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SSI Revisited / Back to Basics on
CLABSI
The Cardiovascular Surgical Translational Study (“CSTS”)
Armstrong Institute for Patient Safety and Quality
Elizabeth Martinez, MD, MHS
Massachusetts General Hospital
Harvard University
[email protected]
Learning Objectives
•To review the evidence based practices for SSI and CLABSI
reduction
•To understand the model for translating evidence into
practice
•To explore how to implement evidence-based behaviors to
prevent SSI and CLABSI and overcome barriers
•To understand strategies to engage, educate, execute and
evaluate
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Impact of hospital acquired infections
Cardiac Surgery
Rate *
Number of
Individuals
Impacted*
Increased
Mortality
Risk*
CLABSI
1–3%
9,000 – 15,000
↑4 x
SSI
0.5 - 3.2 %
13,000 - 19,000
↑37 x
*estimates
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SSI PREVENTION
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Introduction
• Over 300,000 CABG annually
• SSI rates 3.51% (10,500 annually)
– 25% mediastinitis
– 33% saphenous vein site
– 6.8% multiple sites
• Increased mortality:17.3% v. 3.0% (p<0.0001)
• Increased LOS: 47% v 5.9% with LOS>14days
(p<0.0001)
• Increased cost: $20,000 to $60,000
Fowler et al.Circ, 2005:112(S), 358.
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Preventive Measures*
• Appropriate hair removal
• Appropriate prophylactic antibiotic use
– Selection, timing, redosing**,
discontinuation
• Perioperative normothermia
• Perioperative normoglycemia
*Surgical Care Improvement Metrics
**Proposed SCIP measure
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CDC Guidelines for Antibiotic
Prophylaxis: Select talking points
The antibiotic selected must be active
against the major contaminating
organisms and should have previously
been shown to be effective prophylaxis.
It is NOT necessary to cover ALL
organisms present.
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CDC Guidelines for Antibiotic
Prophylaxis: Select talking points
The antibiotic chosen must achieve
concentrations higher than the minimal
inhibitory concentration (MIC) of the
suspected pathogens in the wound site
at the time of incision.
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Relative Risk
Give antibiotics within
60 minutes prior to incision.
Classen. NEJM. 1992;328:281.
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Cardiac surgery prophylaxis
effect of serum levels
Serum Level
at Wound Closure Infection
None
Present
3/11 (27%)
2/175 (1%)
P = .002
Goldmann. J Thorac Cardiovasc Surg. 1977;73:470-479.
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Cefazolin Half-life
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CDC Guidelines for Antibiotic
Prophylaxis: Select talking points
The shortest possible course of the
most effective least toxic antibiotic must
be used for prophylaxis.
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Does prolonged peri-op abx
prophylaxis have consequences?
• Prospective surveillance
– 2641 patients undergoing cardiac surgery
• Exposure outcome:
– cephalosporin resistant enterobacteriaceae and
VRE
• Prolonged antibiotic prophylaxis (>48 h)
– increase the risk of acquired resistance
– (OR 1.6, CI 1.1-2.6)
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Antimicrobial Prophylaxis:
Category IB Evidence
• Do not routinely use vancomycin for
antimicrobial prophylaxis
– IT IS NOT THE BEST AGENT FOR SKIN FLORA!
• If Vancomycin is used
– “it is recommended that an aminoglycoside be considered
for one preoperative and at most one additional
postoperative dose to act as a specific gram-negative agent
when vancomycin is indicated to be the primary prophylactic
agent.”1
– This may not be commonly used but should be considered if
you have a problem with gram negative infections.
1Ann
Thorac Surg 2007;83:1569–76
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Hyperglycemia and Infection Risk:
Abdominal and Cardiovascular Operations
Glucose POD#1
<220 mg%
Any Infection
“Serious” Infection
>220 mg%
12%
31%
5.7-fold increase for any glucose > 220 mg%
Pomposelli. JPEN 1998;22:77
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Portland Diabetes Project:
Mortality
10
CII
8
Mortality
(%)
Patients with diabetes
6
Patients without
diabetes
4
2
0
87 88 89
90
91 92
93
94 95
96
97 98
99
00 01
Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125
Year
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ADDITIONAL CONSIDERATIONS
FOR REDUCING SSI
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Chlorhexidine is Beneficial as
Surgical Skin Prep
Br J Surg. 2010 Nov;97(11):1614-20
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Selective Nasal Decolonization
Bode. N Engl J Med 2010;362:9-17
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Nasal Decolonization
• Selective decolonization
– Rapid PCR
– Patients with S. aureus
• Protocol used Mupirocin PLUS chlorhexidine
baths
– The duration of the study treatment was 5 days, irrespective
of the timing of any interventions. Patients who were still
hospitalized after 3 weeks and those still hospitalized after 6
weeks received a second and third course of the same trial
medication, respectively.
