Download to Anne Massie`s Power Point Presentation

Infection Prevention in the
Perioperative Setting
HIPAN Conference
November 7, 2015
Anne K. Massie, RN, MSN, CIC
Infection Prevention Coordinator
Castle Medical Center
Kailua, HI
Today’s Objectives:
• Describe the role of microorganisms in disease.
• Describe how microorganisms are transmitted in
healthcare settings.
• Define standard and transmission-based precautions in
healthcare settings.
• Describe surgical site infections (SSIs).
• Identify evidence-based SSI prevention measures.
• Apply today’s knowledge to a patient case study.
What Is Infection Prevention?
1. More than control measures
2. Best outcomes for our patients - it is less expensive
financially, emotionally, and physically not to acquire an
infection
3. Everyone has a role - hand hygiene, isolation practices,
clean environment and equipment, best practices for
clinical and non-clinical associates
4. Evidence-based guidelines
5. Regulatory compliance s - TJC, CMS, AH, etc.
Why Prevent Transmission?
•
•
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Saves lives
Prevents pain, suffering , loss of function, and death
Prevents outbreaks
Saves money - for patients, healthcare facilities, and
taxpayers
• Increases patient satisfaction
• It is the caring way
Key Terms
• Infection: The invasion and multiplication of
microorganisms such as bacteria, viruses, and parasites
that are not normally present within the body.
– An infection may cause no symptoms and be
subclinical, or it may cause symptoms and be
clinically apparent.
• Infectious Disease: Illness (infection) caused by
microorganisms. Identified public health diseases require
reporting to local and/or federal authorities.
– Measles, Chlamydia, Influenza, VRSA
Key Terms
• Colonization – Microorganism proliferation on host body
sites without eliciting an immune response, cellular
damage, or clinical expression of infection
• Symbiosis – Two dissimilar organisms living together to
the mutual beneficial association of each other.
– Many bacteria live on and in humans performing
necessary functions for survival of both species:
Bacteroides, Staphylococcus, E. coli
Key Terms
• Community Acquired Infection – An infection that is
present or incubating at the time of admission to a
healthcare facility (e.g., acute care hospital, skilled
nursing facility)
• Healthcare Acquired Infection (HAI) – An infection that
develops in a patient who is cared for in any setting
where healthcare is delivered and was not present or
incubating at the time of the care (POA)
– CMS requires public reporting of certain HAIs as part of pay
for performance:
Colon SSIs, Hysterectomy SSIs, CAUTI, CLABSI,
Clostridium difficile, MRSA bacteremias
Micro 101: Bacteria, Fungi, Protists
• Prokaryotes – Bacteria:
– Single cell, no true nucleus or organelles
(prokaryotes)
– Staphylococcus aureus, Clostridium perfringens,
Mycobacterium tuberculosis, Neisseria meningitidis
• Eukaryotes - Fungi & Protists:
– Single & multi celled organisms with a true nucleus
and organelles;
– Fungi - Yeast, filamentous molds
– Protists - Algae, protozoans, and slime molds
Streptococci & Filamentous Mold
Viruses
• Viruses: acellular,
protein-based,
intracellular parasites
– Influenza,
Meningitis (viral),
Pertussis, Rubella
Did You?
Prions
• Prions: acellular
protein capable
of folding in
unique ways
• Cause
spongiform
encephalopathies
(CJD, aka “Mad
Cow”)
Chain of Infection
Germ Relationships
How Do YOU Break the Chain?
What Does
Evidence-Based
Practice Say?
Hand Hygiene
• Oldest evidence-based
practice (1847)
• National average = 48%
• Decreases HAIs
dramatically when
compliance is high
• Healthcare workers
perceive their compliance
is higher than what is
observed (video,
electronic systems, secret
shopper)
• Alcohol-based rubs take
less time, act faster, kill
viruses, and are less
irritating
• Soap and water removes
visible soil and bacteria
• THE SINGLE MOST
EFFECTIVE INFECTION
PREVENTION
MODALITY
WHO 5 Moments of Hand Hygiene
Missed Opportunity
Who Is Protected?
Protects The Patient
Protects the HCW
Standard Precautions
• A group of infection prevention practices that apply to all
patients, regardless of suspected or confirmed diagnosis
or presumed infection status.
• Determined by the extent of anticipated blood, body fluid
or pathogen exposure.
• Standard Precautions is a combination and expansion of
Universal Precautions and Body Substance Isolation.
• WEAR WHAT YOU NEED TO PROTECT YOURSELF
AND YOUR PATIENTS.
