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SSI Prevention: Bundle
Amber Wood, MSN, RN, CNOR, CIC, FAPIC
• Discuss evidence-based practices to prevent surgical site infections (SSI)
• Develop a plan for implementing a SSI bundle
Objectives
How to Build a Bundle
No two bundles are the same…
Gap Analysis
• New• Improve
Procedure Specific Compliance Your
Bundle
Risk Assessment
Implementation Science
• Behavior (Human Factors)• Change management• Leadership Support• Resources (Equipment, Staff)• Teamwork & Communication
• TeamSTEPPS (AHRQ)• CUSP/SUSP (Johns Hopkins)
Atul Gawande
http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine#t-1128716
Bundle Elements
Core Practices(not procedure-specific)
• Only when indicated• Select agent based on clinical practice guidelines• Time the dose to be in tissue at time of incision
• Within 1 hour• Dosing
• Weight based• Re-dosing
Antimicrobial Prophylaxis
Order Sets,
Time OutCDC HICPAC Draft Guideline for Prevention of SSI
SHEA Compendium SSI Guideline
Strategies corner
• Maintain normothermia (35.5°C) perioperatively• Before, during, and after surgery
• Best method unresolved• Active & Passive• Patient assessment• Temperature monitoring• Selection of method
Normothermia
CDC HICPAC Draft Guideline for Prevention of SSI, SHEA Compendium SSI Guideline,AORN Guideline for Prevention of Unplanned Patient Hypothermia
Pre-warming,Products
General anesthesia with endotracheal intubation• Increase FiO2
• Intraop and post-extubation
Tissue oxygen delivery also needs…• Normothermia• Adequate volume replacement
Oxygenation
Anesthesia
Champion
CDC HICPAC Draft Guideline for Prevention of SSISHEA Compendium SSI Guideline
• Target blood glucose levels <200 mg/dL• SHEA: <180 mg/dL
• All patients• Diabetic and non-diabetic
Glycemic Control
Order sets,
Equipment
CDC HICPAC Draft Guideline for Prevention of SSISHEA Compendium SSI Guideline
• Patient bathing• At home & preop holding• CHG liquid & cloths
• Staphylococcus aureus screening & decolonization• MRSA & MSSA• SHEA Compendium: High-risk procedures (ortho, cardiac)
Bathing & Decolonization
Patient Reminder
s (electroni
c)SHEA Compendium SSI Guideline
• Patient bathing may reduce the microbial flora• Limitations/Gaps
• Optimal bathing procedures• Antiseptics vs soaps (ie, plain, antimicrobial) • Whole body or only the surgical site• Optimal timing before surgery • Optimal number of baths or showers
• Benefits outweigh harms
Evidence Review
AORN Guideline for Preoperative Patient Skin Antisepsis
I.a. The patient should be instructed to bathe or shower before surgery with either soap or a skin antiseptic on at least the night
before or the day of surgery. [1: Strong Evidence]
I.b. A multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists should develop a
mechanism for evaluating and selecting products for preoperative patient bathing. [2: Moderate Evidence]
AORN Recommendations
AORN Guideline for Preoperative Patient Skin Antisepsis
• S. aureus screening prior to surgery• MSSA & MRSA
• CHG baths for 5 days prior to surgery• Ten (10) dose mupirocin regimen• Use vancomycin in MRSA positive and some high risk patients
who cannot be screened• Continue current SCIP Measures
Institute for Healthcare Improvement (IHI)PROJECT JOINTS
“Project Joints, Joining Organizations in Tackling SSI’s”; sponsored by the Institute for Healthcare Improvement (IHI); Kathy D. Duncan, Institute for Healthcare Improvement Faculty, Presented at the AFMC Quality Conference on May 10, 2011.
• Alcohol-based skin antiseptic• Hair removal with clippers vs razor
Skin Antisepsis & Hair Removal
Preferred AntisepticTechnique
(IFU)SHEA Compendium SSI Guideline
Prevent SSI!!!
• Remove soil • Rapidly and persistently remove transient microorganisms at
the surgical site• Reduce resident microorganisms to subpathogenic levels • Minimal skin and tissue irritation
Effective Skin Antisepsis
AORN Guideline for Preoperative Patient Skin Antisepsis
• Organization level & Patient care team• FDA-Approved antiseptic• Alcohol-based antiseptics may be more effective than aqueous-
based antiseptics when not contraindicated
Selection
Maiwald M, Chan ES-Y. The Forgotten Role of Alcohol: A Systematic Review and Meta-Analysis of the Clinical Efficacy and Perceived Role of Chlorhexidine in Skin Antisepsis. PLoS ONE. 2012;7(9).
