Loretta Litz Fauerbach, MS, CIC Fauerbach & Associates – Global Infection Prevention Services March 7, 2013 Taking Quality to the Next Level Kentucky Hospital

Loretta Litz Fauerbach, MS, CICFauerbach & Associates – Global Infection Prevention

ServicesMarch 7, 2013

Taking Quality to the Next LevelKentucky Hospital Association Annual Quality Conference

and Hospital Engagement Network Convening Louisville, Kentucky

Objectives

To identify the components in the Surgical Care Improvement Project

To discuss CMS SSI reporting requirements to NHSNTo clarify NHSN methodology To identify other quality initiatives related to SSI

prevention To identify key stake holders and reporting mechanisms

for a strong surgical site infection prevention program. To identify challenges with data collection and strategies

to improve communications related to identifying surgical site infections

To discuss accrediting and licensing requirements related to SSI prevention

LLF SSI Standards 2013

Impact of SSIs Occur in 2%-5% of patients undergoing inpatient surgery in the United States. Approximately 500,000 SSIs occur each year 7-10 additional post operative hospital days 2-11 times higher risk of death compared to

patients who do not have an SSI Patients with an SSI have a 2-11 times higher risk

ofdeath, compared with operative patients without an SSI.

77% of deaths in patients who have an SSI are directly attributable to SSI

Attributable costs vary depending on procedure and organisms but range from $3000 to $29,000

SSIs are believed to account for up to $10 billionannually in healthcare expenditures.


SSI Burden of Illness Surgical Site Infections: Represent 20 percent of all health care-associated infections reported to the National Nosocomial Infections Surveillance System (NNIS) in 2002. Result in more than 8,000 deaths a year and occur in up to 25 percent of patients following major surgical procedures. Extend average length of stay by 9.7 days while increasing cost by $20,842 per admission. Are preventable in an estimated 40 to 60 percent of cases.


•2.6% of 30 million operations complicated by SSI’s•SSI’s Second most common healthcare associated infection accounting for 17% of all hospital acquired infections• SSI’s most common healthcare associated infection in surgical patients (38%)•Consequences of SSI

•Increased hospital stay by up to 10 days• Increased hospital costs• Increased readmission rates• Increased pain and suffering CDC, 2003


NPSG.07.05.01Implement best practices for

preventing surgical site infections.

• CDC Guideline for the Prevention of Surgical Site Infections

• SHEA Compendium• IHI Bundle Care


• SSI 1• Deep incision and organ space infection rates using

NHSN definitions (SCIP procedures)

• Goal: CDC NHSN Median deep incision and organ space infection rate for each procedure/risk group will be at or below the current NHSN 25th percentile

• Measure: Surgical site infection rate: Deep wound and organ space infections as a result of elective surgery to include coronary artery bypass graft (CABG) and cardiac surgery; hip or knee arthroplasty; colon surgery; hysterectomy (abdominal and vaginal); and vascular surgery.


SSI 2Adherence to SCIP/NQF infection process measures (perioperative antibiotics, hair removal, postoperative glucose control, normothermia) CMS SCIP

Goal: 95% adherence rates to each SCIP/NQF infection process measure.Cardiac surgery patients with controlled postoperative serum glucose; Surgery patients with appropriate hair removal; Prophylactic antibiotics received; Prophylactic antibiotics selection; Prophylactic antibiotics discontinued

Measure: Compliance with Centers for Medicare and Medicaid Services antimicrobial prophylaxis guidelines.

Evidence-Based Practice Guidelines for Surgical Site Infection Prevention

Four components of care include: 1. Appropriate use of prophylactic antibiotics Prophylactic antibiotic received within one hour prior to surgical incision Prophylactic antibiotic selection for surgical patients consistent with national guidelines Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) 2. Appropriate hair removal (if deemed necessary, remove using clippers or depilatory)

Evidence-Based Practice Guidelines for Surgical Site Infection Prevention 3. Controlled postoperative serum glucose in

cardiac surgery • Glucose control is defined as serum glucose

levels below 200 mg/dl, collected at or closest to 6:00 a.m. on each of the first two postoperative days

• Tight glucose control (using an insulin drip) is often performed in an intensive care setting

4. Immediate postoperative normothermia in colorectal surgery


Evidence-Based Practice Guidelines for Surgical Site Infection Prevention

Additional SCIP changes in care: • Beta blockade for patients on beta blockers prior to admission should be continued postoperatively • Venous thromboembolism prophylaxis • Ventilator-associated pneumonia prevention

Source: Institute for Healthcare Improvement, How-to Guide: Prevent Surgical Site Infections. (2012) http://www.ihi.org/explore/SSI/Pages/default.aspx Accessed 7/11/12.


