Download Surgical Site Infection Prevention Toolkit

Surgical Site Infection Prevention Toolkit
The purpose of this toolkit is to support your efforts in implementing evidence-based
practices and improve care for all cardiac surgical patients. Many of the strategies outlined
in this toolkit have been adopted by other ORs in academic and community hospitals of
varying sizes. Many of these teams have improved adherence to evidence-based practice
and observed a significant reduction in their surgical site infection (SSI) rates.
Your leadership is needed to achieve these results in your perioperative areas. Most of
your efforts will be spent working with staff that manages patients during the surgery, or
the intraoperative period (anesthesia, nurse anesthetist, perfusionist, OR nurse, circulating
nurse, other OR personnel, and surgeon). However, some of your time will be spent
working with staff that manages the surgical patient in the immediate pre-operative (prep
area) and post-operative period (recovery room, intensive care unit, intermediate care unit
and other inpatient surgical areas). We have developed a model to support your efforts to
implement evidence-based practices and improve care for all cardiac surgical patients. We
have applied this model to improve adherence to evidence-based practices and achieved
dramatic results for patients in the cardiac OR and ICU. This model has 4 stages that
answer the following questions:
1. Engage: How will this make the world a better place?
2. Educate: How will we do this?
3. Execute: What do I need to do?
4. Evaluate: How will we know we made a difference?
This toolkit details what you should do in each of these stages. All the tools you will
need to eliminate SSI in your OR are provided in the appendices; the rest is up to you.
List of Appendices
Appendix A: Fact Sheet- Surgical Site Infection Prevention
Appendix B: Surgical Site Infection Prevention PowerPoint presentation
Appendix C: Summary of the Society of Thoracic Surgeons recommendations for
perioperative antibiotic management and glycemic control
Appendix D: Intraoperative Glucose Control Protocol
Appendix E: Quiz Questions for SSI
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
1
Engage: How does this make the world a better place?
You need to help staff understand that surgical site infections (SSI) are associated with
significant morbidity, mortality, and costs.1-5 More than 2% of the nearly half million
inpatient cardiovascular operations that occur annually in the US are complicated by an
SSI.1, 6 This translates to over 180,000 SSIs each year. In addition, mortality rates are 2-3
times higher among patients who experience an SSI. Therefore efforts to improve the
quality of perioperative care and decrease SSI rates are paramount.
To engage your colleagues, first make the problem real by telling a story of a cardiac
surgical patient who developed an SSI in your hospital. Identify a patient that has suffered
needless harm from an SSI and share the patient’s story openly with your colleagues and
leadership. Ask them if this is the kind of care they would like for their family, if this is care
they are proud of, if this is the best your hospital can do?
Second, post the number of people who developed an SSI each month in your
perioperative, ICU and floor areas and the total number of SSIs for the previous year in
your cardiac care areas. To keep staff engaged, post a trend line so nurses and physicians
can see at a glance your SSI rate and how it is changing over time. Post the number of
days (weeks or months) since your last SSI. Use formal and informal opportunities to talk
about your compliance with evidence-based practice and about unit or service-line specific
SSI rates. Make a point of recognizing providers who adopt evidence-based practice.
Invite your hospital infection control professional or epidemiologist to become an active
part of the perioperative improvement team and draw on their expertise to help with your
specific challenges. The goal should be that no patient suffers harm from a preventable
complication while in your hospital.
Finally, make sure your staff recognizes that benchmarking your performance against
similar hospitals and striving for the 50th percentile is unacceptable for preventable
complications. Your goal should be that no patient suffers harm from a preventable
complication while in our hospital. You may be able to eliminate infections and any
infection should be viewed as a defect.
Educate: How will we accomplish this?
Medical literature shows several strategies to be very effective in eliminating surgical site
infections. These include: appropriate timing of prophylactic antibiotics, appropriate
selection of prophylactic antibiotics, appropriate discontinuation of prophylactic antibiotics,
appropriate hair removal, perioperative normothermia, and perioperative glucose control
specifically for cardiac surgery patients.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
2
Execute: What do I need to do?
There are 7 steps in the Surgical Site Infection Prevention toolkit:
1. Educate staff by distributing a FACT SHEET (Appendix A) and hold in-services for
bedside providers.
2. Standardize the following as much as you can in the perioperative setting:
 antibiotic choices, timing and discontinuation based on current guidelines and
recommendations7, 8
 surgical skin preparation
 equipment and sterilization practices
3. Improve communication among providers by conducting a briefing and debriefing
4. Implement a perioperative normothermia9 protocol for appropriate patients.
5. Implement a glucose control protocol for cardiac surgical patients.
6. Create independent redundancy to help ensure that all patients receive the
evidence-based interventions they should for the prevention of surgical site
infections.