• Eye• 5% Povidone-iodine
• Gynecologic• 10% Povidone-iodine• 4% CHG recommended in ACOG position statement
• Orthopedic• Conflicting• Alcohol-based antiseptics
Procedure Specific
AORN Guideline for Preoperative Patient Skin Antisepsis
• All available FDA-approved products might be contraindicated • Allergy, Anatomical Location, Wound
• Evaluate the risks and benefits of alternative solutions• Soaps (baby shampoo, castile soap)• Saline
Contraindications
AORN Guideline for Preoperative Patient Skin Antisepsis
• Isopropyl alcohol 70% NOT approved for preoperative patient skin antisepsis
• Injections (eg, IV start)• Select an alcohol-based antiseptic product
• Mixing is compounding (USP 797)• “Painting” is a fire risk (flammable and clear)
• Multi-dose bottle• FDA advises single use containers • Alcohol is not sterile, Bacillus cereus
Alcohol
• Leave the hair and choose an aqueous, water-based antiseptic OR
• Clip the hair and choose an alcohol-based antiseptic
Hairy Patients
AORN Guideline for Preoperative Patient Skin Antisepsis
• Closing instruments• Change gloves at closing
Sterile Technique
Technique,
Resources
• Dressings• Technique, antimicrobial dressings, skin adhesive
• Postoperative wound care education
Dressings & Wound Care
Standardization,
Patient Education
Procedure-Specific
• Nasal antiseptic• Surgical Helmet Systems• Laminar Flow
Total Joints
Multiple APIC 2016 Posters
• Suture closure vs. staple• Vaginal prep with povidone-iodine• Placenta removal with traction vs. manual extraction
Cesarean Birth
Multiple APIC 2016 Posters
• Nasal antiseptic• CHG mouthwash• Disposable telemetry leads
Cardiac Procedures
Multiple APIC 2016 Posters
• Wound protectors (SHEA Compendium)• Bowel technique• Closing instruments• Change gown/gloves• Mechanical/chemical bowel prep• Triclosan coated suture (HICPAC Draft SSI Guideline)
Colon Procedures
Multiple APIC 2016 Posters
• Preop• Fasting & carbohydrate needs• Thromboembolism prophylaxis• Antimicrobial prophylaxis• Skin preparation
• Intraop• Anesthetic protocol• Surgical access• Avoid nasogastric intubation• Normothermia• Fluid management
• Postop• Nausea & vomiting• Eliminating drains• Remove urinary catheter• Prevent ileus• Multimodal analgesia• Nutrition• Glucose• Early ambulation
ERAS: Enhanced Recovery After Surgery
ERAS Society: http://erassociety.org/Hohenberger H & Delahanty K. 2015. "Patient-Centered Care—Enhanced Recovery After
Surgery and Population Health Management". AORN Journal. 102 (6): 578-583.
ElectiveColon
Environment
Temperature & Humidity
Facilities Guideline Institute, 2014AORN Guideline for a Safe Environment of Care, Part 2
Area Humidity Temperature Air Pressure
OR 20% to 60% 68° F to 75° F20° C to 24° C
Positive
Soiled/ Decontamination
< 60% *72° F to 78° F22° C to 26° C(May be too warm for personnel in PPE)
Negative
Clean/Sterile <60% 72° F to 78° F22° C to 26° C
Positive
https://www.aorn.org/guidelines/clinical-resources/position-statements
Harmonization
• Keep doors closed • Entry and exit of patients/personnel • SSIs related to door openings
Traffic
AORN Guideline for a Safe Environment of Care, Part 2
• Preplanning • Preference cards• Confirming all supplies present before the incision• Sign on the door to restrict traffic• Communication without door opening• Locks (opened from the inside only)• Taking breaks• Education
Decrease Door Openings
• High transmission risk Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904.
• 25% mean cleaning rate for objects cleaned in the OR at 6 acute care hospitals
Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93(3):358-364.
Environmental Cleaning
AORN Guideline for Environmental Cleaning
• Determine which items are high touch• Clean those items more frequently
Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM,Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol. 2011;32(2):185-187.
High Touch Objects
AORN Guideline for Environmental Cleaning
• Multidrug-resistant organisms• Enhanced cleaning may reduce MRSA and VRE contamination
& risk of transmission from prior room occupantDatta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch Intern Med. 2011;171(6):491-494.
Enhanced Environmental Cleaning
Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2006.
Adapted with permission from Guidelines for Perioperative Practice. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
AORN Guideline for Environmental Cleaning
http://www.aorn.org/toolkits/environmentalcleaning/
Toolkit
Surgical Attire
AORN Guideline for Surgical Attire
• Home laundering vs. health care-accredited laundering
• Evidence conflicting• Risk for pathogens being carried on the
scrub attire if home laundering
Laundering
AORN Guideline for Surgical Attire
• 3 postoperative Gordonia bronchialis sternal infections after CABG• Nurse anesthetist colonized: scrub attire, axilla, hands, and purse• Roommate also colonized• Home washing machine likely reservoir• Biofilms • Recommended hospital laundered scrub attire• First to demonstrate a causal relationship between home laundering
and human disease
Case Report
Wright SN, Gerry JS, Busowski MTet al. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012;33(12):1238–1241.
• Completely cover arms• Long-sleeved jacket or scrub top
• Restricted areas• Skin prep• Packaging items in sterile processing
Long Sleeves
AORN Guideline for Surgical Attire
• Clean or single-use• Evidence does not support wearing cover apparel to protect
scrub attire from contamination• Lab coats can be contaminated with large numbers of pathogens
Cover Apparel
AORN Guideline for Surgical Attire
• A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn.
• Hair colonized with bacteria & hair sheds• Significantly more bacteria on the ears than foreheads and
eyebrowsOwers KL, James E, Bannister GC. Source of bacterial shedding in laminar flow theatres. J Hosp Infect. 2004;58(3):230–232.
Hair!!
AORN Guideline for Surgical AttireBoyce JM. 2014. "Evidence in support of covering the hair of OR personnel". AORN Journal. 99 (1): 4-8.
Evidence Tables
https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-tables