The Florida Surgical Care Initiative (FSCI)

A partnership between the Florida Hospital Association (FHA) and the American College of Surgeons (ACS), and endorsed by the Florida Chapter of the ACS, Focus initially on four outcome measures of the ACS National Surgical Quality Improvement Program (NSQIP)


FSCI Surgical Outcome Measures

Standard ACS NSQIP* measures that are followed from pre-op to 30 days post-dischargesurgical site infection (SSI),urinary tract infection (UTI), colorectal outcomes and elderly surgery outcomes


* ACS NSQIP - significantly decrease patient mortality and morbidity rates (Annals of Surgery, 250:363-376, September 2009)


FSCI Unique Approach to Measurement

Uses medical chart data gathered by clinically trained personnel rather than insurance claims data derived from medical bills

Adjusts for risk so that the patient’s condition is taken into consideration when assessing the outcome

Evaluates how the patient is doing a month after his or her operation, since more than half of complications occur after discharge

Builds commitment and collaboration among surgeons, surgical teams and hospitals, because it is based on the highest quality data



Ambulatory Surgery Care Standards CMS State Operations Manual, Appendix L, Part I ASC Survey Protocol, and Part II General Conditions and Requirements http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf May also be accessed through the AAAHC.org website

Very Similar to CMSCDC/SHEA/TJC recommendations for hospitals


ASC416.51 Infection Control The ASC must maintain an infection

control program that seeks to minimize infections and communicable diseases


ASC Key Elements of a Risk Assessment

Make it your own through a formal Risk Assessment

Collaborative effort Regularly reviewed and updated Governing body review Forms the basis for your written Infection

Prevention Plan including goals and measureable objectives


Risk Assessment for Facility’sUnique Practice Setting

Identify Risks for Transmission

Populations Procedures – general and

specialty care procedures Geographic

Location/WeatherSize of Facility Referral PatternsOrganisms and risks

common to the community (endemic occurrences)

Surveillance data including HAIs and process monitoring

ConstructionCleaning, Disinfection

SterilizationSupply ChainStaffing

Medical ASC staff


Types of Infections

Surgical Site InfectionsCA-UTIIntravenous Catheters including CLA-BSIsC. difficile or other GI pathogensRespiratory IllnessResistant Organisms


Collaboration is Key Part of IP Risk Assessment

Interdisciplinary Input

Infection Prevention Team

Medical StaffNursing StaffAdministrationOther Leaders

Other potential participantsPatientsPublic RelationsPublic Health 3rd Party Payors


Set Goals Based on Risk Assessment

High Risk - High VolumeLikelihood of event occurringKey Risks

Determine top prioritySet Goals

Establish measurements to evaluate goalsSet protocols for obtaining the data for the

measurements


Infection Prevention Program and QA/PI Program Linkage

416.51(b) …”ongoing program designed to prevent, control, and investigate ..”

416.51(b)(2) …”an integral part of the ASC’s quality assessment and performance improvement program..”


Basic Program Elements SSI Prevention

Hand Hygiene

Cleaning, Disinfection and Sterilization

Safe Injection PracticesLLF SSI Standards 2013

Qualified IP Required416.51 Condition for Coverage – Infection

Control: “The ASC’s infection control program must be directed by a designated health care professional with training in infection control.”

ICSW Item #17 – “Does the ASC have a licensed health care professional qualified through training in IC and designated to direct the ASC’s IC program?”


Impact of ICSW Item #17:

“If the ASC cannot document it has designated a qualified professional with training in IC to direct its IC program, a deficiency must be cited.

Lack of a designated professional responsible for IC should be considered .. for a Condition level deficiency related to 416.51.”


Common CitationsWritten materials are needed, yet are absent, incomplete, or insufficient to meet the standards

Cleaning, disinfection, and sterilization of instruments, equipment and supplies, environmental cleaning

Governing body formal meeting minutes

Policies & procedures Required recordkeeping

such as logs Evidence of delegation

of responsibilities Evidence of compliance

with policies

Manufacturer’s Recommendations

Follow AAMI, AORN, CDC


Common Citations

Safe Injection Practices One Needle, One Syringe, One Patient, One Time

Outbreaks due to improper use of single dose vials, syringes and needles

Single patient use vials are single patient use, unless drawn up under a certified pharmacy hood, no exceptions!


Nationally recognized guidelines adopted by your organization’s Governing Body as evidenced in formal meeting minutes Most current version Adherence Education Surveillance

Common CitationsProcedures to minimize risk of Infection including Surveillance

NHSN

CDC GuidelinesPatient Safety GoalsAORNProcess MonitoringOutcome MonitoringTargeted activities-

high risk /high volumeLegislative Mandates

DefinitionsMethodologyComparisons


Tips for Success for Accreditation Survey

1. Present the most current standards book upfront.

2. Prepare for the challenging aspects3. Set up a space for the surveyor to work4. Document quality and infection prevention

initiatives5. Prepare a list of physicians and staff

a) Make sure credentials are in orderb) Have evaluations and education/orientation

records readily availableLLF SSI Standards 2013

Key Resources Accreditation Association for Ambulatory

Health Care [email protected] for general questions

Association for Professionals in Infection Control www.apic.org

Safe Injection Practices www.oneandonlycampaign.org

Center for Disease Controlwww.cdc.gov


Basic practices for prevention and monitoring of SSI:

1. Perform surveillance for SSI (A-II).2. Provide ongoing feedback on SSI surveillance and process measures to surgical and perioperative personnel and leadership (A-II).3. Increase the efficiency of surveillance through the use of automated data (A-II).

