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Establish a Culture of Safety: Working Toward Zero Surgical Site Infections Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant Email: [email protected] www.workingtowardzero.com www.creativehandhygiene.com Despite current preventive measures, SSIs remain a significant problem In the US, at least 780,000 SSIs occur each year1 SSIs account for about 37% of all hospitalacquired infections for surgical patients1 SSIs 1. 2. occur in up to 5% of surgical patients2 WHO Guidelines for Safe Surgery 2009. Cheadle WG. Risk factors for surgical site infection. Surg Infect. 2006;7: s7-s11. 2 Mortality risk is high among patients with SSIs A patient with an SSI is: 5x more likely to be readmitted after discharge1 2x more likely to spend time in intensive care1 2x more likely to die after surgery1 The mortality risk is higher when SSI is due to MRSA A patient with MRSA is 12x more likely to die after surgery2 1. 2. WHO Guidelines for Safe Surgery 2009. Engemann JJ et al. Clin Infect Dis. 2003;36:592-598. 3 SSIs are costly and are a financial burden on the healthcare system 1. 2. The average cost of treating one SSI is between $11,000 and $35,0001 The average cost of treating one MRSArelated SSI is more than $60,0002 In total, SSIs have been estimated to cost the US healthcare system up to $10 billion/yr1 Scott RD. Centers for Disease Control and Prevention. March 2009. Anderson DJ et al. PLoS One. 2009 Dec 15;4(12):e8305. 4 Changing demographics are increasing patients’ risk for SSIs 1. 2. 3. 4. A patient with even ONE of these risk factors is at greater risk of developing an SSI.1-4 Older (>70 yrs old) Obese (BMI > 25) Smoker Diabetes or poor glucose control Undergoing abdominal surgery Prolonged surgery required (>2 hrs) Longer hospital stay ≥3 discharge diagnoses Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134. SHEA, APIC, CDC, SIS Consensus paper. Infect Control Hosp Epidemiol 1992;13:599-605. Cheadle WG. Surg Infect. 2006;7: s7-s11. Konishi T, Watanabe T, Kishimoto J, Nagawa H. Ann Surg. 2006 Nov;244(5):758-63. 5 6 SSI Risk Factors – Procedures/Techniques Duration of operation Duration of surgical scrub Preoperative shaving, skin preparation Inadequate OR ventilation Inadequate sterilization of instruments Surgical technique Tissue kept moist with saline heals better Poor hemostasis Failure to obliterate dead space Tissue trauma Skin antisepsis Antimicrobial prophylaxis Surgical drains Tissue allowed to air dry do not heal as well Mangram AJ et al. Am J Infect Control. 1999;27:97-134 Orthopedic Surgical Site Infection Orthopedic Total Joint Infections: Hip or Knee aspiration If positive – irrigation and debridement Removal of hardware may be necessary Insertion of antibiotic spacers Revisions at future date Long term IV antibiotics in community or rehab Future worry about the joint In other words – DEVASTATING FOR THE PATIENT AND THE SURGEON 8 Relative Economic Burden Associated with HAIs • SSI Surgical Site Infections • CLA-BSI Central-Line Associated Blood Stream Infections • VAP Ventilator Associated Pneumonia • CA-UTI Est. Annual # of Infections Direct Cost per Patient (2007$) Avg. Increased Length of Stay Attributable Mortality 290,485 $34,670 ~12 days 4% $29,156 ~10-24 days 26% $28,508 ~9-13 days 24% $1,007 1 day 1% ~$30,000 ~9.1 days ~4% (~17% of HAIs) 248,678 (~14% of HAIs) 250,205 (~15% of HAIs) 561,667 Catheter-Associated Urinary Tract Infections (~32% of HAIs) • Other / MDROs* 386,090 Multi-Drug Resistant Organisms (e.g.,(~22% of HAIs) MRSA, C. difficile, VRE, etc.) 9 * NOTE: MDRO often cause other infection types (e.g., SSI, BSI, VAP, UTI); MDRO statistics reflect CDC estimates for methicillin-resistant Staphylococcus aureus (MRSA) only. SOURCES: Klevens, et al., “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Review, 2007; CDC: “The Direct Medical Cost of HAIs in U.S. Hospitals and the Benefits of Prevention”, March 2009; Kirkland, et al., “The Impact of Surgical Site Infections”, Infect Control Hosp Epidemiol, 1999; Arch Internal Med, 1988; Arch Internal Med, 1974; Infect Control Hosp Epidemiol, 2002; CareFusion