7. Monitor compliance with evidence based guidelines and SSI rates over time
Step1. Educate staff
We have found that many healthcare providers are not aware that the interventions
outlined in this surgical site infection prevention bundle toolkit can dramatically improve
patient outcomes, and/or they are not familiar with the evidence behind each of these
measures. One such evidence-based document is The Society of Thoracic Surgeons
Practice Guidelines for Antibiotic Prophylaxis in Cardiac Surgery, an excellent resource to
help you educate providers and increase awareness of the evidence-based interventions
for perioperative antibiotic management.7, 8 We also recommend that you distribute the
Fact Sheet (Appendix A) to all providers (anesthesia, nursing, medical/surgical staff,
pharmacists etc.). Hold staff in-services to review the PowerPoint presentation (Appendix
B), Fact Sheet (Appendix A), and Antibiotic Guidelines (summarized in Appendix C), and
allow providers to have their questions answered. Track the number of providers that have
attended the in-services and received the fact sheet. Continue to provide in-services until
the information has been provided to at least 90% of staff.
There is a correlation between compliance with evidence-based interventions and better
patient outcomes.10 Posting run charts of compliance with the evidence-based
interventions, the number of patients that developed an SSI, and the number of months
without an SSI in your perioperative areas is an effective method for demonstrating to staff
that their actions make a real difference in patient outcomes.
Several education strategies described in the literature focus on changing physician
behavior. These include person-to-person interventions (individualized educational
information packets consisting of research literature, evidence-based reviews, hospital
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
3
specific data, national guidelines), brief reminders (e-mails, letters, phone calls), target
information period reinforced via informal educational meetings and networks, and
educational outreach visits (for example, involving pharmacy staff).11-14 Therefore, identify
an appropriate forum within your cardiovascular service to formally involve ALL staff with
this initiative. In our experience, physicians respond best to other physicians so the
physician champion in your hospital should probably do this if at all possible. A medical
staff meeting may be an appropriate forum for dissemination of this educational
information. A better forum may exist in your hospital (e.g. Grand Rounds) to review the
PowerPoint presentation and distribute the Fact Sheet. Ideally, this information will be
disseminated to the various types of caregivers at the same time, allowing each to know
what that other has learned and to allow for open discussion about local practices, barriers
and plans.
Step 2: Standardizing Care
The reality is that most providers want to do the right thing but CVOR care is complex and
it is often difficult to remember everything we should do in real-time. Strategies that help to
decrease complexity, like checklists, are used extensively in other industries and are
increasingly being employed in health care. Standardizing care can improve compliance
with evidence-based practice.
As an example, several successful strategies have been published in the peer-reviewed
literature to improve the timing and duration of antibiotic prophylaxis. These include the
use of pre-printed standing orders,15, 16 implementing clinical pathways,17 and the use of
checklists.18, 19 Another strategy to improve the timing of prophylactic antibiotics is to
reassign dosing responsibility to the anesthesia team in the CVOR, rendering antibiotic
delivery closer to the induction of anesthesia and subsequent incision. 20-22 Reassignment
to the holding room nursing staff may be appropriate for certain standard antibiotics that
require longer infusion times. In addition, involving other professionals, like pharmacy staff,
is an effective strategy to ensure appropriate timing, selection and duration of perioperative
antibiotics.22-24 Several successful quality improvement initiatives have been implemented
in the cardiac OR.25-27 Much of the earlier literature identified that not only were we
administering antibiotics too late much of the time – but also too early.28
The standardized order sheet (paper or electronic form for hospitals with computer
physician order entry systems) can be inserted into the process when patients are
scheduled for surgery. This encourages a consistent, uniform approach to planning
antibiotic prophylaxis and promotes optimal choice and timing of antibiotic prophylaxis.
This is particularly helpful for patients with a penicillin allergy. The standardized order
sheet should give explicit instructions on who should initiate the antibiotic administration
and the timing of that administration. There can also be a standardized order sheet for
discontinuation of antibiotics according to evidence-based recommendations. This can
also be important to ordering of mupirocin. Our recommendations are that mupirocin
decolonization be used with chlorhexidine baths.29
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
4
Our experts in antibiotic management (HEIC-Hospital Epidemiology and Infection Control)
have created a list outlining the appropriate antibiotic choice and recommended dose for
each procedure/surgical type based on evidence-based medicine of current guidelines.
This tool has been made into color-coded laminated posters and pocket cards. Placing
these posters in a highly visible location in each OR can serve as an accessible reference
in the operating room. Providing clinicians (all surgical and anesthesia staff) pocket cards
of this tool can also serve as a convenient reference when choosing appropriate antibiotic
prophylaxis. Different barriers have been described in the literature to explain the
underused evidence-based recommendations and guidelines in healthcare settings.