LLF SSI Standards 2013 CDC SSI Guideline 1999

SSI Surveillance MethodsDaily Direct Observation by trained person starting

24-48 hours after surgery Considered to be the most accurate method of

surveillance, but rarely used due to resource limitation

Indirect SSI surveillance using a combination of sources Microbiology and Patient RecordsSurvey of surgeons and patientsRe-admission trackingOther information including coded dx, or op reportsEfficacy of Indirect Surveillance

Less time consuming, IP can perform during surveillance rounds

Reliable (sensitivity, 84%-89%) and specific (specificity, 99.8%) when compared to “gold standard” of direct surveillance.


Automated SurveillanceExpanded by using hospital databases

data on administrative claims,days of antimicrobial use, readmission to the hospital,return to the operating room

Automatically import datamicrobiologic culture data, surgical procedure data, and general demographic information

Improve the sensitivity of indirect surveillance for detection of SSI

Improve IP efficiency in data collection


Perform Surveillance

High Risk - High Volume Identify, collect, store, and analyze data

needed for the surveillance program.Implement a system for collecting data

needed to identify SSIs.Develop a database for storing, managing,

and accessing collected data on SSIs.Prepare periodic SSI reports (the time frame

will depend on hospital needs and volume of targeted procedures).

LLF SSI Standards 2013CDC SSI Guideline 1999

Perform Surveillance

Collect denominator data on all patients undergoing targeted procedures, to calculate SSI rates for each type of procedure

Identify trends (eg, in rates of SSI and pathogens causing SSIs).

Use CDC and NHSN definitions of SSIPerform indirect surveillance for targeted

procedures.Perform postoperative surveillance for 30

days; if prosthetic material is implanted during surgery then follow for 12 months


Special Approaches for SSI PreventionPerform an SSI Risk Assessment

Perform Expanded SSI Surveillance

Identify areas that surveillance data suggest lack of effective control. Elements to Consider

High Risk -High Volume

Surveillance Data Rates Processes Organisms Strategies

Determine the source, extent of the problem, and to identify potential interventionsCase findingObservational

StudiesCheck adherence

rates to best practices


Post Discharge SSI SurveillanceMore Procedures are being done in outpatient settingShorter Post OP stays for InpatientsNo standard method for Post OP SSI surveillance

o Questionnaires to patients, surgeons, or clinics o Shown to have poor sensitivity and specificity

Rates do increase after Post Op Surveillance implemented

Superficial incisional infections usually managed as outpatient

Deep incisional and organ/space infections typically require readmission to the hospital for management.



Infrastructure Requirements

Trained personnelInfection prevention and control personnel

SSI surveillance,Able to apply CDC definitions of SSI, Basic computer and mathematical skills,

and Good communication skills and adept at

providing feedback and education to healthcare personnel when appropriate

• NSQIP – surveillance nurse


Computer Assisted Decision SupportCreating automatic reminders

Use computer support to improve pre-op administration of antimicrobial prophylaxisInitial and repeat dosesStop orders

Utilization of automated dataTracking Monitoring


Feedback

Provide ongoing feedback on SSI surveillance and process measures to surgical and perioperative personnel and leadership (A-II).Routinely provide feedback on SSI rates and

process measures to individual surgeons and hospital leadership.For each type of procedure performed, provide

risk adjusted rates of SSI.Anonymously benchmark procedure-specific risk

adjusted rates of SSI among peer surgeons.Confidentially provide data to individual

surgeons,the surgical division, and/or department chiefs.


Will automation and reminders help?

30% of SSI are preventable with

appropriate use of preoperative antibiotics*

LLF SSI Standards 2013 *Dellinger EP 2005


•MD to treat any existing infection at remote site (urine, bloodstream, etc.)Remove hair only when necessary

»Do not shave»When necessary, use clippers or depilatories

• Control hyperglycemiaImplement preoperative showers--CHG preferred• Administer surgical prophylaxis according to guidelines• Maintain appropriate oxygenation control• Maintain normothermia/control of hypothermia

CDC SSI Guideline 1999

SSI Complexity

Microbial characteristics (eg, degree of contamination and virulence of pathogen)

Patient characteristics (eg, immune status and comorbid conditions)

Surgical characteristics (eg, type of procedure, introduction of foreign material, and amount of damage to tissues)


Extrinsic Procedure Related Perioperative: Patient Preparation

Hair Removal Pre-Operative Infections

Do not remove hair unless hair will interfere with the operation

If hair removal is necessary remove by clipping.

Do not use razor. A I

Identify and treat remote infections prior to elective surgical procedures. A II


CDC SSI Guideline 1999


Do Not Remove Hair at the incision site, unless it will interfere with surgery itself.

If the hair must be removed, do it directly beforehand, preferably with electric clippers. (1A)

Pre-surgical patients should perform an antiseptic shower at least the night before and preferably also the morning of the scheduled surgery. Wash and clean the incision site area, scrubbing lightly to remove any gross skin contamination prior to antiseptic surgical preparation. (1B)

CDC, 1999

Hair Removal MethodShaving versus Clipping

Hair Removal Method Clean Wound Infection Rate (%)

Shaved with razor 2.5

Clipped 1.7

Electric razor 1.4

Not shaved, not clipped 0.9

Depilatories 0.6


The increased risk with shaving prior to the operation is associated with microscopic cuts and shaving immediately before seriously reduces the SSI risk ( 20% risk if shaved > 24hrs--CDC, 1999).