MedMined Analysis, 2009 . Pathogens survive on surfaces Organism Survival period Clostridium difficile 35- >200 days.2,7,8 Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days.1,5,10 Vancomycin-resistant enterococcus (VRE) 58- >200 days.2,3,4 Escherichia coli >150- 480 days.7,9 Acinetobacter 150- >300 days.7,11 Klebsiella >10- 900 days.6,7 Salmonella typhimurium 10 days- 4.2 years.7 Mycobacterium tuberculosis 120 days.7 Candida albicans 120 days.7 Most viruses from the respiratory tract (eg: corona, coxsackie, influenza, SARS, rhino virus) Few days.7 Viruses from the gastrointestinal tract (eg: astrovirus, HAV, polio- or rota virus) Blood-borne viruses (eg: HBV or HIV) 1. 2. 3. 4. 5. 6. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5. BIOQUELL trials, unpublished data. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2 Boyce. 2007. J Hosp Infect. 65:50-4. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200. French et al. 2004. ICAAC. 60- 90 days.7 >7 days.5 7. Kramer et al. 2006. BMC Infect Dis. 6:130. 8. Otter and French. 2009. J Clin Microbiol. 47:205-7. 9. Smith et al. 1996. J Med. 27: 293-302. 10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4. 11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7. Why Better Environmental Cleaning? Prior room occupancy increases risk Study Healthcare associated pathogen Martinez 20031 VRE – cultured within room VRE – prior room occupant MRSA – prior room occupant VRE – cultured within room VRE – prior room occupant VRE – prior room occupant in previous two weeks 2.6x 1.6x 1.3x 1.9x 2.2x C. difficile – prior room occupant A. baumannii – prior room occupant P. aeruginosa – prior room occupant 2.4x 3.8x Huang 20062 Drees 20083 Shaughnessy 20084 Nseir 20105 1. 2. 3. 4. 5. Martinez et al. Arch Intern Med 2003; 163: 1905-12. Huang et al. Arch Intern Med 2006; 166: 1945-51. Drees et al. Clin Infect Dis 2008; 46: 678-85. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194. Nseir et al. Clin Microbiol Infect 2010 (in press). Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room) 2.0x 2.1x New England Baptist Hospital Boston, MA Working Toward Zero Teams 150-bed adult medical/surgical hospital located in Mission Hill area of Boston Orthopaedic subspecialty hospital & “Center of Excellence” Acute inpatient discharges: 75% Orthopedic 8% General Surgery 17% Medical Orthopaedic Surgery ~ 12,000/cases a year >4700 total joints >1500 spine >3600 other (foot, shoulder, etc) > 3100 outpatient 2 Orthopedic Service - Infection Rates - Date of Onset 1.5 1 0.5 0 2 Orthopedic Infection Rates - Date of Surgery Antibacterial sutures 1.5 MRSA/MSSA Eradication Program Chloroprep Instituted incisional adhesives and AMD Gauze 1 0.5 0 Increase in Lami infections due to locally administered steroids Increase in total knee infections – due to improper use of needles for OR pain meds Post-op hematomas being investigated Making the Case to Cover Incisions While Hospitalized Post-op Skin Issues in Orthopedics Anterior fusion with tape burns Posterior fusion with contaminated steri-strips Contaminated steri-strips Staples increase infection rate 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 16 Due to Environmental Contaminants – Do Not Recommend Incisions Opened to Air Bacteria use blood (and sugar) as a fuel source Incisions are in exudative stage of wound healing first 2-3 days postop Proliferative stage begins ~ day 3-4 and most patients are sent home around that time Incisions are best protected if sealed – or covered with an antimicrobial gauze, silver dressing Resident and PA Direct Observation Study: ABD with Paper or Gauze Tape Check residents and physician assistant dressing technique ABD pads may be stuffed in lab coat pockets during rounds and gloves may not be worn for dressing changes Lack of hand hygiene before and after patient contact Bandage scissors often used between patients with no cleaning Discard bloody dressings in regular waste Facility Approach: Standardization to an Antimicrobial Dressing (AMD) AMD secured with MeFix tape and dated for protection from exogenous contamination Standardization of Post-operative Dressings