Download Working Toward Zero Surgical Site Infection Rate

Working Toward Zero
Surgical Site Infection Rate
Maureen Spencer, RN, M.Ed.,CIC
Infection Control Manager
September 22, 2009
Boston, MA
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Topics:
• New England Baptist Hospital and
Orthopedics
• Multidisciplinary Team Work
• Identifying Problems: OR
Environment, Central Supply,
Housekeeping, Hand Hygiene
• Action Plans
• The Evidence: What Were The
Outcomes
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Goals
• Develop a multidisciplinary team
• Establish zero tolerance for HAIs
• Enforce infection prevention measures in the
operating room
• Evaluate environmental cleaning and
disinfection procedures
• Evaluate central processing procedures for
instruments
• Implement innovative technologies to reduce
surgical site infections
• Implement a MRSA and Staph aureus
eradication program for inpatient surgery
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
New England Baptist Hospital
Boston, Massachusetts
Orthopedic Center of Excellence
• Acute inpatient discharges
divided among 3 service lines:
Orthopedic
75%
General Surgery
8%
Medical
17%
• Orthopedic Surgery ~ 10,000/cases
a year
– 6000 inpatient, 4000 outpatient)
• 4000 total joints and 2000 spine/sports
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Orthopedic Surgical Site
Infection
• Orthopedic Total Joint Infections:
– Hip or Knee aspiration
– If positive – irrigation and
debridement
– Removal of hardware may be
necessary
– Insertion of antibiotic spacers
– Revisions at future date
– Long term IV antibiotics in
community or rehab
– Future worry about the joint
– In other words – DEVASTATING
FOR THE PATIENT AND THE
SURGEON
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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2003 NEBH Established a
Multidisciplinary Team
The team included representatives from
• OR nursing, CSS
• Orthopedic surgeons (Joint, Spine) & Anesthesia
• Managers from infection control, healthcare quality,
facilities and environmental services
Evaluated
n Procedures and Practices
n Facility design and Environment of Care Issues
n Patient Risk Factors
n
Spencer M, et al. A Multidisciplnary Team Working Toward Zero Infection Rate. Poster
presented at: AORN 2006; March 19-23, 2006; Washington DC.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Intent
Is Everything
Where Thought Goes – Energy Follows
and Form Follows Thought
Intent: Working Toward Zero Healthcareassociated Infections
SSI, VAP, CLBSI, UTI, MRSA, C.difficile
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Issues Identified Per Fiscal Year
•
•
•
•
•
•
Traffic control
Surgical attire
Operating room cleaning
Processing of instruments
Air handling system and laminar flow
Surgical hand scrub
FY2004
•
•
Surgical infection prevention (SIP) core measures
Silver postoperative dressings
FY2005
•
Antibacterial sutures
FY2006
•
MRSA and MSSA Eradication Program - 2 ½ year process
FY2008
•
Chlorhexidine preop, intraop, postop
FY2009
•
Post-op antimicrobial dressings – done by nurses
FY2003
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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NEBH SSI Rates 2003 - 2009
GENERAL SSI
FY03
# Infections
6
# Procedures
Infection Rate
0.6
ORTHOPEDIC SSI
# Infections
63
# Procedures
8837
0.7
Overall Infection Rat
#Hip Infections
14
1.0
Hip Prosthesis Rat
Hip 0 Index
#Knee Infections
21
1.6
Knee Prosthesis R
Knee 0 Index
#Laminectomy Infec
6
0.7
Laminectomy Rate
5
#Spinal Fusions Infe
0.8
Spinal Fusion Rate
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
FY04
1
1073
0.1
FY05
3
920
0.4
FY06
4
780
0.5
FY07
2
692
0.3
FY089 (Oct-Jul)
2
0
567
389
0.3
0
60
9669
0.6
5
0.3
49
9216
0.5
4
0.2
14
1.0
11
0.7
9
0.9
15
2.0
7
0.6
12
1.4
46
8986
0.5
7
0.4
0.0
7
0.4
0.2
7
0.8
12
1.1
39
9027
0.4
5
0.3
0.0
7
0.3
0.2
12
1.3
5
0.4
37
8884
0.4
5
0.3
0.0
11
0.5
0.4
4
0.5
5
0.4
23
7463
0.3
9
0.5
0.5
6
0.3
0.3
0
0.0
3
0.4
9
Communication Consistent
and Timely
1.
