Prevention of Surgical Site Infections

1
Prevention of Surgical Site Infections

• Robert Garcia, BS, MMT(ASCP), CIC
• Infection Control Professional Consultant

2
SSIs Magnitude of the Problem

• 1996 28.4 million ambulatory surgery procedures
  in the U.S.
• 2003 30.8 million inpatient surgical procedures
  and 9.7 million (37) of those performed on
  patients 65 yrs and older
• NNIS SSIs occur in 2.6 of all surgeries
• 1.5 million SSIs annually
• SSIs are the second most common HAI
• LOS in hospital increases by 7.5 days
• Attributable cost 25,546 (range 1783 to
  134,602)
• U.S. National Cost 130-845 million/year

3
Relative Costs of HAIs
4
Risk Factors for SSI The Patient

• Age
• Nutritional status
• Diabetes
• Nicotine use
• Obesity
• Coexistent infection
• Colonization
• Altered immune response
• Long preoperative stay

How effectively can we control these risk
factors?
5
Risk Factors for SSI Pre- and Intraoperative

• Inappropriate use of antimicrobial prophylaxis
• Infection at remote site not treated prior to
  surgery
• Shaving the site vs. clipping
• Long duration of surgery
• Improper skin preparation
• Improper surgical team hand antisepsis
• Environment of the room (ventilation,
  sterilization)
• Surgical attire and drapes
• Asepsis
• Surgical technique hemostasis, sterile field

To a great extent, this is what we can control!
6
Goal Zero

• The All-or-None Measurement
• An option for calculating performance
• Denominator No. of pts. eligible to receive at
  least 1 or more discrete elements of care
• Numerator No. of pts. who actually received
  care.
• No partial credit is given
• The Centers for Medicare Medicaid (CMS) has
  moved to the all-or-none approach

Nolan T, Berwick D. All-or-none measurement
raises the bar on performance. JAMA
20062951168-70.
7
Defining Appropriate Care in Surgery
8
Surgical Infection Prevention Project

• Started in August 2002, by the Centers for
  Medicare Medicaid Services (CMS) and the
  Centers for Disease Control and Prevention (CDC)
• Based on 2 findings
• Estimates indicate that 40-60 of all SSIs are
  preventable
• Overuse, underuse, improper timing, and misuse of
  antibiotics occurs in 25-50 of operations

9
Selected Surgical Procedures

• Cardiac
• Coronary Artery Bypass Graft (CABG)
• Colon
• Hip Knee Arthroplasty
• Abdominal Vaginal Hysterectomy
• Vascular Surgery
• Aneurysm repair
• Thromboendarterectomy
• Vein Bypass

These procedures are being evaluated in the
Medicare project because there is no controversy
over the use of antibiotics for these operations.
This does not imply that antibiotic prophylaxis
should not be used for other procedures.
10
Timing of Antibiotic ProphylaxisGI Operations
Stone HH et al. Ann Surg. 1976184443-452.
11
Perioperative AntibioticsTiming of Administration
14/369
15/441
1/41
1/47
1/81
2/180
5/699
5/1009
Hours From Incision
Classen, et al. N Engl J Med. 1992328281.
12
Clin Infect Dis. 2004381706-1715.
13
Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
14
Surgical Infection PreventionNational
Performance, Qtr. 4, 2004
15
Pre-operative shaving

• Shaving the surgical site with a razor induces
  small skin lacerations
• potential sites for infection
• disturbs hair follicles which are often colonized
  with S. aureus
• Clipping rather than shaving may be superior
• Evidence regarding best time for hair removal is
  inconclusive
• Patient education
• It may be best NOT to have patient shave before
  they come to the hospital.

Niel-Weise BS, et al. Hair removal policies in
clean surgery systematic review of randomized,
controlled trials. ICHE 200526923-8.
16
Perioperative Glucose Control

• 1,000 cardiothoracic surgery patients
• Diabetics and non-diabetics with hyperglycemia

Patients with a blood sugar gt 300 mg/dL during or
within 48 hours of surgery had more than 3X the
likelihood of a wound infection! Latham R, et
al. Infect Control Hosp Epidemiol. 2001.
17
Temperature Control

• 200 colorectal surgery patients
• control - routine intraoperative thermal care
  (mean temp 34.7C)
• treatment - active warming (mean temp on arrival
  to recovery 36.6C)
• Results
• control - 19 SSI (18/96)
• treatment - 6 SSI (6/104), P0.009