There are a number of strategies to improve the compliance with the surgical site infection
prevention measures and to overcome these barriers. In the literature, one of the first
strategies used for increasing the correct use of antimicrobial prophylaxis in surgery is the
dissemination of local or international guidelines.30 Increasing compliance with the best
evidence based knowledge will be most successful with locally developed (among
surgeons and anesthesiologists, infectious disease specialists) procedures allowing for
adaptation at specifics settings as needed.31-33 This development coincides with that of an
antibiotic chart specifying type of antibiotic and dosage for specific surgical procedures as
explained above.
The dry erase board traditionally used to keep track of instrument counts in the OR can
also be utilized to standardize communication of the timing of initial antibiotic dose and to
plan the timing of re-dosing during the case. Standardizing the layout, purpose and
placement of the dry erase board across all operating rooms will help to make this
successful.
Another strategy to decrease complexity in the OR is to control and standardize equipment
practices in the operating room. Shaving the skin with razors can cause microabrasions,
which can increase the risk for deep wound infections.34 Using a clipper to shave hair is
recommended.9 We recommend that all razors be removed from the operating room and
supply areas. Surgeons and staff should not be allowed to provide their own razors.
Nursing and surgical support staff should be aware of equipment policies. A protocol for
determining when hair removal is necessary should be in place. When hair removal is
deemed necessary clippers should be provided by the hospital and used immediately prior
to surgery; hair should be removed as close to the time of surgery as possible and the
area of hair removal should be limited to the minimum necessary. The type of clipper
should be standard for your hospital and all staff should be educated regarding proper use.
Patients should also be made aware of the risk associated with shaving and should be
instructed not to shave the surgical site themselves prior to their date of surgery.
The introduction of multidisciplinary protocols has also been shown to improved success
with evidence-based interventions.26 We have implemented glycemic control and
perioperative normothermia protocols. While there are little data assessing the association
between hypothermia and infection in cardiac surgical patients and cases that are done on
bypass, are excluded from the national measures for perioperative normothermia, we
believe locally that maintaining post-CPB normothermia is important and utilize measures
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
5
to try to maintain normothermia after CPB is complete. To ensure compliance with best
practices it is also important to make available the means to achieve them. We have
invested in body and fluid warmers to be available in every OR suite.
Finally, standardizing the skin prep is critical. Consider a ‘skin prep’ team to perform skin
preps on all patients. We implemented a skin prep team (designated providers who
perform the prep on every patient) and standardized training for all new hires and annual
auditing of their performance. Training included appropriate use of chlorhexidine and
methods for avoiding cross-contamination.
Step 3: Improve communication among providers
Take advantage of the Time-Out and Briefing to communicate to all providers the name of
the antibiotic given, time of dosing and required time to re-dose. In non CPB cases, state
estimated blood loss of case to trigger possible re-dosing earlier.
Intraoperative communication can also be improved by using a dry erase board hanging
on the wall of every OR room to specify antibiotic given, time given and when re-dosing is
required. The board can also state type of warmer to be used during the case along with
perioperative temperature.
Many institutions have implemented the use of electronic databases to send re-dosing
reminder pages or pop-ups.35, 36
Communication can be improved preoperatively by sending patients letters about the
importance of not shaving their surgical site prior to their surgical procedure.
Step 4: Implement a Perioperative normothermia protocol
Every patient undergoing surgery is at risk of developing hypothermia, which is defined as
a core temperature of less than 360C. Preventing and treating perioperative hypothermia is
a challenge since heat is lost very rapidly in patients undergoing surgery with or without
anesthesia. Among non-cardiac surgery patients the benefits of normothermia go beyond
prevention of SSI, and include prevention of perioperative myocardial ischemic events.
The benefits for cardiac surgical patients who have gone on bypass are less clear.
The goal should be prevention of hypothermia by implementing a protocol to treat patients
who may present with a temperature less than 360C, and proactive mechanisms to
decrease heat loss in the OR and postoperative settings for patients not undergoing CPB.
The Association for Perianesthesia Nurses (ASPAN) has recently published updated
guidelines for perioperative normothermia.9
We have both body warmers (convective) and fluid warmers in every OR to support our
efforts. The use of the body warmer is supported by all team members, and the ancillary
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
6
support staff understands that these need to be maintained and supplies available at all
times for their use. In the cardiac CVORs specifically we utilized under-body fluid warmer
with some success. Some centers are utilizing a newer device with gel pads that are
adherent to the skin (e.g. The Arctic Sun Temperature Management System) to maintain
perioperative normothermia in off-CPB cases.9 Of course, local consensus on this practice
would need to be developed.
