Surgical Site Infection and the Operating Room Checklist

PREVENTION OF SURGICALSITE INFECTION

Refueling Your Quality EngineWinnipegMarch 3 & 4, 2011

11Risk Factors for SSIAgeNutritional statusDiabetesSmokingObesitySteroid useProlonged pre-op LOS PatientOperationPost-op careAntimicrobial prophylaxisBlood GlucoseNormothermiaHair RemovalAntiseptic techniqueSurgical techniqueWound classificationLength of surgeryBlood transfusionOR VentilationTraffic Control

Wound careDischarge2When exploring opportunities for prevention of SSI, it is helpful to recognize some of the specific factors that place patients at risk. Some of the patient related, or intrinsic, characteristics include age, current level of glucose control, obesity, smoking history and whether the patient has been able to stop smoking within 30 days of the surgical procedure, and whether or not the patient is on immunosuppressive medications. Other factors that are extrinsic, or procedure related, include activities such as hair removal, presence of preoperative infection, surgical scrub, skin preparation, antimicrobial prophylaxis, the skill or technique of the surgeon, ventilation and traffic control in the OR, and sterilization of surgical instruments and equipment.

ReferencesWHO Guidelines for Safe Surgery. First Edition. 2008.Mangram AJ, et al. The hospital infection control practices advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

2Prophylactic Antibiotics3

Appropriate Use Of AntibioticsThe right drug The right doseAt 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% )

4Choice of drug varies based on surgical procedure. There is currently no literature to support antibiotic use post 24 hours. If you make the time range 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: 750-72Zanetti et al., Emerg Infect Dis, 20017Weight-based antibiotic prophylaxis dosingGap in the literatureDated evidence that antibiotic prophylaxis weight-based dosing for cefazolin and vancomycin lowers SSI rates among obese surgical patients1Not enough evidence for SHN! to make recommendation

Weight Based Dosing in Canada: Evidence into PracticeHealthcare FacilityCefazolinVancomycinFraser Health Authority, Vancouver, British Columbia1g IV if 80kg2g IV if >80kgNot AvailableEdmonton and Area Acute Care Facilities, Alberta Health Services, Alberta1g IV if 100kg2g IV >100kgVancomycin 1g for everyoneGrace Hospital, Winnipeg Regional Health Authority, Winnipeg, Manitoba1g IV if 80kgNot AvailableHorizon Health Network, Moncton, NB1g IV if 100kg2g IV >100kgNot Available8SHN! RecommendationBased 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 IdeasUse 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.

10Hair Removal11SHN! Recommendation1Based on the evidence, the Safer Healthcare Now! SSI 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 IdeasDevelop a letter for surgeons 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 surgery13Perioperative Normothermia14Consequences of Mild HypothermiaIncreases duration of hospitalizationIncreases intra-operative blood lossIncreases adverse cardiac eventIncreases patient shivering in PACUPromotes metabolic acidosisIncreases SSI rates11. Melling et al. 2001 Lancet, 358: 876-8015SHN! Recommendation1Based on the evidence, the Safer Healthcare Now! SSI faculty recommend that measures are taken to ensure that surgical patient core temperature remain between 36.0C and 38C preoperatively, intraoperatively, and in PACU.

1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010Change IdeasPre operative warming utilizing forced warm air blankets for 30+ min pre-opContinue active warming in the OR (include warmed IV fluid and lavage for abd. cases)Increase the ambient temperature in the operating room to 20CHats and booties on patients during surgeryPACU warming to discharge as neededDo this routinely on all procedures slated 60 min. +17Blood Glucose Control18Recent ResearchStrict 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 patientsSHN! Recommendation1Based 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

20Change IdeasPre-op blood sugar analysis to pick up on undiagnosed diabetics

Referral to endocrinology or initiate treatment prior to slated date21Skin PrepPrevention Strategies and Skin Antisepsis2222The next section addresses infection control basics and reviews the characteristics of skin antisepsis solutions.

The Ideal Skin AntimicrobialThe ideal antimicrobial agent for skin should have the following properties: Broad spectrumRapid bactericidal activityPersistence or residual properties on the skin Effective in the presence of organic matterNon-irritating or have low allergic and/or toxic responsesNone or minimal systemic absorption 2323Current Approaches: Prevention of SSIsMultiple 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, 2007.2424The combination of these parameters makes CHG-containing agents more effective than many other antiseptic agents at reducing skin and wound microbial counts and thus decreasing SSIs.

Reference:Florman S, Nichols RL. Current Approaches for the Prevention of Surgical Site Infections. Am J Infect Dis. 2007;3(1):51-61.

SafetyCHG 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

25SHN! Recommendation1Based on the evidence, the Safer Healthcare Now! SSI faculty recommends that the skin should be cleansed before surgery with a chorhexidinebased 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

26SHN! Recommendation1To 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 CHG-alcohol 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

27http://www.youtube.com/watch?v=4IG8ItaTTzY