Kurz A, et al. N Engl J Med. 1996. Also Melling
AC, et al. Lancet. 2001. (preop warming)
18
Advantages of All-or-None Measurement

• .all-or-none measurements more closely reflects
  the interests and likely desires of patients.
  This is especially true when process components
  interact with each other synergistically.violatio
  n of a single step in the sterile technique in
  surgery may vitiate the benefits of proper
  execution of all other steps
• Nolan, Berwick. JAMA 2005
• The Take Away Message in SSI prevention, it
  makes little sense to assure that the surgeon has
  washed his hands properly if the patients skin
  has not had optimal prepping

19
The Missing Link Antiseptic Skin Prepping

• When we consider pathogenesis of SSI, it has been
  accepted for decades that most SSI are endogenous
  in nature
• Surgical Infections. Dellinger EP, Ehrenkranz.
  In Hospital Infections, Bennett Brachman, 1998
• Surgical Infections Including Burns. Kluymans J.
  In Prevention and Control of Nosocomial
  Infections, Wensel RP, 1997.
• Surgical Site Infections. Wong ES. In Hospital
  Epidemiology and Infection Control, Mayhall CG,
  1999.
• Surgical Antisepsis. Crabtree TD, Pelletier SJ,
  Pruett TL. In Disinfection, Sterilization, an
  Preservation, Block SS, 2001

20
Infection Rates by Wound Classes
Dellinger EP, Ehrenkranz NJ. Surgical Infections.
In Hospital Infections. Bennett JV Brachman
PS, eds., 1998
21
Sources of S. aureus Infection in Cardiac Surgery

• Prospective study of 376 patients undergoing CABG
• Pre-op nasal cultures, intra-op wound cultures of
  patients
• Nasal cultures of all CV surgery/OR personnel
• DNA subtyping of patients colonizing/infecting
  strains and personnel strains
• 38 SSIs (10.1), 14 deep infections (3.3), 5
  mediastinitis (1.3)
• Of gt30 wound infections, all except 1 from
  patient ( endogenously-derived infections)

Jakob et al. Eur J Cardiothorac Surg
200017154-60. Slide courtesy of D. Maki
22
CDC on Skin Preparation

• Require patients to shower or bathe with an
  antiseptic agent on at least the night before the
  operative day. Cat IB
• Thoroughly wash and clean at and around the
  incision site to remove gross contamination
  before performing antiseptic skin preparation.
  Cat IB
• Use an appropriate antiseptic agent for skin
  preparation. Cat IB
• Apply preoperative antiseptic skin preparation in
  concentric circles moving toward the periphery.
  The prepared area must be large enough to extend
  the incision or create new incisions or drain
  sites, if necessary. Cat II

Guideline for Prevention of Surgical Site
Infection, 1999. HICPAC, Centers for Disease
Control.
23
AORN on Skin Preparation

• The surgical site and surrounding areas should be
  clean.
• The skin around the surgical site should be free
  of soil and debris. Removal of superficial soil,
  debris, and transient microbes before applying
  antiseptic agent(s) reduces the risk of wound
  contamination by decreasing the organic debris on
  the skin.
• Cleansing should be accomplished by any of the
  following methods before surgical skin
  preparation
• Patient showering and/or shampooing before
  arrival in the practice setting
• Washing the surgical site before arrival in the
  practice setting, or
• Washing the surgical site immediately before
  applying the antiseptic agent in the practice
  setting

Standards, Recommended Practices, and Guidelines,
2005 Edition. AORN, Denver, CO.
24
AORN on Skin Preparation (contd)

• When indicated, the surgical site and surrounding
  area should be prepared with an antiseptic agent
• Antiseptic agents should be.used in accordance
  with the manufacturers written instructions.
  Antiseptic agent(s) should have a broad range of
  germicidal action.

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26
Skin Prep Protocols Example I
Package directions Use sponge to prep desired
area
27
Skin Prep Protocols Example II
28
2 CHG Cloth Skin Prep Instructions

• Use first cloth to prepare the skin area
  indicated for a moist or dry site, making certain
  to keep the second cloth where it will not be
  contaminated. Use second cloth to prepare larger
  areas.
• Dry surgical sites (such as abdomen or arm) use
  one cloth to cleanse each 161 cm2 area (approx 5
  x 5 inches) of skin to be prepared. Vigorously
  scrub skin back and forth for 3 minutes,
  completely wetting treatment area, then discard.
  Allow area to air dry for one (1) minute. Do not
  rinse.
• Moist surgical sites (such as inguinal fold) use
  one cloth to cleanse each 65 cm2 area (2 x 5
  inches) of skin to be prepared. Vigorously rub
  skin back and forth for 3 minutes completely
  wetting treatment area, then discard. Allow to
  air dry for one (1) minute. Do not rinse.