Cruce and Forde, 1981

Implement evidence based standards (A-II)

Policies and practices should include but are not limited to the following:Reducing modifiable patient risk factorsOptimal cleaning and disinfection of equipment

and the environmentOptimal preparation and disinfection of the

operative site and the hands of the surgical team members

Adherence to hand hygieneTraffic control in operating rooms


Intrinsic Patient Related - Perioperative

Un-Modifiable Modifiable

Un-modifiableAge

No formal recommendation: relationship to increased SSI due to comorbidities or immune status.

• Obesity Increase dosing pre-op antimicrobial

prophylaxis for morbidly obese patients.A-II

Smoking Cessation Encourage within 30 days before

procedure A-IIImmunosuppressive Meds

No formal recommendations Avoid if possible in perioperative period

if possible.C-II

• Glucose Control, diabetes Control serum glucose levels Reduce glycosylated hemoglobin A1c

levels to <7% before surgery, if possible


Operative Characteristics

Surgical ScrubUse appropriate antiseptic agent to perform 2-5

minute preoperative surgical scrub or an alcohol-based surgical hand antiseptic product. A-II

Skin PreparationWash and clean skin around incision site; use an

appropriated antiseptic agent. A-II


Operative Characteristics

Surgical skill/techniqueHandle tissue carefully and eradicate dead

space (A-III)

Antisepsis Adhere to standard principles of operating

room asepsis (A-III)

Operative TimeNo formal recommendation in most recent

guidelines; minimize as much as possible (A-III)


Operative Characteristics - Operating Room Ventilation

Follow AIA recommendations (C-I)Traffic

Minimize operating room traffic (B-II)Environmental Surfaces

Use a US Environmental Protection Agency-approved hospital disinfectant to clean surfaces and equipment. (B-III)

Sterilization of surgical equipmentSterilize all surgical equipment according to

published guidelines (B-II)Minimize the use of flash sterilization


Sterile GownsSelect Sterile gowns

When you will be at the sterile field When you are inserting a central line

Select based on level of potential blood exposureImperviousFluid Resistant

Twirl for closure and Tie securelyMaintain sterile area

Sides and back are not considered sterileDo not turn side or back to sterile field within 12

inches



Sterile above the table

Side, back and below table areas are non-sterile

Shaded portion indicates protective

barrier zones


Sterile during

procedure

Protective Barrier

Not part of sterile field when below

table

Gowns for Non-scrubbed Personnel

Select gown for blood borne pathogen protection requirementsHow likely are you to be splattered during a procedure?

How likely are you to contaminate yourself with potentially infectious material

Is the patient on isolation precautions?


Lead ApronsEstablish cleaning procedure

After useInspect prior to procedure to make sure

they are clean and ready to goHang and store to prevent

contamination by splashing


General Infection Control for Non-scrubbed Participants

Hand Hygiene Prior to entry of OR After touching patient or patient’s equipmentDuring procedure as appropriate

Wear gloves if likely to be contaminated with blood or body fluids

Wear mask appropriately


Alcohol gel : Place on cart or desk for easy access and use

Perform hand hygiene and don clean gloves before and after handling patient devices IV, Foley, etc

Perform hand hygiene before and after positioning patient


Hand Hygiene Plus Changing Gloves Hand Hygiene Plus Changing Gloves is critical for infection preventionis critical for infection prevention

General Infection Prevention for Non-scrubbed Participants

Use appropriate technique to enter vialsClean top with alcohol - do not just pop or

access without cleaningMaintain distance from sterile field

Non-sterile participants must maintain at least a 12” distance from sterile field

Minimize talking Minimize moving around in roomMaintain all precautions until surgery is

completed and surgical site is closed



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Sterile field tables•Set up so there is 1’ clearance for staff to work between tables

•Do not turn back to sterile field within 1’

•All non-scrubbed staff must maintain distance

Maintain sterility of equipment cover

•Do not turn back to equipment

Below table tops are not sterile - do not bend down or turn to side

Anesthesia Cart

•Make sure tables are clean before starting to set up the room•Set up using sterile technique•Evaluate the amount of items that are opened and on sterile table

OR Traffic Flow

Personnel must enter by sub-sterile room Enter by larger corridor door only when

Bringing patient into room Bringing large equipment into room

Do not enter by larger doors during procedure May enter if a piece of equipment is absolutely

necessary for case Keep doors to corridor closed at all times

except for above situations (1&2)


Equipment & Product Reps

Educate and require sign in prior to coming to ORAll reps must

complete mandatory Infection Control Education

Wear hospital provided scrubs

Perform hand hygiene prior to entry and as appropriate during case

Don and wear mask appropriately

If going to be near sterile field to assist in equipment utilization, representative should:Wear sterile attireScrub inUse laser pointer

Consider wearing long sleeve jacket or gown to decrease shedding

Limit the number of observers to those who are essential to the case

Limit movement and talking in OR suite during procedure


Handling of Equipment from Outside Company

Must be cleaned, inspected and sterilized by OR staff Staff should use appropriate lighting and

magnification to inspect smaller piecesOR techs must inspect for cleanliness and residual

debris after re-stocking by representative prior to sterilization

Equipment must be brought to OR the day before surgery to assure appropriate handling

No routine flash sterilization of company equipment


Set up fluid basins using sterile techniqueLabel all fluid basins with content and doseChange all fluids every 4 hours for longer

proceduresUse single use products /Single Patient

Product vials must be maintained until the end of surgery as a patient safety measure

Discard at end of caseWhen in doubt - throw it out!

Discard fluid from basin if any potential for contamination occurs


Safe Management of Fluids

Maintain sterile fields and practices until site is completely closed

Do not start to break down tables and remove hoses, etc while suturing is being done


Operating Room - Patient Advocacy

Maintain watchful eye for any break in sterile technique

Empower everyone to point out breachesCirculator should actively assist in observing

practice and recognizing breaches Simulation of incidences will improve response

during surgeryEveryone is responsible for the patient’s safety!


Immediate-Use Steam Sterilization (IUSS)

Shortest possible time between a sterilized item’s removal from the sterilizer and its aseptic transfer to the sterile fieldProtect during transfer from contaminationUse containers for transport-AORN

recommendation Survey Readiness for Cleaning, Disinfection & Sterilization

Do not store for future useDo not hold from one case to another


IUSS Recommendations, cont.

Follow same cleaning, decontamination and transport step as other processingCleaning agents and brushesPPEsWater qualityFollow manufacturer’s recommendationsMonitor sterilization process including

biological, chemical and others


IUSS Recommendations, cont

Implants must not be process by IUSS except in a documented emergency situation and no other option is available

Only process devices and loads that have been validated with the specific cycle employed

IUSS is not to be a substitute for adequate inventory


Survey Readiness for Cleaning, Disinfection &

Sterilization


Focus on Cleaning PracticesManufacturer’s Instructions for Use (IFU)

Up to date oneSource document site

(www.onesourcedocs.com or 1-800=701-3560)Available and used

Staff competency for cleaning and decontamination based on IFUsAttention to detail for cleaning and rinsingCleaning implements such as brushes, clothes, etc

Discard or Re-use: be sure staff knows exactly how a brush should be handled

Documentation of Training and Competency


Standardized Processes

Instruments cleaned and processed the same regardless of area (i.e. OR, CSS, etc)

Loaner and other instruments handled identicallyTake apart rigid containers for cleaning

NO SHORT CUTS


Sterilizer Biological MonitoringAAMI ST79

Test at least weekly, once a day betterTest all types of loads

Rigid containersProtective caseSurgical wrap Hint- since each configuration must be tested

it is wise to limit the number of configurations Temperature/PressureGravity and Dynamic Air Removal


Implants

Test all cycles with implant BI, Class 5 Integrator

Do not release until biological result is availablePolicy for early release

Multidisciplinary Input Who can determine it?

Surgeon OR Administration Define emergency exceptions

Traceability of Implants


IUSS Monitoring

Place BI on bottom shelf over drainUse a Class 5 indicator as an internal chemical

indicatorPhysical Monitors

Document - who started and then who removed item from sterilizer

Reconcile with patient informationReview all data by experienced personDo not use if any data suggests a failure


Loaner Policy

Know Contents and Manufacturer’s IFUDetailed inventory of contentsFDA clearance

Adequate time for cleaning, decontamination and sterilization prior to procedure

Maintain records Identify responsibility of surgeon, OR staff,

sterile processing area and sales repLoaner Checklist Communication is Key


CMS Mandatory Reporting for Surgical Cases 2012

Centers for Medicare and Medicaid Inpatient Prospective Payment System

Hospitals must report SSI surveillance data for COLO and HYST via NHSN to avoid a reduction of 2.0 percent in their Medicare Annual Payment Update


In PatientNHSN Operative Procedure Categories

COLO: Incision, resection or anastamosis of the large intestine; includes large-to-small and small-to-large bowel anastamosis; excludes rectal repairs*

HYST: Removal of uterus through the abdomen* (includes laparoscopic)

* General descriptions only; follow ICD-9-CM list


SSI Requirements

Facilities must observe NHSN SSI protocol in entirety

NHSN will submit a subset of data to CMS: – >18 years of age – Inpatients – Deep incisional and/or organ/space SSI – Identified on admission or readmission



http://www.cdc.gov/nhsn/index.html

http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

http://www.cdc.gov/nhsn/library.html

http://www.cdc.gov/nhsn/PDFs/pscManual/14pscForm_Instructions_current.pdf

Tenets of Surveillance

Surveillance versus Clinical Definitions Different purposes

– May not agree –Comments section useful to note important factors

Can submit questions to NHSN mailbox [email protected]


Tenets of Surveillance

Consistency is a Must! Criteria designed to look at a population

at risk Identify patients meeting the criteria Consistently apply the criteria Ensures the comparability of the data-

protects your facility and others


NHSN Requirements for Surveillance Active Patient-based not culture-based ProspectiveRequires that a variety of sources for case

finding be utilized: Culture results Nursing unit rounds; kardexes, wound care

and ID consults, temperature logs, etc. Staff notification Readmissions


Definitions

SSISuperficial Incisional SSI (primary or

secondary)Deep Incisional SSIOrgan/Space SSI

ORImplantsEmergencyEndoscope


SSI DefinitionsCDC/NNIS/NHSNTypes

Superficial incisional (involving only skin or subcutaneous tissue of the incision)

