Surgical Site Infection Collaborative

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Surgical Site Infection Collaborative
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January 1 September 2, 2001

• 13 orthopedic surgeons involved in 36
  musculoskeletal cases that developed infections

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of Days Between Total Joint Replacement
InfectionsJanuary 1, 2002 through June 2003
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Trending of Hip Prosthesis Infection Rates
NNIS Risk 1
NNIS Risk 0
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Trending of Knee Prosthesis Infection Rates
NNIS Risk 2
NNIS Risk 1
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Surveillance Focus Included

• ASA score
• Length of surgery
• Number of personnel in OR suite
• Microorganism cultured
• Timing of preoperative antibiotic

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Time Line of Events
Memo sent to orthopedic surgeons recommending
chlorhexadine 4/isopropyl alcohol as skin prep
of choice
Teleconference Multifactorial Interventions to
Prevent Surgical Site Infections
05/16/02
Meeting with key players regarding surgical wound
infections
05/09/02
Infection Control Nurse and Hospital
Epidemiologist perform and videotape a surgical
scrub using chlorhexadine 4/isopropyl alcohol
05/02/02
04/15/02
Orthopedic surgical infections report presented
to Infection Control Committee
Infection Control Nurse and Hospital
Epidemiologist meet with orthopedic surgeons
regarding ortho infections in 2001
03/06/02
01/28/02
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Time Line of Events
Meeting with Hospital CEO and key players
regarding ortho infections
Hospital Epidemiologist presents recommendations
at Ortho Q.A. Meeting
12/30/02
Discussion regarding ortho surgical infections
deferred at Ortho Dept. Meeting
12/16/02
Meeting with key players to discuss ortho
surgical wound infections
10/28/02
Ortho surgeon addressed the issue of ortho
infections briefly at department meeting
10/17/02
Infection Control Nurse and Hospital
Epidemiologist meet with Board Members to discuss
ortho surgical wound infections
09/30/02
09/16/02
Orthopedic infections on Ortho Dept. Meeting
agenda, discussion deferred
06/24/02
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Recommendations

• Employ chlorhexadine 4 / isopropyl alcohol as
  skin prep
• Use clippers for hair removal
• Maintain a core body temperature of gt 36ºc
  throughout surgery
• Administer oxygen at 80 / 50 intra-operatively
  and at 80 by sealed mask/conventional
  non-rebreather mask for first two hours of
  recovery
• Test blood glucose thirty minutes after incision
  time
• Administer appropriate antibiotic within 30
  minutes of incision time
• Discontinue antibiotics within 24 hours

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Team Members

• Raymond Palesch, MD Orthopedic Surgeon, Trauma
  Medical Director
• Neil Barg, MD Hospital Epidemiologist
• Carl Olden, MD Medical Staff Quality
• Amy Crook, MD Anesthesiologist
• Mario Domenzain, MD OB/GYN
• Paul Novak, CRNA
• Ken Eakin, RN Surgical Services Supervisor
• Kristy Cure, RN Surgical Services Nurse Manager

• Connie Conklin, RN Ortho/Neuro/IV Tx Nurse
  Manager
• Gay Scott, RN, CIC Infection Control Nurse
• Greg Matsuura, Pharm-D
• Kay Anyan, RHIA Director Medical Staff Services
• Linda Bluhm, CPHQ Director Performance
  Improvement
• Sandy Dahl, RN VP Nursing Patient Care
• Linda Haralson, RN LD/Peds/NICU Nurse Manager
• Cecilia Bray, RN Womens/Gen. Surgery Nurse
  Manager

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Timely Antibiotics Administered

• Anesthesia/Nursing responsible
• Development of protocol for administration within
  30 minutes prior to incision
• 2 gms of antibiotic for adults over age 16
• Repeat intraoperative dosing at 3 hours

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Antibiotics Within One Hour
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Appropriate Antibiotics Given

• Initiation of Antibiotic Review of perioperative
  antibiotics
• Development of Penicillin Allergy Algorithm

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Appropriate Antibiotics Given
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Antibiotic Prophylaxis

• Given within 30 minutes of cut time
• Exception Vancomycin and Levofloxacin
• 1 hr infusion time
• Infusion must be finished prior to cut
• Recommended duration
• discontinue within 24hrs1

• Bratzler DW, et al. Antimicrobial Prophylaxis for
  Surgery An advisory statement from the National
  Surgical Infection Prevention Project. Clinical
  Infectious Diseases 2004381706-1715
• Antimicrobial prophylaxis for surgery. Treatment
  Guidelines from the Medical letter, 2004
  2(20)27-32.

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Orthopedic Antibiotic Prophylaxis

• 2gms Cefazolin IV within 30 minutes of incision
  in all patients over age 16.
• If Penicillin allergic use Vancomycin 1gm IV over
  a 60 minute infusion time.

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Penicillin Allergy Assessment Tool (Elective
Orthopedic Surgery)
Does the patient have a reported cephalosporin
allergy?
No
What type of penicillin reaction was it?
Has the patient been able to tolerate a
cephalosporin without an allergic reaction?
No
Did the patient develop severe hypotension,
respiratory distress, or systemic swelling?
Yes
Yes
Yes
No
Yes
Did the patient develop hives (raised, itchy,
systemic welts) during a treatment course?
No
Use Vancomycin
Use Cefazolin
Use Cefazolin
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Antibiotics Discontinued in 24 Hours

• Nurse Manager provided SSI collaborative
  PowerPoint presentation to Surgical Services
  staff - 3/31/03
• Physician Champion provided SSI collaborative
  slide presentation to orthopedic surgeons and
  anesthesia 4/21/03
• Orthopedic Section voted to revise order sheet to
  discontinue antibiotics in 24 hours 5/27/03

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• Orthopedic Post-op Orders
  Page 2 of 2
• .Antiemetic Protocol
• .Respiratory
• If on Oxygen, oximetry every 8 hrs, D/C O2 when
  SAT gt92
• Respiratory Care, evaluate and treat ?
  Incentive Spirometry
• .Activity ? Bed Rest ? OOB this PM ?
  Chair TID
• Physical Therapy Begin treatment ?this P.M.
  ?in A.M. _______________WB affected extremity
• Total Hip Protocol ______________________ WB
  affected extremity
• Total Knee Protocol ____________________ WB
  affected extremity
• Elevate affected extremity ? 6 above heart
  level ? heart level ? stockinette ? calves
  elevated on pillows
• CPM _____________________________________________
  __________________________________________________
  ______________________________________
• Other ___________________________________________
  __________________________________________________
  ________________________________________
• .Misc
• X-Ray ____________________________________________
  __________________________________________________
  _______________________________________
• Dressing _________________________________________
  __________________________________________________
  _______________________________________
• Autotransfusion
• Discontinue Hemovac ? 24 hours post-op ? 48
  hours post-op
• R/C or straight cath PRN inability to void
  Discontinue R/C 48 hrs post-op, reinsert PRN. CS
  PRN
• TEDS Protocol ? SCD Protocol ? Abduction
  Bolster

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Antibiotic Discontinued in 24 Hours
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Hair Removed Appropriately

• Two clippers stocked in each OR suite
• Re-inserviced staff via poster boards
• Specific staff member assigned responsibility for
  stocking
• Use of clippers implemented for other surgical
  procedures

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Hair Removed Appropriately
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Normothermia

• Calibration checked on forced air warming
  machines and adjusted
• Forced air warming machines placed on
  preventative maintenance schedule
• Pre-op warming blankets
• Increase of room temperature abandoned
• Abandoned cooling vests for surgeons after trial
• Space hats in pre-op
• Underbody warmers in OR

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Body Temperatures
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Supplemental Oxygen

• Implemented use of non-rebreather mask at high
  flow
• Patient education regarding rationale in pre-op
  holding areas
• Set standard mask removal time at 2 hours post
  arrival to patient room
• Non-rebreather mask application to patient with
  initiation of oxygen flow
• Utilization of timer abandoned

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Supplemental Oxygen Perioperatively
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Patient Satisfaction Non-Rebreather Mask

• Interview each patient post discontinuation
• 246 out of 255 patients were satisfied with the
  use of the non-rebreather mask (96.5)

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Chlorhexadine 4/Alcohol PrepMarch 19, 2003
February 29, 2004
Total Knee/Total Joint Recommendations
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Other Inpatient Ortho

• Started July 2003

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Neuro Surgery

• Started November 2003

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SSI Collaborative 3 Year Plan
February 2005 General Surgery and Urology
May 2004 OB/GYN
November 2003 Neuro
March 2003 Ortho Hips and Knees
January 2004 C-Sections
November 2004 Colon
September 2005 Wound Care, Podiatry, and Plastics
July 2003 Other Ortho
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Appropriate Prophylactic Antibiotic Selected
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Percent of Abx Given Within 1 Hour of Incision
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Percent of Prophylactic Abx Discontinued Within
24 Hours After Surgery End Time
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Trending of Total Hip Infection Rates
NNIS Rate 1.61
NNIS Rate 0.88
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Trending of Total Knee Infection Rates
NNIS Rate 1.26
NNIS Rate 0.87
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Recommendations

• Employ chlorhexadine 4 / isopropyl alcohol as
  skin prep
• Use clippers for hair removal
• Maintain a core body temperature of gt 36ºc
  throughout surgery
• Administer oxygen at 80 / 50 intra-operatively
  and at 80 by sealed mask/conventional
  non-rebreather mask for first two hours of
  recovery
• Test blood glucose thirty minutes after incision
  time
• Administer appropriate antibiotic within 30
  minutes of incision time
• Discontinue antibiotics within 24 hours

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Surgical Site Infection Collaborative