What are Standard Precautions?
• Hand Hygiene
• Personal Protective
Equipment (PPE):
– Gloves, gown, goggles
• Appropriate disposal of
sharps
• Respiratory Etiquette
• Safe injection practices:
– One needle, one
syringe, one time only
(The One & Only
Campaign)
• Clean up biohazardous
spills wearing PPE
• Textiles and laundry
– Store and transport
appropriately
• Clean shared patient
equipment
– Sani Wipes, High
Level Disinfection or
Sterile Processing
– Single Use Items – Do
NOT Reuse (Label)
Transmission-Based Precautions
• Used when Standard Precautions alone do not
completely interrupt transmission of infectious agents
• Three types:
– Airborne
– Contact
– Droplet
• Use in addition to Standard Precautions
• Some diseases have multiple routes of transmission
requiring more than one precaution type, e.g., MERS,
Measles, Varicella, SARS, Ebola
• Use: Patients with suspect or confirmed infections
Airborne Transmission
• Dissemination of either
airborne droplet nuclei or
small particles from the
respiratory tract containing
infectious agents that remain
suspended in the air for long
periods of time
• PPE: N95 Respirator
• Requires negative pressure
room
• Diseases: TB, Measles,
Chicken Pox, Shingles
(disseminated), Ebola
Contact Transmission
• Most important and frequent
mode of transmission of
HAIs
• Direct: Body surface to
body surface
• Indirect: Susceptible host
touches contaminated
surface
• PPE: Gown and gloves
• Use for MDROs, infectious
diarrhea, Ebola,
conjunctivitis, draining
wounds, bed bugs
Droplet Transmission
Droplet Transmission
PPE: Surgical Mask, Eye
Protection within 6 feet
• Droplets generated from
the infected person are
propelled a short distance
through the air and
deposited on the host’s
conjunctivae, nasal
mucosa, and mouth
• A form of contact
transmission
• Influenza, Neisseria
meningitidis (Bacterial
Meningitis), Pertussis
Defining SSIs
Perioperative Setting
• The area utilized immediately before, during and after
the performance of a clinical intervention or clinically
invasive procedure
– Complex healthcare area: procedures, instruments,
technologies
– Regulatory scrutiny: CDC, FDA, EPA, CMS, TJC
• Summary: Unique and challenging environment
• Goal: Ensure the highest standard of care to each
patient during their journey within the perioperative arena
• Infection Prevention Goal: Prevent surgical site
infections and disease transmission
Surgical Site Infections (SSIs)
• SSI – Infection following an operative procedure that was
performed in an inpatient or outpatient setting where:
– Procedure performed in an operative setting per
FGI/AIA criteria when constructed or renovated
– Procedure or reoperation (via an incision that was left
open) involved at least one incision
• Now account for 31% of all HAIs
• Most prevalent HAIs today
replaced CAUTIs as #1
• Associated with prolonged hospitalization, increased
morbidity and mortality, and loss of function
• Mortality rate = 3%
Surgical Site Infections (SSIs)
• Patients with an SSI:
– 3-5x higher readmission risk and rates than non-SSI
patients
– More likely to be admitted / transferred to the ICU
– More likely to die if SSI is due to MRSA
• Average cost of an SSI > $20,000
• Average cost of an orthopedic SSI > $90,000
• SSIs are devastating to the patient, the perioperative
team, and the hospital
SSIs – Superficial
• Superficial Incisional
– Occurs within 30 days of procedure
– Involves only the skin and subcutaneous tissue
– Primary or secondary incision (CABG graft site)
– Purulent drainage, pain, tenderness, swelling,
erythema, heat
– Positive culture collected aseptically
– May exhibit spontaneous dehiscence or be
deliberately reopened by physician
SSIs – Deep Incisional*
• Deep Incisional
– Occurs within 30 or 90 days (depending on NHSN
procedure type)
– Involves deep soft tissues: fascial and muscle layers
– Purulent drainage, fever, pain, tenderness
– Abscess
– Positive culture collected aseptically
– May exhibit spontaneous dehiscence or be
deliberately reopened by physician
SSIs – Deep Incisional
• Organ Space
– Occurs within 30 or 90 days (depending on NHSN
procedure type)
– Involves any part of the body deeper than the fascial
and muscle layers that was opened or manipulated
during the surgical procedure
– Purulent drainage – Closed drainage, T-tube, CT
guided drain
– Abscess
– Positive culture collected aseptically
Oh my gosh!
SSI Prevention
Infection Prevention Management
• Evidence-based guidelines:
– SHEA / IDSA 2014 Update (Anderson et al.)
– 7S Bundle (Spencer)
– NHSN SSI Definition (CDC)
• Apply appropriate precautions for suspect or confirmed
infection status: Standard + Transmission-Based
• Communicate plan to the entire healthcare team
• Process Improvement Teams
• Report suspected infections to Infection Preventionist
• Report breaches in infection prevention practices per
hospital policy/protocol
Patient SSI Risk Factors
• Patient Risk Factors
– Glycemic control (Diabetes)
– Smoking status
– Steroid Use, other medications
– Obesity
– Preoperative albumin level (malnutrition)
– MRSA and MSSA colonization
– Renal function
– Prolonged hospitalization prior to surgical procedure
– Medical and surgical history
Pre OP Nursing Assessment
• Physical assessment: rash with fever and/or cough,
cough – wet or paroxysmal, chronic wound infection,
abscess
• Patient history: Recent surgical procedure, wound
healing, diarrhea with recent antibiotic use or
hospitalization, cough with weight loss, paroxysmal
cough, physician notes, SNF resident, HD
• Lab & Imaging: Abnormal chest x-ray, culture results,
HbA1C, albumin level, renal function
• Antimicrobials – Which one and Why?
• Travel History: Foreign vs. domestic
• Patient knowledge
Patient Decolonization
• Staphylococcus aureus carriers have a 3-6x higher risk
of SSI than non-carriers (colonized)
• Management:
1. Screen for Staphylococcus aureus colonization
(MSSA and MRSA)
2. Intranasal treatment with mupirocin
3. Chlorhexadine gluconate (CHG) bathing
• 2% CHG wipes persist for 12 hours while 4%
solution does not
Shared Patient Equipment
• Clean, disinfect, and/or
sterilize per
manufacturer’s
instructions (IFUs)
• Use correct products for
the equipment
• Use correct reprocessing
methods
• Reduce “flashing” (IUSS)
– Purchase additional
instrumentation
– OR Scheduling
Pre OP Prep &
• Clipping preferred method for hair removal when
indicated
• Surgical site prep: Follow (IFUs) during application
– Allow to completely air dry; no “fanning”
• Surgical hand scrub
– First scrub of the day
– Avagard® for subsequent scrubs
Antimicrobial Prophylaxis
• Antimicrobial prophylaxis: Recommended antimicrobial
for procedure type and known allergies
– Administer within 1 hour of incision cut time
– Two (2) hours for fluoroquinolones and vancomycin
– Fluoroquinolone use linked to C. diff infections
• “Scrub the Hub” for 15 seconds or use CHG
impregnated hub cover
• Hand hygiene, don clean gloves
• Disinfect med vial rubber septum
prior to accessing
Perioperative Environment
• OR Room Ventilation
– Positive to the outside hallway or clean/sterile core
• OR Temperature and humidity
– Temperature range: 62 - 75⁰ F
– Humidity: 20 to 60%
• Minimize OR traffic
• Between case cleaning
• Daily Terminal OR
cleaning
Quality Improvement Processes
• PDCA (Plan, Do, Check/Study, Act)
– RCI (Rapid Cycle Improvement) – 90 day process
•
•
•
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SSI Drilldown Team with each SSI or cluster
Periop Rep attends Infection Control Meetings
Hand hygiene and PPE audits and feedback
Physician notification of SSIs -> results in improved SSI
risk reduction
• Surgical Technique - physician dependent
– Peer Review process when a high SSI rate is
attributed to an individual surgeon
• Collaboratives and Bundles: Premiere, Quest, SUSP
Application
CASE STUDY
• Teams will work together (Just like at work!)
• Review case scenario to develop a plan addressing
these questions:
• What risk factors are present?
• What disease(s) are of concern in this case?
• What interventions should be done?
• How does this differ from your current practice?
What YOU Learned Today
Today’s Objectives:
• Describe the role of microorganisms in disease.
• Describe how microorganisms are transmitted in
healthcare settings.
• Define standard and transmission-based precautions in
healthcare settings.
• Describe surgical site infections (SSIs).
• Identify evidence-based SSI prevention measures.
• Apply today’s knowledge to a patient case study.