Deep incisional (involving fascia and/or muscular layers)

Organ/space


NHSN Risk Factors

Patient Risk Factors Hospital Factor LevelGeneral anesthesiaAge Wound class Emergency Gender ASA score Trauma Endoscope Duration of procedure

Bed sizeMed School Affiliation



Standard Infection Ratio (SIR)

Based on Standardized Mortality Ratio (SMR) Used extensively in public health research Compares the experience in one facility to that in a

standard population Advantage: Presents in single metric how the

number of infections experienced relates to the expected number

Number Observed/Number Expected


COMPUTING THE SIR

Numerator: Simply the number of infections at that facility during time period

Denominator: Multiply the referent stratum-specific rates by the number of patients in each stratum Sum all of these Equals the “expected denominator”


What does a SIR mean?

An SIR of “1” signifies that the observed and expected numbers of HAI are the same when compared to like locations in NHSN

An SIR of > “1” signifies that there were more

observed HAIs CAUTIs than expected when compared to like locations in NHSN. i.e., SIR= 1.50 = 50% more Infections

An SIR of < “1” signifies that there were fewer observed HAIs than expected when compared to like locations in NHSN. i,e, SIR=0.50 = 50% fewer infections


Accurate Denominator Data Is Critical

Surgery completed in a single trip to the OR Incision closed before leaving OR Surgery conducted in defined operating

room suite May be an in- or out-patient procedure

(based on monthly reporting plan) Laparoscopic & traditional approaches

included


Operative CharacteristicsSCIP Antimicrobial prophylaxis

Administer antimicrobial prophylaxis only when indicated A-I

Timing o Administer within 1 hour before incision to maximize tissue

concentration A-Io Vancomycin and fluoroquinolones can be given 2 hours before

incision. Choice

o Select appropriate agent on basis of surgical procedure, most common pathogens causing SSI for a procedure, and published recommendations. A-I

Duration of Therapyo Stop prophylaxis within 24 hours after the procedure for all

procedures, except cardiac surgery; for cardiac surgery, antimicrobial prophylaxis should be stopped within 48 hours. A-I


Do not use these strategies routinely to prevent SSIs

1. Do not routinely use vancomycin for antimicrobial prophylaxis;

a) vancomycin can, however, be an appropriate agent for specific clinical circumstances (B-II).

b) Reason for use must be documentedc) Does not cover gram negative bacteria

2. Do not routinely delay surgery to provide parenteral nutrition (A-I).


SSI Prevention Measures4. Measure and provide feedback to providers on therates of compliance with process measures, includingantimicrobial prophylaxis, proper hair removal, and

glucosecontrol (for cardiac surgery) (A-III).

5. Implement policies and practices aimed at reducingthe risk of SSI that meet regulatory and accreditationrequirements and that are aligned with evidence-basedstandards (eg, Centers for Disease Control and

Preventionand professional organization guidelines) (A-II).


SSI Prevention EducationEducate surgeons and perioperative

personnel about SSI prevention (A-III). Teach strategies aimed at minimizing

perioperative SSI risk through implementation of recommended process measures.

Provide education regarding the outcomes associated with SSI, risks for SSI, and methods to reduce risk to all patients, patients’ families, surgeons, and perioperative personnel.

Local epidemiology including MDROs includingMRSA

Basic prevention strategiesLLF SSI Standards 2013

SSI Prevention EducationEducate patients and their families about SSI

prevention, as appropriate (A-III). Provide instructions and information to

patients before surgery, describing strategies for reducing SSI risk.

Specifically provide preprinted materials to patients in accordance with evidence-based standards and guidelines



Points Discussed / Questions asked in Handout:-Will I receive and antibiotic prior to surgery?-Should I take a shower with antibacterial soap prior to surgery?

Infection Control Tips:-Keep your hands clean-Do not hesitate to ask your healthcare provider if he/she has washed their hands-Cover your mouth and nose when you cough or sneeze. Discard

the tissue and then clean your hands-Safely care for wounds and catheters by learning proper aseptic or clean techniques-Handle needles and other sharp items safely and discard into a sharps container to prevent injury to you and others


Patient Education

Web Pages and Materials for PatientsJAMA patient page: wound infections (from the

Journal of the American Medical Association; available at:http://jama.ama-assn.org/cgi/reprint/294/16/2122)

Surgical Care Improvement Project consumer info sheet (available at: http://www.ofmq.com/Websites/ofmq/Images/FINALconsumer_tips2.pdf)

What you need to know about infections after surgery: a fact sheet for patients and their family members (available at: http://www.ihi.org/NR/rdonlyres/0EE409F4-2F6A-4B55-AB01-16B6D6935EC5/0/SurgicalSiteInfectionsPtsandFam.pdf)


IHI SSI Prevention Bundle

Appropriate use of antibioticsAppropriate hair removalMaintenance of post operative glucose for major cardiac surgical patients

Post operative normothermia for colorectal surgery patients


Checklists in OR Improve Performance

When checklists were available to surgical teams, they missed just 6 percent of life saving steps, compared with 23 percent when the tool was not available, according to results published online Wednesday in the New England Journal of Medicine.

January 2013








Current Issues Preoperative bathing with chlorhexidine-

containing productsNot conclusiveOther processes in study

Impregnated wipes Regular or foam CHG direct application Routine bed bath with CHG

To gain the maximum antiseptic effect of chlorhexidine, it must be allowed to dry completely and not be washed off.

Studies do show reduction in skin flora and some also correlate now to reduction in SSI

Patient ComplianceDid they do it?Did they reach critical areas?


Current Issues Routine screening for MRSA or routine attempts to

decolonize surgical patients with an anti-staphylococcal agent in the preoperative settingTimingOpportunity

Mupirocin in specific patient groups undergoing orthopedic or cardiac surgery may be effective Not randomized controlled trials.

Preoperative intranasal and pharyngeal chlorhexidine treatment for patients undergoing cardiothoracic proceduresAlthough data exist from a randomized, controlled trial to

support its usage, chlorhexidine nasal cream is neither approved by the US Food and Drug Administration nor commercially available in the United States.


Do the new Antimicrobial Products reduce SSIs?

Product Types Future NeedsSutures

Dressings

Skin Preps or CleansersWipesOther forms

Intra operative Irrigation Products

Industry sponsored

Multi-center trials needed

Independent studies with enough cases

Value Analysis



Packet given in the clinics or during preop testing -Instruction sheet-Patient Safety Handout-Packet or container with CHG product

Other areas for pre-operative showering:-Pre-op Admissions or Pre-Op Holding Area-Pre-admission on a floor or ICU

Documentation of pre-operative showering:-Pre-op nursing notes in holding area-Clinic notes-Transplant coordinator notes-Unit nurse who assisted with bath


•Preoperative shower or bath with CHG reduces skin microbial counts more effectively than povidone-iodine or other antimicrobial soaps

• Bathing 2 times with CHG (once the evening before & then the morning of ) is recommended to increase effectiveness.

• New IHI Ortho recommends showering x3 days

• Daily bathing with CHG has been shown to reduceCatheter Line Associated Bacteremias, MRSA, and C. difficile.


Pre-Operative Showering & No Shaving

for the Prevention of Surgical Site InfectionsTips for SSI Prevention:• Showering with CHG soap both the night before and morning surgery• Shaving is no longer recommended unless ordered specifically by the physician

Why Pre-op Shower, you ask? To reduce normal skin flora at the surgical site and minimize the risk of developing infections. Also, by not shaving any areas, you keep the skin intact and reduce micro tears that could become sources of infection.

What do I tell the patient to do:• Shower both the night before and the morning of the surgery• Use the CHG soap provided at time of the clinic visit• Do not shave any areas of the body within 48 hours prior to surgery• Scrub body from head to toe avoiding mucous membranes, eyes, ears, etc.• Dry off with clean dry towel

What do I Give to the Patient:• Written instructions and information sheet•CHG soap (approximately 30 ccs)

How do I document this information:• Please note in the progress / clinic note that info and product was given• If in Pre-Op area, please note on peri-operative form if pt showered in pm and am

Questions:

Please call Infection Control

Thank you for your participation in this initiative to reduce Surgical Site Infections.


Preoperative Chlorhexidine Bathing InstructionsOnce the decision to have surgery has been made, there are a few steps you can take to reduce your

risk of acquiring an infection at the surgical site. Your skin is not sterile and contains germs that are present everyday. We are able to live with these germs because of our skin barrier. Once the barrier is broken, for example, with a surgical incision, you become more vulnerable to these germs. In an effort to protect yourself from these germs, a preoperative shower with a special soap is recommended. This soap contains a substance called chlorhexidine gluconate (CHG)* and helps to reduce the numbers of bacteria on your skin. This soap will be given to you or it may be purchased at a local drug store. (Call ahead and ask if it is in stock).

*Not to be used by people with known allergies to chlorhexidine. If an allergic reaction occurs, call you doctor immediately.

Soap is for topical use only; DO NOT DRINKBathing Instructions:1)Shower or bathe with CHG both the night before and the morning of your surgery. Do NOT shave

any body area.2)Wash your hair in the usual fashion with your own shampoo and rinse your hair and body thoroughly.3)From the neck down, apply the CHG to your entire body paying close attention to the area where

your surgery will be performed. (DO NOT put the CHG near your face, eyes, or ears as it can cause permanent damage).

4)Turn the water off to prevent rinsing prematurely and continue to lather and wash your body for 5 minutes. Do NOT scrub your skin too hard as you wash and do not wash your body with regular soap after the CHG.5)Turn the water back on and rinse thoroughly, then pat yourself dry with a clean, fresh towel.