29
Antiseptic Agent Characteristics

• Significantly reduce microbial counts on intact
  skin
• Contain a non-irritating, safe antimicrobial
  preparation that maintains the skins integrity
• Be broad-spectrum
• Be fast-acting and/or have residual effect
• Clearly define time of application and time of
  drying
• Be cost effective

30
Crowded and Confusing Market
Variance in protocols and practice
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32
Chlorhexidine SSIs

• Why are there no studies that link use of CHG and
  SSI prevention?
• Lack of good study design
• Inclusion of surgery types other than clean
• Inadequate application of agent (bathing with
  agent followed by rinsing)
• New study comparing three commercially available
  skin prep products (with CHG, iodine, triclosan)
  provides evidence that pre-op skin prepping with
  a CHG-impregnated cloth without rinsing or
  showering at 12 hrs. and 3 hrs. prior to OR skin
  prepping significantly lowers microbial
  colonization

Maki DG, Paulson DS. abstract Evaluation of 6
preoperative cutaneous antiseptic regimens for
prevention of surgical site infection. SHEA
Conference, 2006.
33
What we commonly see in the medical record

• The patients skin was prepped in the usual
  sterile manner

34
Pre-operative Shower/Bath Protocol

• Protocol should consider the following aspects
• An antiseptic should be selected based on certain
  characteristics as addressed by the FDA
• How and when is the antiseptic dispensed to the
  patient?
• How often should the patient use the antiseptic
  product once or twice?
• When are the best times to accomplish
  preoperative antiseptic shower/bath?
• Is the whole body cleansed or just the incisional
  site?
• What kind of educational materials are available
  or does the facility need to create their own?
• Is the surgeons support necessary for this
  initiative, or does it involve only nursing?
• Who verifies completion of this patient
  responsibility and where is this documented?

Nancy B. Bjerke. Preoperative skin preparation a
system approach. Infection Control
Today. http//www.infectioncontroltoday.com/articl
es/1a1topics.html?wts200605100734198hc39reqbj
erke
35
Surgical Skin Prep Protocol

• Work Outward. Begin at the incision site and move
  out in concentric circles. Discard the sponge
  applicator when periphery is reached and do not
  return a sponge/applicator to the incision site
  once it has been applied to that area. Extend
  prep beyond the anticipated drape borders.
• Prep problem areas last. Certain areas within the
  incision site with the potential to house excess
  bacteria need particular attention during the
  prepping process. The umbilicus typically has a
  high microbial count and needs to be cleaned with
  a Q-tip prior to prepping. Open wound, and
  perineal areas should be prepped last.
• Be careful with drapes. When applying a drape, it
  is critical you follow the drapes individual
  product instructions. Certain preps need to
  remain in contact with the skin for a specified
  amount of time to be fully effective. Placing a
  drape before the solution dries could interfere
  with this time requirement, so check the
  products package label for special instructions.

Cynthia Spry. Outpatient Surgery Magazine.
http//www.outpatientsurgery.net/infection_control
/2005/brush_up_skin_prep_protocol.php
36
Skin Prep Protocol (contd)

• Avoid pooling. Applying excess amounts will cause
  the prep solution to pool under the patient.
  Pooled prep solution in contact with the skin can
  cause irritation or burn and can compromise the
  adhesive of a dispersive electrode. Be especially
  careful to prevent pooling under a tourniquet
  cuff. If a flammable agent, such as alcohol, is
  used, allow the solution to dry to reduce the
  possibility of fire. Use of an active electrode
  in the presence of a flammable agent could result
  in fire.
• Document action. Performing a skin assessment,
  documenting the assessment, prepping and
  observing the condition of the skin after surgery
  are other key components of a successful
  infection control strategy. Look at the condition
  of the skin before the prep. Is there a rash? Do
  you notice a break in skin integrity? Written
  documentation of your assessment will create a
  baseline record and will let staff in the
  recovery unit determine if a later skin reaction
  was the result of the prep.

Cynthia Spry. Outpatient Surgery Magazine.
http//www.outpatientsurgery.net/infection_control
/2005/brush_up_skin_prep_protocol.php
37
Prevention of Ventilator-Associated Pneumonia

• Robert Garcia, BS, MMT(ASCP), CIC
• Infection Control Professional

38
VAP Facts

• Third most common HAI and most common among ICU
  patients
• Second most costly HAI
• Between 10 and 20 of patients receiving gt48
  hours of mechanical ventilation will develop VAP
• Critically ill patient who develop VAP appear to
  be twice as likely to die compared to those
  without VAP
• Patients with VAP have significantly longer
  lengths of stay (mean 6.10 days)

39
Current Preventive Recommendations
IHI 100K Lives Campaign. Getting Started Kit VAP
How-to Guide CDC Guideline for Preventing
Healthcare-Associated Pneumonia, 2002. UI
unresolved issue NA not addressed
40
Elevation of the Head of the Bed

• Recent randomized controlled study that disputes
  study referenced by CDC to recommend use of
  semirecumbent positioning to prevent VAP
• Study is unique in three aspects
• Patient positioning was continuously monitored in
  first week
• The semirecumbent position was compared to the
  standard of care
• Data analyzed according to the intention-to-treat
  principle
• Results
• Patients in supine position (control) reached
  only 9.8 to 14.8 degrees (i.e., standard of care)
• Mean backrest position in study group was 30
  degrees
• No difference in VAP rates between the groups

van Nieuwenhoven CA, et al. Feasibility and
effects of the semirecumbent position to prevent
ventilator-associated pneumonia A randomized
study. Crit Care med 200634396-402.
41
Stress Ulcer Prophylaxis
Flanders SA, Collard HP, Saint S. Nosocomial
pneumonia State of the Science. Am J Infect
Control 20063684-93

• 7 meta-analyses, gt20 studies
• 4 showed significant VAP reductions
• 3 showed similar but non-significant VAP
  reductions

• Cook D, et al. A comparison of sucralfate and
  rantidine for the prevention of upper
  gastrointestinal bleeding in patients requiring
  mechanical ventilation. Canadian Critical Care
  Trials Group. N Eng J Med 1998338781-97.
• Large randomized trial showed no benefit in
  either sucralfate or H2 antagonists
• Kantorova I, et al. Stress ulcer prophylaxis in
  clinically ill patients a randomized controlled
  trial. Hepatogastroenterology, 2004200451757-61
  .
• randomized, placebo-controlled trial, 287 pts.
• studied omeprazole (PPI), famotidine (H2
  antagonist), sucralfate
• No significant differences in bleeding or
  pneumonia rates among the 4 groups

42
Subglottic Secretion Drainage

• Meta-analysis of randomized trials
• 5 trials met inclusion criteria (patients gt72
  hrs. of mechanical ventilation)
• Results
• shortened duration of ventilation by 2 days
• shortened length of stay by 3 days
• delayed onset of pneumonia by 6.8 days

Dezfulian C, et al. Subglottic secretion drainage
for preventing ventilator-associated pneumonia a
meta-analysis. Am J Med 200511811-18.
43
Pathogenesis Interventions

• Strategies to prevent VAP are likely to be
  successful only if based upon a sound
  understanding of pathogenesis and epidemiology.
  The major route for acquiring endemic VAP is
  oropharyngeal colonization by endogenous flora or
  by pathogens acquired exogenously from the
  intensive care unit environment, especially the
  hands or apparel of health-care workers,
  contaminated equipment, hospital water, or air.
  The stomach represents a potential site of
  secondary colonization and reservoir of
  nosocomial gram-negative bacilli.

Safdar N, Crnich CJ, Maki DG. The pathogenesis of
ventilator-associated pneumonia its relevance to
developing effective strategies for prevention.
Respir Care 200550725-39.
44
Linking Oral and Dental Colonization with
Respiratory Infection

• A review of the published evidence linking
  oropharyngeal colonization and respiratory
  infection, including VAP (20 studies)
• Provides suggested oral and dental interventions,
  some beyond the scope of current guidelines

Garcia R. A review of the possible role of oral
and dental colonization on the occurrence of
health care-associated pneumonia
Underappreciated risk and a call for
interventions. Am J Infect Control 200533527-41.
45
Suggested Oral Dental Care Interventions
46
Suggested Oral Dental Care Interventions
(contd)
47
VAP Bundle Success Stories

• Rochester Medical center, Rochester, NY
• At least 220 days without a VAP case
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/UniversityofRochesterStr
  ongMemorialHealthWorkingtoReduceComplicationsfromV
  entilatorsandPreventVAPint.htm
• Overlake Hospital, Bellevue, WA
• Reduced VAP by 80 in one year
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/DoingBetterSpendingLess.
  htm
• Consortium of 127 ICUs in 70 hospitals
• 68/127 ICUs eliminated VAP for at least six
  months
• Along with CLAB bundle, estimates are that 1,500
  lives were saved, 81,000 hospital days, and 165
  million
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/DoingBetterSpendingLess.
  htm
• Owenboro Medical Health System, Owensboro, KY
• Reduced VAP by 72 in 18 months
• http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
  veCare/ImprovementStories/ReducingVentilatorAssoci
  atedPneumoniaOwensboro.htm

48
Swedish Medical Center, Results of VAP Bundle
Intervention
http//www.ihi.org/IHI/Topics/CriticalCare/Intensi
veCare/ImprovementStories/EliminateVentilatorAssoc
iatedPneumonia.htm
49
VAP Bundle Comprehensive Oral Care

• Used HMO Acronym
• Head of Bed keep at least 30 degrees or greater
  unless contraindicated
• Mobility Each even hour, complete or assist the
  patient in performing mobility
• Oral Care Perform oral care every even hour on
  intubated and trached patients. Suction brush at
  0800 and 2000. Suction catheters at extubation,
  position changes, and every 6 hours or as needed.

Simmons-Trau D. ZAP VAP with a back-to-basics
approach. Nurs 2006 Crit Care128-36.
50
Adding Comprehensive Oral Care to the IHI VAP
Bundle Achieving Zero

• Baptist Memorial DeSoto
• Baptist Memorial Hospital Golden Triangle
• Bay Regional Medical Center
• McLeod Regional Medical Center
• OSF Saint Francis Medical Center
• Overlake Hospital Medical Center
• Palmetto Health Baptist
• Upper Chesapeake Medical Center

51
48-month Study on Effect of Oral-Dental Care on
VAP Brookdale University Hospital Medical
Center, NY

• Objective to determine the effect of a
  comprehensive oral care program on rates of VAP,
  mortality, cost
• MICU patients on mechanical ventilation gt48 hrs.
• Pre-intervention 1/1/01-12/31/02, standard
  oral care
• Intervention 1/1/03-12/31/04, education and use
  of a novel oral-dental care system designed to
  reduce bacterial colonization of the
  oropharyngeal tract and teeth
• Standards of care during the entire 48-month
  study included 7d vent circuit replacement,
  24-hour HME filter replacement, 24-hour closed
  suction catheter replacement, semirecumbent
  position unless contraindicated, administration
  of stress ulcer prophylaxis, and use of a weaning
  protocol.

Garcia R, Jendresky L, Colbert L, Bailey A.
48-month study on reducing VAP using advanced
oral-dental care protocol compliance, rates,
mortality, and cost. Abstract presented at the
2006 APIC Conference, Tampa, FL. publication
pending, Crit Care Med
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Patient Demographics Baseline Measurements
53
Protocol Compliance
54
Outcome Data
55
VAP Rates, MICU, 2001-2005
56
Cost of VAP
Warren DK, et al. Outcome and attributable cost
of ventilator-associated pneumonia among
intensive care unit patients in a suburban
medical center. Crit Care Med 2003311312-3. Rell
o J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm
L, Redman R, Kollef MH. Epidemiology and outcomes
of VAP in a large US database. Chest
20021222115-2121. Cocanour et al. Cost of
ventilator-associated pneumonia in a shock trauma
intensive care unit. Surg Inf, 2005665-72. Kolll
ef MN, et al. Epidemiology and outcomes of
health-care-associatedpneumonia Results from a
large US database of culture-positive pneumonia.
Chest 20051283854-62.
57
Cost Avoidance BUMC VAP Project
Total product cost 59,133
58

• My thanks to the Brookdale family for their
  dedication and supreme efforts in improving the
  care of our patients

59
Robert Garcia, BS, MMT(ASCP), CIC Assistant
Director of Infection Control Brookdale
University Hospital Medical Center One Brookdale
Plaza Brooklyn, NY 11212 718.240.5924 rgarcia_at_broo
kdale.edu President, Enhanced Epidemiology,
LLC P.O. Box 211 Valley Stream, NY
11580 516.810.3093 rgarciaicp_at_aol.com