Microbiology and Precautions
• Microorganisms can colonize or infect humans
• Hand hygiene is the single most effective method to
prevent infection transmission in healthcare settings
• Standard Precautions are used for every patient
• Transmission-Based Precautions are used for patients
with suspect or confirmed infections
– Includes Airborne, Droplet and Contact Precautions
– Some diseases require multiple types of precautions
SSIs: Definition and Risks
• SSIs are costly to both patients and healthcare facilities
• There are 3 types of SSIs per the CDC:
– Superficial Incisional
– Deep Incisional
– Organ Space
• Patients present with a variety of SSI risk factors
• Healthcare facilities have risk factors for SSIs
– Temperature and humidity
– OR ventilation
– Cleaning, disinfecting, and sterilizing equipment
SSI Prevention
• SSI Prevention includes (not limited to):
– Using evidence-based guidelines: SHEA, 7S Bundle
– Patient decolonization and CHG bathing
– Hand hygiene and PPE
– Antimicrobial Stewardship: Right drug, Timing
– Surgical site prep
– Scrub the Hub
– Process Improvement Teams
– Reporting infections to surgeons
– Collaborative and Bundles
SSI Prevention Goals
• Goal: Ensure the highest standard of care to each
patient during their journey within the perioperative arena
• Infection Prevention Goal: Prevent surgical site
infections and disease transmission
Scrub Your Paws!
References
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Anderson, D., et al. (2014). SHEA / IDSA Practice Recommendations: Strategies to Prevent Surgical Site
Infections in Acute Care Hospitals – 2014 Update. Retrieved from
http://www.jstor.org/stable/10.1086/676022
Bode, L., et al. (2010). Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. The New
England Journal of Medicine, 362:9-17.
Centers for Disease Control and Prevention. (2007). Guidelines for Isolation Precautions: Preventing
Transmisison of Infectious Agents in Healthcare settings. Retrieved from
http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Centers for Disease Control and Prevention. (2011.) Healthcare associated infections (HAIs). Retrieved from
http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/transmission-basedprecautions.html
Centers for Disease Control and Prevention. (2006). Management of Multi-Drug Resistant Organisms in
Healthcare Settings. Retrieved from http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf
Centers for Disease Control and Prevention. (2015). National Healthcare Safety Network: Surgical Site Infection
(SSI) Event. Retrieved from http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
Darouiche, R., et al. (2010). Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. The New
England Journal of Medicine, 362:18-26.
Gibbs, J., et al. (1999). Preoperative serum albumin level as a predictor of operative mortality and morbidity.
Archives of Surgery, 134(1).
Gokce, N., et al. (2002). Risk stratification for postoperative cardiovascular events via noninvasive assessment of
endothelial function. Circulation, 105, 1567-1572.
References
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Infectious Disease Society of America. (n.d.). What is an infectious disease specialist? Retrieved from
http://www.idsociety.org/ID_Specialist
Khuri, S. F., et al. (1995) The National Veterans Administration Surgical Risk Study: risk adjustment for the
comparative assessment of the quality of surgical care. Journal of the American College of Surgeons, 180(5), 519531.
Magill, S.S., et al. (2012). "Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville,
Florida". Infection Control Hospital Epidemiology, 33(3): 283-91.
Pittet, D. (2001). Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerging
Infectious Diseases. 7(2), 234-240.
Plodkowski, R. A. (2001). Pre-surgical evaluation of diabetic patients. Clinical Diabetes, 19(2), 92-95.
Spencer, M. (2013). The 7S Bundle. Retrieved from
http://eo2.commpartners.com/users/apic/downloads/130828_PPT_Final_[Compatibility_Mode].pdf
St. Jacques, P., Minear, M. (n.d.) Improving perioperative patient safety through the use of information technology.
Retrieved from http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safetyresources/resources/advances-in-patient-safety-2/vol4/Advances-StJacques_105.pdf
Sweeney, W. B. (2009). Preoperative evaluation and risk management. Clinics In Colon and Rectal Surgery,
22(1), 5-13.
Ryder, M. (n.d.) Improving Skin Antisepsis: 2% No-Rinse CHG Cloths Improve Antiseptic Persistence on Patient
Skin Over 4% CHG Rinse-Off Solution. Retrieved from http://www.hqinstitute.org/sites/main/files/fileattachments/ryder_poster_0.pdf
References
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Waisbren, E., et al. (2010). Percent body fat and prediction of surgical site infection. Journal of the American
College of Surgeons, 210(4), 381-389.
World Health Organization. WHO 5 Moments of Hand Hygiene. Retrieved from
http://www.who.int/apsc/tools/Five_Moments
Xu, J., et al. (2007). Evolution of Symbiotic Bacteria in the Distal Human Intestine. PLOS Biology, 5(7).
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