10 ssi bundle 'use cats to prevent ssi

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3M Infection Prevention Division

SURGICAL SITE INFECTIONCATS

ROAZALINA HASANUDDIN

Manager, Clinical

RN, BSc (Hons), Post Basic Peri-Operative

Infection Prevention Division

3M Malaysia

Every Day Practices + 3M Solutions =Positive Patient Outcomes

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OBJECTIVES

SSI Overview

Understand the Best Practices in Prevention of SSI

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WHAT IS SURGICAL SITE INFECTION (SSI)?

SSI is the infection that occurs after

24 hours of surgery

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SURGICAL SITE INFECTION

SSI usually occurs between _________ surgery.

SKIN

SUBCUTANEOUSTISSUE

DEEP SOFT TISSUE(MUSCLE)

ORGAN

Deep Incisional SSI

Organ /Space SSI

Superficial Incisional SSI

SSI CITERIA

24 hours to 30 days (non Implant).

24 hours to a Year for Implant Surgery

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Respiratory16%

Surgical Site15%

Blood Stream13%

Urinary Tract32%

Other24%

SSI % vs other HAIs %

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INFECTIONS

• Infections cause patients’ condition to worsen • Infections increase a patient’s risk of death

• Infections result in prolonged hospital stays

• Longer stays and more serious problems that must be treated result in higher costs

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3M Infection Prevention DivisionFacts about Surgical Site Infections:

SSI account for 14 % to 16% of all nosocomial infections among hospitalized

patients

Estimated added cost per SSI: Average cost of an infection: $3,152

7.3 additional days in hospital

Number of deaths: ~10,000 due to SSI

Surgical site infections: Increase patient’s length of stay Increase need for powerful antibiotics Decrease positive outcome of surgery

Additional cost must be absorbed by the hospital

*CDC Guideline for the Prevention of SSI, 1999

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CDC Guidelines for Prevention of Surgical Site Infection (1999)Symptoms: “Irritative Fever”

Purulent Drainage

Overwhelming Sepsis

DeathThus to reduce the risk of SSI, a systematic and realistic approach must be applied with the awareness that this risk is influenced by characteristics of the patient, operation, personnel, and hospital.

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http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

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IHI

Use “CATS” to prevent SSI

How do we start to prevent SSIHow do we start to prevent SSI

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SURGICAL SITE INFECTION PREVENTION SURGICAL SITE INFECTION PREVENTION

Describe the Best Practices to Prevent SSIs

http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

A: Use Antibiotics Appropriately

C: Hair Removal

T: Maintain Normal Body temperature

S: Maintain Normal Blood Glucose

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Hair follicles contain bacteria—released through friction, micro abrasions, cuts created by shaving with razors

Recommendations include: No hair removal at all Clipping(AORN 2011) has remove recommendation of depilatory use.

Inappropriate Razors Depilatory use

Describe Clinical Care Protocols and Best Practices to Prevent SSIs

Hair Removal

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Do not remove hair unless it will interfere with surgical procedureIf removal necessary only use clippers Maintain the skin integrity Remove hair as close to the time of surgery as possiblePerform procedure outside of OT

Interventions for Hair Removal

Jepson et al SSI Rate

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Hair Removal Methods:

No Hair Removal

Razor

Depilatory/Surgi-Cream

Clipper

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Hair Removal

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CLIPPER vs. RAZOR CLIPPER vs. RAZOR

Clipper Razor No micro-abrasions Causes micro-abrasions

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CLIPPER vs. RAZOR CLIPPER vs. RAZOR

Clipper RazorLow chance of infection High chance of infection

Clinical Study

At time of discharge

Hair Clipping: 1.8 %.

Razor shaving: 6.4 %

At 30 days follow-up.

Hair Clipping: 3.2%

Razor shaving: 10% Alexander et al.

Hair removal methods using a razor compared to an electric clipper. The study showed that for hair removal performed the morning of surgery.

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THE “FACTS”

We know what AORN 2010 says about hair removal…

Interpretive Statement 4:

“If hair is to be removed, it should be done in a mannerthat preserves skin integrity.”

Rationale:

“Hair removal by shaving can disrupt skin integrity…”

Discussion:

“An electric or battery powered clipper with a disposable orreusable head that can be disinfected between patients is

acceptable…”

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Antibiotics administered within specific time framesGive initial dose of the IV antibiotic to provide a bactericidal level of drug in the

serum and tissues when incision is made (within 30 minutes prior to the incision)Provides concentration of the drug in serum and tissues that is at a bactericidal

level when the incision is made

Use Antibiotics Appropriately-Preoperative Antibiotic Prophylaxis


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Antibiotics present in the tissue at the time of the incision and for a specified period of time after surgery support existing host defenses in killing microorganisms present in the wound

For colon surgery, oral non-absorbable antibiotics may ALSO be used to reduce the counts of bowel microorganisms

Doses may be in the upper range for obese patients, and repeat doses of antibiotics may be necessary for long operations

Discontinue antibiotics within 24 hours after surgery except for cardiothoracic procedures in adult patients (as per ordered by doctors)

Use Antibiotics Appropriately-Preoperative Antibiotic Prophylaxis

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Normothermia: the body’s ideal thermal state

Core temperature:3

37.0°C (98.6°F)

Temperature gradient: 2-4°C between the core and periphery

Core:37°C

Periphery:2-4°C cooler

3.Sessler DI. Current concepts: Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.

©2011 Arizant Healthcare Inc. All Rights Reserved.

Maintain Normal Body temperature


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Normal responses to temperature changeInterthreshold range:3

Core temperature is normally tightly regulated by the body

When external factors push core temperature outside this range, the body takes corrective steps

Body’s response to cold:3

Behavioral changes Vasoconstriction Non Shivering Thermogenesis (NST) Shivering

Body’s response to heat:3

Vasodilation Sweating

33°C 35°C 37°C 39°C 41°C

ShiveringVasodilation

Sweating

Interthreshold Range

VasoconstrictionNST

0.2ºC

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Characteristic Patterns of General Anesthesia-Induced Hypothermia

An average core temperature drop of 1.6°C can occur in the first hour of general anesthesia1

81% is from core-to-periphery heat redistribution due to anesthesia-induced vasodilation1

Adapted from: Sessler, Anesthesiology 2000

1hr

0

-1

-2

-3

0 2 4 6

Δ

Cor

e T

emp

(°C

)

Elapsed Time (h)

Characteristic Patterns of General Anesthesia-Induced Hypothermia

-1.6°C

1. Matsukawa T, et al. Heat Flow and distribution during induction of general anesthesia. Anesthesiology 1995;82:662-73

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3M Infection Prevention DivisionEvolution of forced-air warming: pre-warming

Warm periphery before induction to prevent redistribution temperature drop

Problem: prevent hypothermia before it starts

Answer: active pre-warming

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Use warmed forced-air blankets preoperatively, during surgery, and in the post anesthesia care unit (PACU).

Use warming blankets under patients on the operating table.

Use hats and foot covers on patients perioperatively.Adjust engineering controls so operating rooms and

patient areas are not permitted to become excessively cold overnight when many rooms are closed

Designate responsibility and accountability for thermoregulation.

How to Maintain Normal Body temperature

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3M Infection Prevention DivisionComparing active warming modalities

Area warmed (patient’s back)

Convective (forced-air) Conductive (water mattress)

Limited recruitment

Risk of warming pressure points

Recruits more skin surface area to warm (at relatively low temperatures)

No risk of warming pressure points

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Adverse effects of unintended hypothermia

There are many documented adverse effects of unintended hypothermia2 including:

Surgical site infection Morbid myocardial outcomes Blood loss and tranfusion requirement Prolonged and altered drug effect Prolonged recovery Shivering and patient discomfort

General or regional anesthesia

2. Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28.

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Surgical Wound Infections

Hypothermic colorectal surgical patients with mild hypothermia have:7

77

7. Kurz A, Sessler DI, et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334:1209-1215.


Adapted from: Kurz et al., New Engl J Med, 1996

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Maintain Normal Blood Glucose


Increased risk for SSIs because of impaired host defenses from the disease Diabetes mellitus has long been considered a risk factor for SSI, studies

inconclusive. Postoperative medical complications more common in patients with diabetes

mellitus

SSI Host Factor: Diabetes Mellitus

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Blood Sugar Concentration Level: Normal blood sugar ranges

For the majority of healthy individuals, normal blood sugar levels are as follows:

The normal blood glucose level in humans is about 4 mmol/L (72 mg/dL)The body, when operating normally, restores the blood sugar level to a

range of about 4.4 to 6.1 mmol/L (82 to 110 mg/dL) Shortly after eating the blood glucose level may rise temporarily up to 7.8

mmol/L (140 mg/dL)

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Poor glycemic control is an independent risk factor for SSIs in a variety of surgical procedures.

Many patients may have had undiagnosed diabetes mellitusVigorous efforts to ensure patients with diabetes are well controlled and

glucose levels are carefully managed prior to, during, and following the surgical procedure

High-risk patients should be screened to stabilize and to control blood-glucose levels prior to the surgery.

Staff should set goals with the patient and family, such as lowering hemoglobin A1c levels to less than 7% before the surgical procedure

Interventions for Diabetes Mellitus


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Develop a single protocol for use on all surgical patients.Use a glucose control protocol, implementing a sliding scale or insulin

drip as appropriate.Check preoperative glucose levels on a regular basis on all patients to

identify hyperglycemia. Time the risk assessment to provide time for adequate treatment.

Designate a person responsible and accountable to monitor blood glucose and control.

www.IHI.org

Institute for Healthcare Improvement (IHI) Recommendations for Management of Glucose and A1c Levels in Coronary Artery Bypass Graft Patients

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IHI

C A T S

Remember CATS remember SSI Preventions..

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OR & CSSD Characteristics/Environment

Other Best Practices to Prevent SSIs

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OR: Hand Hygiene

CDC: Hand Hygiene in Health-Care Settings Surgical hand antisepsis using either an antimicrobial scrub or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures

Other Prevention of SSI

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Surgical Hand Preparation

Optimum antiseptic Broad-spectrum activity Fast acting Persistent

Use agents that have been found to have greatest residual activity

For first scrub of the day - clean under nails It is not clear that such cleaning is necessary for subsequent

scrubsCDC GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

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3M Infection Prevention DivisionStandardizes Procedure for Hand Hygiene

Hand wash:• Application technique, length of exposure to product, correct

concentration of product• Use of soap and water for at least 15 seconds

Hand rub:• Application technique, length of exposure to product, correct

concentration of product• Use of alcohol-based antiseptic hand rub when soil is not present on

hands• At least 15 seconds

Surgical hand scrub: • Application technique, length of exposure to product, correct

concentration of product• Use of either an antimicrobial surgical scrub agent or an alcohol-based

antiseptic surgical hand scrub

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SURGICAL HAND RUB Formulations

(CDC)

Studies have demonstrated that formulations containing 60%–95% alcohol alone or 50%–95% when combined with limited amounts of a quaternary ammonium compound, hexachlorophene, or chlorhexidine gluconate (CHG), lower bacterial counts on the skin immediately post scrub more effectively than do other agents. .(Table 4)

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OR: Surgical Solution (Skin Prep)

It is important to choose the proper and correct solution which its reduce the potential of skin microbes to contaminate the surgical wound.

Every surgical solutions should provides rapid bacteria kill and persistent antimicrobial activity.


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Selection of Skin Prep Agent

Desirable qualities Nonirritating chemical Broad spectrum activity Ability to act fast Persistent effect Difficult to wash away or inactivate by blood/saline

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Antimicrobial Agents Key Terms

Persistent Activity Single application Ability to lower bacterial

count Maintain low count over

specified period of time

Cumulative Activity Repeated use Lower overall resident

bacterial count Count continues to

decrease over time

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Selecting Antiseptic Products

• “When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent”.

AORN Recommended Practice

• “Use an appropriate antiseptic agent for skin preparation”.Category IB

Patient Preoperative Skin Preparation

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OR: Use of Surgical Barrier (Drapes)

Sterile Surgical Drapers protect the patient form infection by preventing microorganisms form making their way into the skin opening created during surgery.

If the drape gapes or moves, contamination can be introduced into the sterile field and an infection can arise because everything under the sterile surgical drape is a source of contamination.


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ISOLATIONISOLATION

6 PRINCIPLES OF DRAPING

STERILE FIELDSTERILE FIELD FLUID CONTROLFLUID CONTROL

Drapes used beforesurgery to wall off dirty areas or equipment.

These can be sterile or non-sterile drapes.

Any sterile drapeapplied to a surface in a sterile manner creates a sterile field.

Fluid collectionpouches collect bloodand body fluids.An absorbent drape that does not allow fluid strike -through also controls fluids byabsorbing spills andsplatters.

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BARRIERBARRIER STERILE SURFACESTERILE SURFACEEQUIPMENTEQUIPMENT

Sterile drapes usedduring the drapingprocess to create abarrier layer to blood and body fluids.

Incise drapes provide a sterile surface up to the wound edge.

Drapes that isolates and non-sterile equipment from the surgical siteand protects expensiveequipment.

6 PRINCIPLES OF DRAPING

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SURGICAL DRAPES AND GOWNS

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Surgical Drapes are designed to establish and maintain a sterile field. It is very important to select a surgical drape that provides reliable performance and

protection.

A drape that allows fluid transfer, and thus bacteria transfer, compromises the sterile field, which increases the risk of surgical site infection. That’s why creating a true barrier with a drape that’s

impervious to fluid strikethrough is so important.

NOT SUITABLENOT SUITABLE BEST PRACTICE BEST PRACTICE

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CSSD Characteristics

Proper Instrument management in CSSD which include the proper Sterilization Monitoring Process


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Questions?

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SURGICAL SITE INFECTION (SSI)

SSI usually occurs between _____________after Operation.

And

Occurs between a Year for Implant Surgery

Q&A

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Core:___°C

Periphery:2-4°C cooler


Maintain Normal Body temperature

Q&A

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When is the best time to do Hair Removal as to Reduce/Prevent SSI?

Q&A

A CB

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10 ssi bundle 'use cats to prevent ssi

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