Goal Primary goal is to cover all incisions with AMD gauze dressing (antimicrobial) Leave primary dressing in place for at least 2 days post-op or until the day of discharge to create an occlusive environment for wound healing Nursing staff will assume responsibility for dressing changes, assessments, and reporting of complications to MD, PA, or NP Initial Dressing Change Will be completed as specified on the orthopedic order sheet Example: POD # 2 Preferably dressing would be left in place until day of discharge Exception: Significant strike through (post-op drainage) Alert the MD, PA, NP Initially reinforce and change dressing in 24 hrs Subsequent Dressing Changes On the morning of discharge change the dressing and record the condition of the incision in the progress notes Notify the Attending MD if available or resident, PA, or NP of any significant findings Report Significant Findings Notify the Attending MD: Evidence of wound dehiscence Drainage Sanguinous and Purulent drainage Moderate or Copious amount of drainage Incisional Complication Blisters Erythema Edema Skin Tears Warmth Ecchymosis Incisional Breakdown Postop Dressing Care Sanitize hands Wear clean gloves to remove primary dressing Sanitize bandage scissors with alcohol between use Discard old dressing in red bag if saturated and dispose in soiled utility room Apply a sterile dressing using Kendall’s AMD gauze (antimicrobial dressing – purple package) Affix gauze with MeFix tape (hypoallergenic self-adhesive fabric tape), Tegaderm, or Ace Wrap as appropriate MeFix Tape Pull the sides of the tape to break open the backing Remove one side all the way down the piece of tape Tape one side of the gauze and then the other Do not stretch as you apply to prevent blisters Hip Dressing Typically the original dressing will be covered with either Microfoam or Tegaderm Microfoam dressing Tegaderm dressing Dressing Treatments Hip Incisions Apply 2 - 4 AMD Gauze Over Incision Loosely secure with MeFix tape to allow for swelling Date and initial the dressing If dressing is removed for a brief inspection it may be resecured in place If dressing removed entirely by surgeon or other – reapply as soon as possible Dressing Treatments Knee Incisions AMD gauze directly over incision 6 inch Ace wrap dressing Applied distal to proximal and should extend to mid-thigh level above any suprapatellar pouch swelling to avoid a tourniquet affect just above the knee Spine Service and Shoulders AMD Island dressing – left on until discharge AMD sealed with Tegaderm left on until discharge Rotator cuff (and total shoulders) – Dermabond is being used or an AMD gauze covered by tegaderm – left on until discharge Strike Through Minimal strike-through drainage Leave dressing intact Change dressing as indicated on orders Significant strike-through drainage Notify MD, PA, or NP and reinforce unless otherwise ordered Change dressing on Post-op Day1 Documentation: Daily Skin Assessment in Meditech Location Description Drainage Periphery Wound Edges Amount of Exudate Type of Exudate Nursing Intervention Comment: Incisional Complications Progress Notes for any complications Specify who was notified and when Specify treatment and plan for any incisional complications Discharge Dressings Hip, Knee, Spine, and Shoulder Discharge Dressings Apply same dressing used in the hospital Wounds Without Drainage Patient should be instructed to remove the dressing after 2 days. It can then be left open to air. Once the dressing has been removed, the patient may shower after the 2 days but should be instructed not to use washcloths or scrub the incision with any soap. Wounds With Drainage VNA services required at home Dressings may vary depending on amount of drainage Wounds with Sutures or Staples Should be kept covered until the sutures or staples are removed Cost Savings Discharge Supplies Patients Supply patient with 2 additional dressing changes at home Shower drapes: (for patients without Tegaderm) 2 per patient or more if appropriate They can be cut in half Patients with Sutures or Staples: with Steri Strips Unless draining, patient will not need any supplies for home Questions?