Collaborative communication:
•
consistent and timely manner
•
infection rates and control measures
•
•
•
•
•
ICP attends
Patient Care Assessment Committee
Orthopedic Staff meeting
Patient Care Operations Council
Hospital Operations Council
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Action Plans and Implemented
Control Measures
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Hand Hygiene Educational
Programs
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Most Important Control Measure
• HAND HYGIENE –
wash off the dirt!
• Wash hands several
times a day –
especially if you have
had gloves on for more
than 20 minutes –
organisms multiply
every 20 minutes
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Alcohol Foam, Liquid and Hand Wipes
Patients receive
package of alcohol
wipes
In each patient
room, outside
rooms, cafeteria
and other areas
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Wash hands often –
before eating, before
leaving work, after
contamination
Operating Room - 2003
• Re-training - CHG/alcohol
surgical scrub solution (6 hr
residual activity)
• Orderlies - room turnover
• Improved traffic control:
new signage and monitoring
system
• Cloth cap use – must be
covered when in surgery
and total hair coverage
monitored
– Hair harbors organisms
– Sweating in cloth caps?
– How often do they really get
washed?
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Orthopedic Surgical
Instruments
• Inspection of Orthopedic Instruments
– Lumens, grooves, sorting, hand
cleaning, disassembly required –
massive kits
– Many instruments cannot be
disassembled
• Instituted better pre-soaking and
rinsing of tissue and blood from the
instruments in the operating room
before decontamination
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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SCIP Measures - 2004
Implemented Joint Commission
Surgical Care Improvement Program
“core measures”:
• warming patient
• surgical prophylaxis
• hair clippers
• increased oxygen
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Environment of Care
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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FY 03 Areas of Review
• Peri-operative environmental
evaluation
– Overall maintenance schedule
– HVAC – filters and calibration of
system, air quality & exchanges
– Laminar flow in all operating rooms
– Terminal room cleaning procedures
on night shift
– Autoclave maintenance, instrument
processing
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Operating Room - 2004
• Terminal cleaning
• Night shift – what do they
really do? How many on night
shift
• Upgraded OR facilities
• new floors, fixed walls, paint,
mats
• Upgraded HVAC system
• installed visual system (ball
check valves) for air pressure
in laminar flow rooms
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Environmental Cleaning Study
• Identifying Opportunities to Enhance
Environmental Cleaning in 23 Acute Care
Hospitals. Phil Carling et al. Infec Control Hosp
Epidemiol 2008;29:1-7
• Method:
A transparent stable solution that fluoresces
when exposed to ultraviolet light was applied to
various environmental surfaces in patient rooms
• Results:
Overall thoroughness of terminal cleaning was
49%
Patient telephones, nurse call devices and
bedside rails were inconsistently cleaned
• Conclusion:
Suboptimal cleaning is being done in hospitals
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Equipment Cleaning
• Ultrasonic scrub
• movable carts, tables,
poles and equipment
• 1500 pieces were
cleaned
• OR, radiology, nursing
units
• Cost: ~$20,000
• Annually
•
•
APIC 2005 - Poster
M Spencer: The E=MC2 Project: Environment =
Maintaining Cleanliness: A Multidisciplinary
Approach To Establish a Routine Cleaning
Schedule for Medical Equipment. APIC Baltimore
Conference
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Cleaning the Environment
• Cleaning schedules for
departments in Patient
Care Services
• Micro fiber mop per
OR room and wash/dry
onsite
• Daily check sheet for
OR room cleaning,
patient rooms and
precaution cases
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Teamwork: Computers on
Wheels, Dinamaps,
Rollaboards, IV Poles, Phones
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hands and Gloved Hands as
Sources for Spread
• Scientists cultured the
imprint of a health care
worker's gloved hand
after examining a
patient infected with
Clostridium difficile.
• The larger yellow
colonies outlining
the fingers are clusters of
Clostridium difficile
• The patient had
showered an hour before
the specimen was
collected.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Clinical Infectious Diseases, February
2008.