Bode. N Engl J Med 2010;362:9-17
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Mupirocin Recommendations
• STS recommendations
– “beginning at least the day before
operation (sooner, if elective operation)
and continuing for 2 to 5 days after
surgery.” 1
• CSTS recommendations
– Selective decolonization
1Ann
Thorac Surg 2007;83:1569–76
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Preoperative Chlorhexidine
Baths
• Mixed data
– Do demonstrate decrease in skin colony
count
• Little data including cardiac surgical
patients
• Consider as part of a comprehensive
program
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Summary Recommendations
1. First line antibiotic Cefazolin 2 grams to be given within 60
minutes prior to incision
2. Cefazolin to be redosed within 4 hours
– Consider 2-3 hours
3. Perioperative antibiotics to be discontinued prior to 48 hours
4. Use a clipper to remove hair; remove the least area as possible
5. Maintain glucoses in the 140-180 range and prevent
hyperglycemia >200mg/dL
6. Chlorhexidine for skin prep
7. Selective nasal decolonization
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Execute
• Make certain that the antibiotics are available in the
OR – where the patient will be receiving the abx
• Redundancy: add discussion about abx to time-out –
selection, dose, redosing
• Abx Discontinuation: Add auto stop to electronic poe
– Use standard paper orders with an automatic stop
• Standardize: Implement a glycemic control protocol
• Standardize skin prep: chlorhexidine and who is
allowed to do the prep; training
• Get rid of all razors
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CLABSI PREVENTION
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Evidence-based Behaviors
to Prevent CLABSI
1. Remove Unnecessary Lines
2. Wash Hands Prior to Procedure
3. Use Maximal Barrier Precautions
4. Clean Skin with Chlorhexidine
5. Avoid Femoral Lines
6. * Line maintenance
Marschall et al. Infect Control Hosp Epidemiol 2008
CDC.gov
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Other Best Practices
• When adherence to aseptic technique cannot be
ensured, replace all CVCs as soon as possible and after
no longer than 48 hours
• Use CVC with the minimum number of ports or lumens
• Do not use topical antibiotic ointment or creams on
insertion sites
• Do not routinely replace central venous or arterial
catheters
• Replace all CVCs if the patient is unstable
• Use an antimicrobial or antiseptic-impregnated CVC if
expected to remain in place >5 days and if, after
implementing a comprehensive strategy, the CRBSI rate
remains above goal.
MMWR. 2002;51:RR-10
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Execute
• Standardize: Create line cart or kit that includes necessary supplies
for line insertion
• Create independent checks
• Create line insertion checklist
• Empower nurses to ensure that physicians comply with checklist
– Nurses can stop takeoff for non-emergent insertions
• Learn from mistakes
• Review every infection using learning from defect tool
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Daily Goals
• What needs to be done for the
patient to be discharged?
• What is the patients greatest
safety risk?
• What can we do to reduce the
risk?
• Can any tubes, lines, or drains
be removed?
Pronovost, Berenholtz, Dorman. J Crit Care 2003
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Translating Evidence
into Practice
Pronovost, Berenholtz, Needham. BMJ 2008
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Ensure Patients Reliably
Receive Evidence
Senior
leaders
Team
leaders
Staff
Engage
How does this make the world a better place?
Educate
What do we need to do?
Execute
What keeps me from doing it?
How can we do it with my resources and
culture?
Evaluate
How do we know we improved safety?
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Engage
• Make the problem real
– Share local infection rates
– Share local compliance with process measures
– Share a story of a patient with SSI or CLABSI
• Have the patient share their story
• Publicly commit that harm is untenable
– Institutional commitment
– Champions within the OR and the ICU and floor teams
– Partnership with Infection Preventionist
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Educate
– Develop an educational plan to reach ALL
members of the caregiver team
– Educate on the evidence based practices AND the
data collection plan and other steps of the
process.
– Use multiple methods to educate
– Posters to educate the teams about the evidence-based
process measure
– Presentations at staff/faculty meetings, M&M
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Execute
• Culture
– Develop a culture of intolerance for infection
• Standardize/Reduce complexity of the process
–
–
–
–
–
Checklists -Confirm abx administration during briefing
Utilize a glycemic control protocol
Local antibiotic guidelines posted in ORs
Standardize surgical skin prep
Develop a line cart
• Redundancy
–
–
–
–
Add best practices to briefing/debriefing checklist
Post reminders in the OR (White board)
Antibiotic timer program for redosing
Use central line checklist
• Regular team meetings
– Develop a project plan
– Identify barriers
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Evaluate
• Track compliance with SCIP measures
– Performance measures already being tracked by hospitals
as part of SCIP participation*
– Post performance on monthly basis
• Post in the OR, ICU and floor
• Investigate non-compliant cases on a monthly basis
– Use Learning from Defect (LFD) tool
• Post SSI and CLABSI rates on a monthly/quarterly basis
– Investigate each SSI and CLABSI with the CUSP team to
identify areas for improvement using the LFD tool
• Audit performance
*based on data availability
on Hospital compare
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Evaluate: Audit
• CLABSI:
– Observe line placement and maintenance,
including dressing changes
• SSI
– Observe skin prep and audit Abx redosing
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CLABSI: Central Line Insertion
• Someone who is not involved in the insertion watches at least
10 line insertions this month
OBSERVATION 1 DATE:_________________________
1)
2)
3)
4)
5)
6)
7)
8)
9)
Yes
No
Yes, after
reminder
Was an assistant present during line insertion?