Step 5: Implement a glucose control protocol
Achieving success with appropriate glucose control is a more difficult challenge for several
reasons. First, unlike the other elements in the SSI Prevention Bundle, providers are often
skeptical about the benefits of maintaining intraoperative glycemic control and express
concerns about increasing the risk for hypoglycemia, since there is substantial data on the
risk of hypoglycemia. Second, unlike other medication orders that are written once,
appropriate glucose control requires insulin titration in a setting where a patient’s insulin
requirements are constantly changing. Finally, appropriate and safe glucose control
requires hourly glucose checks and can be labor intensive.
The first point of discussion must focus on achieving some agreement on what target
glucose level providers are comfortable with in your ORs and ICUs. The Society of
Thoracic Surgeons has published guidelines on intra- and perioperative glucose targets.37
This guideline may be beneficial for your discussion. If you can’t get buy-in for your goal,
work with your anesthesiologists, surgeons and ICU physicians to identify a starting point
they are comfortable with. Identify and document their concerns regarding your desired
goal. If hypoglycemia is a concern, collect rates of hypoglycemia. In our experience,
hypoglycemia has not been a big issue- our current rates are <2%. In our cardiac ORs we
started with a threshold of 200mg/dL and have systematically decreased this initiation
threshold after providing feedback to the caregivers on the rate of individuals with
hypoglycemia and admission to ICU glucose levels. We are now initiating an infusion at
150mg/dL to meet the goal of maintaining glucoses <180mg/dL. Some centers initiate
insulin upon entry to the OR on all cardiac surgery patients. It may be helpful to engage
your local endocrinologist as well.
We have provided a copy of our intraoperative glucose control protocol for cardiac surgery
(Appendix D). You are welcome to use it. Our protocol offers a range of insulin boluses
and drip changes so that the bedside caregiver (anesthesiologist in the OR and nurse in
the ICU) can incorporate other aspects of the patient’s care into their dosing. Others have
been extremely proscriptive. You need to determine what level providers in your OR and
ICU can live with as a starting point, but we encourage movement toward the STS goals in
the postoperative period.
We began glycemic control in the OR in response to the difficulty of obtaining glycemic
control in the ICU, despite what was felt to be an aggressive protocol, with patients being
admitted from the OR with glucoses in the 300 mg/dl range. We implemented an insulin
protocol in the OR and this has improved our ability to reach our ICU goal more effectively.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
7
We also worked toward eliminating high-glucose containing cardioplegia solutions. Please
note, since insulin is one of the high-risk medications identified by The Joint Commission,
and since many errors have been related to inappropriate dilution, you should consider
partnering with pharmacy to request that they prepare all insulin infusions. This was a
safety measure that we undertook.
One strategy that has been effective in our ORs is feedback of the data – specifically
focusing on the safety of the insulin infusion.
Achieving glycemic control is a dynamic and complex process. Success is linked to staff
that understand the complexities and are comfortable asking questions when they are
confused or concerned about patient specific implementation. We have also found it useful
to monitor compliance with the protocol and discuss in broad fashion our performance. For
example, we post results openly in our ICU and review performance in existing physician
and nursing meetings. We also have a box for questions related to appropriate glucose
control.
Step 6: Create independent redundancy
Creating independent redundancy involves developing unique and separate system
checks for critical procedures. Highly reliable industries use independent redundancies to
monitor those procedures that are highest risk or most likely to cause harm if not done
correctly. We are just beginning to develop independent redundancies in healthcare.
You can make a Standardized Antibiotic Prophylaxis Tool. Laminated posters can be
placed in every operating room. All surgical and anesthesia staff can be given laminated
pocket guides to have with them at all times.
You can add the allergies and, name, and timing of the initial antibiotic dosing to the “Time
Out” process so that all individuals are aware that the dose was given and that the choice
was appropriate.
You can use a dry erase board in the OR to create independent redundancy for the
evidence based care changes you are making. You can add the name and dosage of the
antibiotic to be given to the patient for the specific procedure and the time of the first dose
and anticipated subsequent doses – checking them off once completed. You can also use
this board to state the selected warmer to be used to remind all staff of the importance of
normothermia and when the warmer will be turned on (i.e. after CPB or during warming).
For cardiac surgery patients, you can list pre-op glucose level and other levels as reported.
You can use “automatic stop” orders per pharmacy and pre-printed orders to help with
correct selection and discontinuation of prophylactic antibiotics. You can use “antibiotic
reports” from pharmacy to notify you of patients on antibiotics greater than 24 hours.
There are several other ways to create redundancy in the system. Consider incorporating
antibiotic reminders using computer decision support systems. Computerized decision
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
8
support is one of the most effective tools described in the literature. Automated reminders,
supported by computer-based decision systems, lead to reductions in human error (error
of omission) and decrease the variability of the process.22, 36, 38-42
Engaging all caregivers can provide another type of independent redundancy. Many OR
suites have ancillary staff members who assist with supplies, including pharmacists who
can support the efforts to have the right medications available at the right times.
Summary: Suggestions for creating redundancy
Standardized Antibiotic Dosing Posters and pocket cards
Time-Outs to include antibiotic dose and redosing times
Dry Erase Boards in the ORs to facilitate communication
Standardized Pre-Printed Antibiotic Orders
OR Clinical Pathways
We suspect you will be able to identify additional opportunities to create redundancy in
your OR and we hope that you will share your ideas with other ORs. Nevertheless, there is
no “one-size-fits-all” solution that will be effective for every health care setting. For being
successful in the implementation of the different strategies and suggestions, each strategy
must be adapted at the situations and circumstance of every ward and clinical setting.
Step 7: Monitor compliance with evidence based guidelines
According to literature another strategy is conducting periodic audits with continuous timely
feedback of both process and outcome measures to all staff involved in this quality
improvement process. To accomplish this, we recommend that you monitor compliance
with all the evidence-based measures that we have given you and report back to your staff
each month. Report the percentages of compliance to each measure in a bar graph for
your team to track their performance. Also let your staff know about each month that goes
by without an SSI diagnosed.
You may also obtain reports from your hospital quality improvement officers who may be
tracking the national SCIP measures for your institution and report these. The more realtime data you have access to the better. We partnered with our officers to send letters from
the cardiac surgery leadership to providers who were not compliant with a given measure
and requested that they investigate why the defect occurred and submit a response for the
team to review. This enhances the sense that everybody is responsible for the successes
– and the failures. Furthermore, while the officer had previously been investigating each
defect, the front line providers frequently had important insights into why there was a
failure and new protocols, guidelines or practices have been implemented as a result.
Other/New Areas to Consider
The following interventions are still under investigation and do not have as strong of
evidence base to support their use. Consult with members of the cardiac care team and
infection prevention professionals at your institution to determine which, if any, to include.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
9
As with any intervention, the unintended consequences need to be considered with the
potential risks/benefits.
Chlorhexidine Skin prep in OR – Similar to findings with reduction of catheter related blood
stream infections, chlorhexidine has been demonstrated to be more effective than
povidone-iodine (Betadine) in preventing SSIs.43, 44 Two other studies have shown
conflicting data on the benefit of Chloraprep compared with Duraprep or povidine-iodine.45
Each of these were supported by either Chloraprep or Duraprep manufacturers in which
their respective products were found to be superior, so therefore are potentially biased. We
have converted to chlorhexidine in our CVORs. When performing skin antisepsis, proper
technique is essential. To apply chlorhexidine, use a back and forth friction rub for at least
30 seconds over the area to be prepped – this is very different from the way we used
Betadine.
Preoperative Chlorhexidine Showers – Several studies have indicated that chlorhexidine
showers may be effective in reducing SSIs as a part of a wider clinical process
improvement.46-48 We implemented this practice as well. Outpatients were given packets of
chlorhexidine washcloths when they came in for their pre-op visit. They were instructed to
use them according to the package instructions and bring in the empty packet. We used
this empty packet as a way to document whether they had been used or not. For
inpatients, we added this to our pre-op standardized order set.
Nasal decolonization: Nasal colonization with MRSA has been correlated with higher risk
of SSI following cardiac surgery.49 While both mupirocin50, 51 and chlorhexidine have been
shown to be effective in either reducing colonization and perhaps reducing SSI after
cardiac surgery52-55 there remains a concern for using this strategy broadly. There is
definitely concern for the development of resistant MRSA strains with widespread,
common use of decolonization.55 Newer strategies that utilize individualized
decontamination for those patients with laboratory proven colonization may be preferred
but many centers do not have the rapid assays available. This would be an important
intervention that you should seek input from your local infection prevention experts. Many
current protocols include intranasal mupirocin beginning at least the day before surgery
(sooner, if elective operation) and continuing for 2 to 5 days after surgery. In the recent
randomized controlled study by Bode and colleagues, they demonstrated a reduction in
SSI rates (not cardiac surgery specific) in patients who were colonized with nasal S.
aureus using a 5 day course of mupirocin PLUS daily chlorhexidine soap total body wash.
