edge
protector – when to apply?
What about wound closure and care –
what’s best?
What I have added to my
checklist this year
From the News: Lumen cleaning Instrument reprocessing
Eaton, J. “Filthy surgical instruments: The hidden threat in America's operating
rooms Danger in dirty instruments”. The Center for Public Integrity I Watch.
February 22, 2012.
Medl, N., Guerrero, T. G., Hölzle, L., Hässig, M., Lochbrunner, S. and Montavon,
P. M. (2012), “Intraoperative Contamination of the Suction Tip in Clean
Orthopedic Surgeries in Dogs and Cats.” Veterinary Surgery, 41: 254–260.
53
From case observations: Skin prep prior to
epidural anesthesia
Bedoya A, Gentilesco B. Prosthetic valve endocarditis: a complication of spinal
epidural abscess. Case Report Med. 2010;2010:105426.
From a conference: Pain control and
infection risk
Sacerdote P, Franchi S, Panerai AE. Non-Analgesic Effects of Opioids: Mechanisms and
Potential Clinical Relevance of Opioid-Induced Immunodepression. Curr Pharm Des.
2012 Jun 28.
De Oliveira GS Jr, Fitzgerald P, Streicher LF, Marcus RJ, McCarthy RJ. Systemic lidocaine
to improve postoperative quality of recovery after ambulatory laparoscopic surgery.
Anesth Analg. 2012 Aug;115(2):262-7.
From an ASC: Cleaning and disinfection of
lead gowns in OR
Grogan BF, Cranston WC, Lopez DM, Furbee C, Murray CK, Hsu JR; Skeletal
Trauma Research Consortium. Do protective lead garments harbor harmful
bacteria? Orthopedics. 2011 Nov 9;34(11):e765-7.
Sue Barnes Sue.Barnes@kp.org
510-267-4871
57
www.cynosurehealth.org
Thanks for joining us today