Was hand hygiene performed prior to line insertion?
Were full barrier precautions used?
a. IF NO, circle what was missed: Full Drape Hat Mask Gown Gloves
b. IF NO, circle who was not fully covered: Assistant
Inserter
Was the sterile field maintained?
Was chlorhexidine used to clean the site?
a. IF YES, was CHG applied using a rigorous back and forth motion?
Was the skin prep allowed to dry for 2 minutes?
Was the line insertion site NOT the femoral site?
No other procedures were performed at the same time as line insertion (e.g.,
placement of a urinary catheter).
Is the dressing adhering well to the skin?
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CLABSI: Central Line Maintenance
• Someone who is not involved in the line watches at least 10 central
line activities this month (line use, line check, or dressing change)
OBSERVATION 1
DATE:_________________________
1.
Was proper hand hygiene (hand washing with soap and water or with
alcohol-based hand sanitizer) used by all personnel involved in line care
for this patient?
2.
3.
Did the care provider inspect the line insertion site for infection?
Was the needleless connector scrubbed for 30 seconds with 70% alcohol
or Chlorascrub before access?
4.
5.
If the dressing was soiled, damp or non-occlusive was it changed?
Was the dressing changed for any other reason? (i.e., date indicated a
dressing change was needed)
6.
If dressing was changed, was chloraprep or 2% chlorhexidine in 70%
isopropyl alcohol used for skin antisepsis? Leave blank if N/A
7.
If the dressing was changed, was the skin prep allowed to dry for 2
minutes? Leave blank if N/A
8.
If the dressing was changed, was sterile technique maintained during
dressing change?
9.
If the dressing was changed, was the change documented in the patient’s
record?
Yes
No
Yes, after
reminder
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SSI: Skin Prep
• Someone who is not involved in the preparation for incision
watches at least 10 skin preparations this month
OBSERVATION 1 DATE:_________________________
1)
What type of skin prep was used for this case? Circle: Betadine
Name if other: __________________
2)
Was the skin prep allowed to air dry for 2 minutes (please time it)?
Yes
No
Yes, after reminder
3)
If Chloraprep, was CHG applied using a rigorous back and forth
scrubbing motion?
Yes
No
Yes, after reminder
4)
Who prepared the skin for incision? Circle:
Any available staff
Chloraprep
Duraprep
Other/Combo
Designated person
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SSI: Abx Redosing
• Pull at least 10 charts randomly for this month (e.g. all charts
with numbers ending in “X”). Mark answers to the following
questions for each patient chart.
Patient Chart 1
Date of procedure:_________________________
Was a short-acting cephalosporin used for this patient?
 Yes
 No (IF NO, replace chart and do not count it in the audit numbers. Pull a
replacement chart.)
Fill in Antibiotic Name: _______________________________
Time of 1st administration (the preop dose): _________________________
Time of 2nd administration (1st redose,): _________________________
Time of 3rd administration (2nd redose): _________________________
Time of 4th administration (3rd redose): _________________________
Time of 5th administration (4th redose): _________________________
Surgery start time (incision): _________________________
Surgery end time (surgeon end time, skin closed): _________________________
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How process measurement
helps you
• Compliance is key to providing evidence-based
practice
• EBP allows you to meet your outcomes goals
• Process measures provide a “map” to what’s working
well and what’s not
• Regular feedback on performance essential to
performance and buy-in (transparency)
• Use your data to inform, motivate, communicate
laterally and upward
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Identify Barriers
• Ask staff
– about knowledge of prevention recommendations
– what is difficult about doing these behaviors
• Walk the process of staff placing a central line
• Observe staff placing central line and line maintenance
– Audits
Gurses, Murphy, Martinez. Jt Comm J Qual Patient Saf 2009
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Share Results
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Acknowledgements
Deborah Hobson, BSN
Pamela Lipsett, MD
Sara Cosgrove, MD
Lisa Maragakis, MD
Trish Perl, MD
Matthew Huddle, BS
Nicole Errett, BS
Justin Henneman, BS
Joyce Wahr, MD
The Johns Hopkins SSI Prevention Collaborative teams
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QUESTIONS?
Thank you!
Elizabeth Martinez, MD, MHS
Massachusetts General Hospital, Harvard Medical School
[email protected]