This regimen was repeated every 3 weeks for those with prolonged hospitalizations.29 Our
local infection preventionist recommends using this combined method or mupirocin plus
chlorhexidine washes if you elect to adopt nasal decolonization.
Blood Transfusion – Some studies support limiting the number of allogeneic blood
transfusions during cardiac and other surgeries. A higher number of blood transfusions has
been associated with higher postoperative infection rates, longer hospital stay, and
increased mortality.1, 56-60 Strategies to reduce unnecessary transfusion should be a part of
best practices in general, however there are no data to support that should you decrease
your transfusion rates that your cardiac surgery SSI rates would improve.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
10
Fraction of Inspired Oxygen (FIO2) – An intraoperative FIO2 has been reported to be a risk
factor for postoperative SSI in patients undergoing spinal surgery.61 A meta-analysis
published in 2009, reported a decrease in the risk for SSI with perioperative maintenance
of 100% FIO2 in colorectal patients.62 A recent study in cardiac surgery did not show any
benefit using this strategy. There are no data specifically looking at cardiac surgical
patients, however this might be something to consider, and certainly should be researched
further.
Evaluate: How will we know that we added value?
The first step is to collect baseline rates of compliance with SSI Prevention evidencebased measures in your unit. To accomplish this you need to collect data on the current
process measures, which your hospital is likely already doing. The second step is to track
SSI rates over time in your unit.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
11
REFERENCES
1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of
surgical site infection, 1999. hospital infection control practices advisory committee. Infect
Control Hosp Epidemiol. 1999;20(4):250-78; quiz 279-80.
2. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health
care-associated infections. Am J Infect Control. 2005;33(9):501-509.
3. Stone PW, Hedblom EC, Murphy DM, Miller SB. The economic impact of infection
control: Making the business case for increased infection control resources. Am J Infect
Control. 2005;33(9):542-547.
4. Gummert JF, Barten MJ, Hans C, et al. Mediastinitis and cardiac surgery--an updated
risk factor analysis in 10,373 consecutive adult patients. Thorac Cardiovasc Surg.
2002;50(2):87-91.
5. Filsoufi F, Castillo JG, Rahmanian PB, et al. Epidemiology of deep sternal wound
infection in cardiac surgery. J Cardiothorac Vasc Anesth. 2009;23(4):488-494.
6. DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 national hospital discharge
survey. Natl Health Stat Report. 2008;(5)(5):1-20.
7. Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR, Society of Thoracic
Surgeons. The society of thoracic surgeons practice guideline series: Antibiotic prophylaxis
in cardiac surgery, part I: Duration. Ann Thorac Surg. 2006;81(1):397-404.
8. Engelman R, Shahian D, Shemin R, et al. The society of thoracic surgeons practice
guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice. Ann
Thorac Surg. 2007;83(4):1569-1576.
9. Hooper VD, Chard R, Clifford T, et al. ASPAN's evidence-based clinical practice
guideline for the promotion of perioperative normothermia: Second edition. J Perianesth
Nurs. 2010;25(6):346-365.
10. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to
surgical care improvement project measures and the association with postoperative
infections. JAMA. 2010;303(24):2479-2485.
11. D'Escrivan T, Lemaire JS, Ivanov E, et al. Surgical antimicrobial prophylaxis:
Compliance to guidelines and impact of targeted information program. Ann Fr Anesth
Reanim. 2005;24(1):19-23.
12. Everitt DE, Soumerai SB, Avorn J, Klapholz H, Wessels M. Changing surgical
antimicrobial prophylaxis practices through education targeted at senior department
leaders. Infect Control Hosp Epidemiol. 1990;11(11):578-583.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
12
13. Savino JA, Smeland J, Flink EL, et al. Implementation of an evidence-based protocol
for surgical infection prophylaxis. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds.
Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation
Issues). Rockville (MD): 2005.
14. Smith KS, Quercia RA, Chow MS, Nightingale CH, Quintiliani R, Millerick JD.
Multidisciplinary program for promoting single prophylactic doses of cefazolin in obstetrical
and gynecological surgical procedures. Am J Hosp Pharm. 1988;45(6):1338-1342.
15. Girotti MJ, Fodoruk S, Irvine-Meek J, Rotstein OD. Antibiotic handbook and pre-printed
perioperative order forms for surgical antibiotic prophylaxis: Do they work? Can J Surg.
1990;33(5):385-388.
16. Lipsy RJ, Smith GH, Maloney ME. Design, implementation, and use of a new
antimicrobial order form: A descriptive report. Ann Pharmacother. 1993;27(7-8):856-861.
17. Gregor C, Pope S, Werry D, Dodek P. Reduced length of stay and improved
appropriateness of care with a clinical path for total knee or hip arthroplasty. Jt Comm J
Qual Improv. 1996;22(9):617-628.
18. Burke JP. Maximizing appropriate antibiotic prophylaxis for surgical patients: An
update from LDS hospital, salt lake city. Clin Infect Dis. 2001;33 Suppl 2:S78-83.
19. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis
in surgical procedures. the infectious diseases society of america. Infect Control Hosp
Epidemiol. 1994;15(3):182-188.
20. Matuschka PR, Cheadle WG, Burke JD, Garrison RN. A new standard of care:
Administration of preoperative antibiotics in the operating room. Am Surg. 1997;63(6):500503.
21. Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in
selected inpatient surgical procedures. the antibiotic prophylaxis study group. Am J Surg.
1996;171(6):548-552.
22. Gyssens IC, Knape JT, Van Hal G, ver der Meer JW. The anaesthetist as determinant
factor of quality of surgical antimicrobial prophylaxis. A survey in a university hospital.
Pharm World Sci. 1997;19(2):89-92.
23. Galindo C, Olive M, Lacasa C, et al. Pharmaceutical care: Pharmacy involvement in
prescribing in an acute-care hospital. Pharm World Sci. 2003;25(2):56-64.
24. Prado MA, Lima MP, Gomes Ida R, Bergsten-Mendes G. The implementation of a
surgical antibiotic prophylaxis program: The pivotal contribution of the hospital pharmacy.
Am J Infect Control. 2002;30(1):49-56.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
13
25. Sun TB, Chao SF, Chang BS, Chen TY, Gao PY, Shyr MH. Quality improvements of
antimicrobial prophylaxis in coronary artery bypass grafting. J Surg Res. 2011;167(2):329335.
26. Graf K, Sohr D, Haverich A, Kuhn C, Gastmeier P, Chaberny IF. Decrease of deep
sternal surgical site infection rates after cardiac surgery by a comprehensive infection
control program. Interact Cardiovasc Thorac Surg. 2009;9(2):282-286.
27. Trussell J, Gerkin R, Coates B, et al. Impact of a patient care pathway protocol on
surgical site infection rates in cardiothoracic surgery patients. Am J Surg. 2008;196(6):8839; discussion 889.
28. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major
surgery: Baseline results from the national surgical infection prevention project. Arch Surg.
2005;140(2):174-182.
29. Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical-site infections in
nasal carriers of staphylococcus aureus. N Engl J Med. 2010;362(1):9-17.
30. Talon D, Mourey F, Touratier S, et al. Evaluation of current practices in surgical
antimicrobial prophylaxis before and after implementation of local guidelines. J Hosp
Infect. 2001;49(3):193-198.
31. Gorecki W, Grochowska E, Krysta M, Wojciechowski P, Taczanowska A, Stanek B. A
prospective comparison of antibiotic usage in pediatric surgical patients: The safety,
advantage, and effectiveness of the surgical infection society guidelines versus a common
practice. J Pediatr Surg. 2002;37(10):1430-1434.
32. Alerany C, Campany D, Monterde J, Semeraro C. Impact of local guidelines and an
integrated dispensing system on antibiotic prophylaxis quality in a surgical centre. J Hosp
Infect. 2005;60(2):111-117.
33. Sellick JA,Jr, Stelmach M, Mylotte JM. Surveillance of surgical wound infections
following open heart surgery. Infect Control Hosp Epidemiol. 1991;12(10):591-596.
34. Association of Operating Room Nurses. Recommended practices for skin preparation
of patients. AORN J. 2002;75(1):184-187.
35. Rothman B, Sandberg WS, St Jacques P. Using information technology to improve
quality in the OR. Anesthesiol Clin. 2011;29(1):29-55.
36. Zanetti G, Flanagan HL,Jr, Cohn LH, Giardina R, Platt R. Improvement of
intraoperative antibiotic prophylaxis in prolonged cardiac surgery by automated alerts in
the operating room. Infect Control Hosp Epidemiol. 2003;24(1):13-16.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
14
37. Lazar HL, McDonnell M, Chipkin SR, et al. The society of thoracic surgeons practice
guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac
Surg. 2009;87(2):663-669.
38. Evans RS, Pestotnik SL, Burke JP, Gardner RM, Larsen RA, Classen DC. Reducing
the duration of prophylactic antibiotic use through computer monitoring of surgical patients.
DICP. 1990;24(4):351-354.
39. Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management
program for antibiotics and other antiinfective agents. N Engl J Med. 1998;338(4):232-238.
40. Larsen RA, Evans RS, Burke JP, Pestotnik SL, Gardner RM, Classen DC. Improved
perioperative antibiotic use and reduced surgical wound infections through use of
computer decision analysis. Infect Control Hosp Epidemiol. 1989;10(7):316-320.
41. Pestotnik SL, Evans RS, Burke JP, Gardner RM, Classen DC. Therapeutic antibiotic
monitoring: Surveillance using a computerized expert system. Am J Med. 1990;88(1):4348.
42. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice
guidelines through computer-assisted decision support: Clinical and financial outcomes.
Ann Intern Med. 1996;124(10):884-890.
43. Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, Koh JL. Efficacy of surgical
preparation solutions in shoulder surgery. J Bone Joint Surg Am. 2009;91(8):1949-1953.
44. Darouiche RO, Wall MJ,Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidoneiodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18-26.
45. Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of
preoperative skin preparation on postoperative wound infection rates: A prospective study
of 3 skin preparation protocols. Infect Control Hosp Epidemiol. 2009;30(10):964-971.
46. Dizer B, Hatipoglu S, Kaymakcioglu N, et al. The effect of nurse-performed
preoperative skin preparation on postoperative surgical site infections in abdominal
surgery. J Clin Nurs. 2009;18(23):3325-3332.
47. Rao N, Schilling D, Rice J, Ridenour M, Mook W, Santa E. Prevention of postoperative
mediastinitis: A clinical process improvement model. J Healthc Qual. 2004;26(1):22-7; quiz
28.
48. Martorell C, Engelman R, Corl A, Brown RB. Surgical site infections in cardiac surgery:
An 11-year perspective. Am J Infect Control. 2004;32(2):63-68.
49. Munoz P, Hortal J, Giannella M, et al. Nasal carriage of S. aureus increases the risk of
surgical site infection after major heart surgery. J Hosp Infect. 2008;68(1):25-31.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
15
50. Coates T, Bax R, Coates A. Nasal decolonization of staphylococcus aureus with
mupirocin: Strengths, weaknesses and future prospects. J Antimicrob Chemother.
2009;64(1):9-15.
51. Jabbour H, Madi-Jebara S, Jabbour K, et al. Does nasal decontamination reduce the
incidence of infections after cardiac surgery? J Med Liban. 2010;58(2):65-70.
52. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of
nosocomial infection in cardiac surgery by decontamination of the nasopharynx and
oropharynx with chlorhexidine gluconate: A randomized controlled trial. JAMA.
2006;296(20):2460-2466.
53. Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active
surveillance screening of MRSA and eradication of the carrier state decreases surgical-site
infections caused by MRSA. J Am Coll Surg. 2009;208(5):981-6; discussion 986-8.
54. Jog S, Cunningham R, Cooper S, et al. Impact of preoperative screening for meticillinresistant staphylococcus aureus by real-time polymerase chain reaction in patients
undergoing cardiac surgery. J Hosp Infect. 2008;69(2):124-130.
55. Tom TS, Kruse MW, Reichman RT. Update: Methicillin-resistant staphylococcus
aureus screening and decolonization in cardiac surgery. Ann Thorac Surg.
2009;88(2):695-702.
56. Rogers MA, Blumberg N, Saint S, Langa KM, Nallamothu BK. Hospital variation in
transfusion and infection after cardiac surgery: A cohort study. BMC Med. 2009;7:37.
57. Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased
mortality, postoperative morbidity, and cost after red blood cell transfusion in patients
having cardiac surgery. Circulation. 2007;116(22):2544-2552.
58. Reeves BC, Murphy GJ. Increased mortality, morbidity, and cost associated with red
blood cell transfusion after cardiac surgery. Curr Opin Cardiol. 2008;23(6):607-612.
59. Talbot TR, D'Agata EM, Brinsko V, Lee B, Speroff T, Schaffner W. Perioperative blood
transfusion is predictive of poststernotomy surgical site infection: Marker for morbidity or
true immunosuppressant? Clin Infect Dis. 2004;38(10):1378-1382.
60. Schwarzkopf R, Chung C, Park JJ, Walsh M, Spivak JM, Steiger D. Effects of
perioperative blood product use on surgical site infection following thoracic and lumbar
spinal surgery. Spine (Phila Pa 1976). 2010;35(3):340-346.
61. Maragakis LL, Cosgrove SE, Martinez EA, Tucker MG, Cohen DB, Perl TM.
Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site
infection after spinal surgery. Anesthesiology. 2009;110(3):556-562.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
16
62. Qadan M, Akca O, Mahid SS, Hornung CA, Polk HC,Jr. Perioperative supplemental
oxygen therapy and surgical site infection: A meta-analysis of randomized controlled trials.
Arch Surg. 2009;144(4):359-66; discussion 366-7.
© Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
17