Consider “GloGerm” Studies
• Glo-germ fluorescent
powder can be used in
bathrooms, on room
surfaces and on shared
patient equipment and
monitoring with a black
light to ascertain if
adequate cleaning is
being done
• www.glogerm.com
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental Services
• Silver Disinfectant Spray
that kills organisms up to 24
hrs on surfaces
- Ambulatory Care Unit
– Radiology
– PACU and Pre-surgery Unit
• Cubicle-curtain change
policy
after each precaution
APIC 2007 – Poster Presentation:
M Spencer: “Microbiologic Evaluation
of a Silver Antimicrobial Disinfectant
Spray” APIC San Jose, June 2007
discharge
6 months on nursing unit
3 months - ICU and ACU
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Focus: The Patient as a Source
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Risk Factors and Infections
• Fact:
• Fact:
• Fact:
• Fact:
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Obesity
Diabetics and
pre-diabetics
Poor patient
hygiene
Revision
surgery
29
Obesity and Surgical Incision
• Incision collects fluid –
serum, blood - growth
medium for organisms
• Spine fusions - incisions
close to the buttocks or neck
• Heavy perspiration common
• Body fluid contamination
from bedpans/commodes
• Friction and sliding - skin
tears and blisters
• Itchy skin - due to pain
medications - skin
breakdown
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Prevention Measures
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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UTI Prevention
• Closed catheter systems
• Silver-coated latex urinary catheters
– Prevent UTIs postoperatively
– Leave in for 24 hrs to prevent
urinary retention
• No Bactrim prophylaxis post-op
unless re-catheterized for
urinary retention
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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2004
Spine Service – Silver Dressing
•
•
•
•
•
Silver absorbing material for
exudative incisions
Increased fluid absorbency
Can be covered by a
transparent dressing to protect
from exogenous contamination
Left in place until discharge
50% reduction in Staph aureus
and MRSA spine infections
NAON Boston May, 2006 Poster
M. Spencer, RN
et al. The Use of A Silver Gauze Dressing in Spine Surgery
to Reduce The Incidence of MRSA Surgical Site Infections
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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Incisional Adhesive
Physician, Hospital -centered Benefits
•
Proven microbial barrier for lasting protection
•
7 days of wound healing strength in 3 minutes for
strong closure and peace of mind
•
No time spent removing staples or sutures
•
Reduces needle stick exposure
•
Increases patient satisfaction
•
Reduced Hospitalization Costs
Nurse, Patient -centered Benefits
•
Reduces number of suture set ups
•
Ease of Post Op wound checks
•
Reduces number of wound dressings
•
Shower immediately
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
2009 ASHES Annual Conference
September 20-24, 2009
© ETHICON, INC. 2007
Reno, NV
Antibacterial Suture
Staph aureus Culture Plate Study
•
A pure culture - 0.5 MacFarland
Broth - of Staph aureus was
prepared
• A coated antibacterial suture was
aseptically cut and planted on the
plate and incubated for 24 hrs
• Photo #1 shows zone of inhibition
at day 5
• Photo # 2 day 10 in plate on left.
Plate on right is non-coated
suture.
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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2005 - Antimicrobial Sutures
• In July, 2005 – implemented
use of antibacterial sutures for
a full year evaluation
At the end of the trial period:
45% reduction in surgical
site
infections caused by
Staph
aureus and MRSA
Reduction in total joint
infections during trial
period 0.48% - 0.34%
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
37
MRSA and Staph aureus Eradication
Program
Prescreening Process
Topical Decolonization Protocol
Vancomycin for MRSA
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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February 2006
Anonymous Nares Cultures
133 patients
Obtained nasal cultures
Purpose: to determine pre-op
MRSA and MSSA colonization
Results:
38 – Staph aureus (29%)
*5 - MRSA
( 4%)
*all undiagnosed and no
precautions used in OR or postop
nursing unit
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
39
Cost of the MRSA/MSSA
Program
•
~$400,000 implementation
–
Two full-time positions:
Micro and Prescreening Unit
– ~$60,000 Polymerase Chain
Reaction Equipment
(Cepheid – GeneXpert)
– ~$40.00/PCR test
• x ~6,000 = $240,000
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
40
MRSA Reimbursement Code
CPT Code
Charge
87081 Rule Out Cx
$28.00
87641 MRSA by PCR
$110.00
as of 4/30/09
BC Indemnity
$76.13
Tufts
$62.39
Blue Care Elect
$55.42
HMO Blue
$53.20
HPHC
$49.49
Medicare
$38.03
Medicaid
$27.17
United Healthcare
$82.01
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Treatment Protocol
•5-day application of intranasal 2%
mupirocin - applied twice daily - for
MRSA and Staph aureus positive
patients.
•Daily body wash with
chlorhexidine
•MRSA Patients - Vancomycin
surgical prophylaxis.