Pay particular attention to the circled areas

SCIP INFECTION MEASURESSCIP 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 SCIP Inf-4 - Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose SCIP Inf-6 - Surgery Patients with Appropriate Hair Removal SCIP Inf-9 - Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIP Inf-10 - Surgery Patients with Perioperative Temperature Management



Improvement StrategiesIncorporated into OR ChecklistLetters to team members with timing failuresReview by SCIP committeeEmail to all noting how many days since

failure by OR locationCulture Change – self reporting of failuresAntimicrobial Team – Selection education and

interventions


Infection Prevention CommunicationWhere

Each Surgical Service Patient Care Units for

CA-UTI prevention C-Suite Infection Prevention &

Control Committee Service/Unit

Departmental Meetings Quality Safety

Evaluation Committee SCIP Team Board Quality

When QuarterlyDaily for CA-UTIOther

WhatQuarterly Service

Specific SSI Rate Trending + Recommendations

CA-UTI Prevention by Units



Strategies of the Neurosurgery Infection Prevention Team

Employed Adverse Event Trigger Strategy Every Monday IPC notified NSG Chair of potential cases Investigation and Data Collection related to procedure and team

members NSG Team reported infections to IP Each case reviewed with all participants at meeting 2x’s a month Root Cause Analysis discussion concerning each case was done Evaluation of Practice, including surgical and unit procedures and

OR setting OR observational studies performed by IP with feedback to team

and staff Education – every meeting addressed a “hot topic” Development of Checklist


Surveillance & Data Trending• SSIs detected through reporting of infections

from the NSG Team as well as by routine surveillance methodology used by the IPC Department.

• Class I SSI and procedure-specific SSI rates were calculated on a quarterly basis.

• Reported to IPC Committee, NSG team, Surgical Committee and Operations Committee of the Medical Staff and through the quality committee structure.



Risk Factors Analyzed for Class 1 NSG SSI

Name

Medical Record Number

Admission Date

Discharge Date

Diagnosis

Attending Physician

Resident Physician

Operation Performed

OR Date

Time of Surgery

Post-operative Unit

Culture Date

Organism

Source of Culture

# of Days from OR to Culture Date

Location Prior to OR

OR Room Number

OR Personnel

Choice of Pre-operative Antibiotics

Timing of Pre-operative Antibiotics

Dosage of Pre-operative Antibiotics

ASA Score

Patient’s Sex

Patient’s Age

Patient’s Race

Hair Removal

Body Mass Index

Re-dosing of Antibiotics

Risk Index

Re-admissions

Process & Practice Improvements• Improved classification with implementation of a mandatory

classification field• Developed & implemented checklist and improved

consistency in following recommended practices• MRSA screening has identified about 8% of their elective

surgical patients are MRSA positive. Noted that more patients had infections with MSSA• NSG staff screened for MRSA/MSSA- no MRSA isolated,

4 MSSA identified and decolonized. No linkage to cases.• Implemented pre-op screening for MRSA/MSSA and

decolonization


Process & Practice Improvements• Improved consistency of Pre-op Showering with CHG • Improved Management of medications, vials and fluids

• Created signage to make sure vial tops were scrubbed with alcohol before each entry

• Improving OR environment (new carts, more storage, on-going monitoring by 2 OR patient safety nurses, no personal items in the OR room)

• NSG to report infections to IP


Process & Practice Improvements• Education for Anesthesiology, OR team and Patient Care

Unit staff

• Pre-Op Antibiotics (ABX) Prophylaxis• Changed ABX prophylaxis to Kefzol from

Vancomycin based on literature review, if Vancomycin is used Kefzol is still needed, unless allergic

• DC ABX at 24 hours according to SCIP


References CDC Prevention of Surgical Site Infections, 1999 http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf Altemeir WA, Burke JF, Pruitt, BA, Sandusky,WR and the American College of

Surgeons, Committee on Control of Surgical Infections of the Committee on Pre-and Postoperative Care. Manual on Control of Infection in Surgical Patients.Second Edition. JB Lippincott Company. Philadelphia. 1984.

Janelle J, Howard, RJ, and Fry D. Chapter 23 Surgical Site Infections. APIC Text of Infection Control and Epidemiology, 2nd Edition, 2005.

Mangram AJ, Horan TC, Person ML, Silver LC, Jarvis WR. The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Infection Control and Hospital Epidemiology 1999;20:247-280.

LeFrock, SHEA Annual Meeting, Philadelphia, 2004. Bratzler, DW. Surgical Infection Prevention and Surgical Care Improvement:

National Initiatives to Improve Care for Medicare Patients. http://www.medqic.org/dcs/

Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, et. al.Compendium of Strategies to prevent HAIS. Infection Control and Hospital Epidemiology October 2008, Vol. 29, supplement 1www.shea-online.org

World Health Organization www.who.org IHI www.ihi.org Surgical Site Infection (SSI) Reporting Through NHSN: Tips, Trips and

Best Practices . Kathy Allen-Bridson. Nurse Consultant , Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention , November, 2011, Webinar


Resources1. Klevens R.M., Edwards JR, Richards CL Jr., et al. (2007) Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. 2. de Lissovoy G, Fraeman K, Hutchins V, et al. (2009) Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387-397. 3. Five Million Lives Campaign. (2008) Getting Started Kit: Prevent Surgical Site Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2


ReferencesAAMI http://www.aami.org/publications/standards/ST79 http://www/aami.org/pubications/standards/ST79_Immediate Use Statem

ent.pdf

AORN Perioperative Standards and Recommended Practices Recommended Practices for Sterilization in Perioperative Setting Recommended Practices for Cleaning and Care of Surgical Instruments

and Powered Equipment Recommended Practices for Surgical Attire

Centers for Medicare & Medicaid Services Ambulatory Surgical Center Survey



Documents

Loretta Litz Fauerbach, MS, CIC Fauerbach & Associates – Global Infection Prevention Services March 7, 2013 Taking Quality to the Next Level Kentucky Hospital