•Re-screen positive MRSA before
surgery
•Contact precautions if positive
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
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AORN Journal –Nov 2008 Vol 88, Nov. pages 818-820
“Dealing with Antibiotic Resistant Organisms”
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
AORN
•
Contact Precautions in Pre-op area, OR & PACU
– Gowns and gloves throughout procedure (in addition to Mask
already worn) by Circulator ad Anesthesia
– Circulator removes gown and gloves before leaving OR to
retrieve supplies/equipment
– Enhanced environmental cleaning after precaution cases –
therefore last case in room or scheduled last case of day
– Use outside runner or circulator if possible to prevent
contamination of perioperative environment
• MRSA – survives from 22-90 days on polyethylene
• Enterococci – 11 days
• Clostridium difficile – five months
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
2008 Initiative - Chlorhexidine
ƒ Chlorhexidine preop showers
(night before, morning of)
ƒ 2% CHG/70% alcohol skin
preparation (tinted orange)
ƒ Antimicrobial gauze dressings
for primary and secondary
dressings
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
46
2009
• Antimicrobial (AMD) gauze for
all post-op incisions
• Impregnated with a 0.2% PHMB
(Polyhexamethylene
Biguanides)
• Initial dressing and subsequent
dressings done by nursing staff
• At day of discharge – dressing
left in place for 48 hrs postop
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
What were the outcomes?
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
48
MRSA/MSSA Eradication
Results
From July 17, 2006 through July 30, 2009
18,676 patients screened
• 4433 (24%) positive for Staph aureus
• 803 ( 4%) positive for MRSA
• Repeat nasal screens on MRSA patients
revealed 78% eradication
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
49
MRSA and Staph aureus Infection Rates
Time Period
Inpatient surgeries
Surgical Infections
Infec. Rate
FY06
10/01/05-07/16/06
5293*
24
0.46%
FY07
07/17/06-09/30/07
7019**
13
0.18%
FY08
10/01/07-09/30/08
6245**
7
0.11%
*historical controls
**screened inpatient surgeries
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
50
Surveillance Data
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
51
Orthopedic Surgical Site
Infection Rates
Orthopedic SSI rate
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
FY03
FY04
FY05
FY06
Orthopedic SSI rate
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
FY07
FY08
FY09 (thru Jul)
NEBH SSI Rates 2003 - 2009
GENERAL SSI
FY03
# Infections
6
# Procedures
Infection Rate
0.6
ORTHOPEDIC SSI
# Infections
63
# Procedures
8837
0.7
Overall Infection Rat
#Hip Infections
14
1.0
Hip Prosthesis Rat
Hip 0 Index
#Knee Infections
21
1.6
Knee Prosthesis R
Knee 0 Index
#Laminectomy Infec
6
0.7
Laminectomy Rate
5
#Spinal Fusions Infe
0.8
Spinal Fusion Rate
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
FY04
1
1073
0.1
FY05
3
920
0.4
FY06
4
780
0.5
FY07
2
692
0.3
FY089 (Oct-Jul)
2
0
567
389
0.3
0
60
9669
0.6
5
0.3
49
9216
0.5
4
0.2
14
1.0
11
0.7
9
0.9
15
2.0
7
0.6
12
1.4
46
8986
0.5
7
0.4
0.0
7
0.4
0.2
7
0.8
12
1.1
39
9027
0.4
5
0.3
0.0
7
0.3
0.2
12
1.3
5
0.4
37
8884
0.4
5
0.3
0.0
11
0.5
0.4
4
0.5
5
0.4
23
7463
0.3
9
0.5
0.5
6
0.3
0.3
0
0.0
3
0.4
53
Tools for Success
• Senior leadership and Board of
Trustees involvement – “lead the
effort” from top down
• Structured program with clearly
defined goal of zero tolerance for
HAIs
• Communication – effective and
consistent
• Ongoing and creative education
• Financial support to Infection
Control program
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
54
Goals were met
• Developed a multidisciplinary team
• Established zero tolerance for HAIs
• Enforced and monitored infection prevention
measures in the operating room
• Implemented changes in environmental cleaning
and disinfection procedures
• Implemented changes in central processing
procedures for instruments
• Implemented several innovative technologies to
reduce surgical site infections
• Implemented a successful MRSA and Staph
aureus eradication program for inpatient surgery
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
THANK YOU
We are all in this together!
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV