Orthopedic Residents and Fellow Orientation

Maureen Spencer, RN, MEd, CICInfection Control ManagerNew England Baptist HospitalBoston, Mass. 02120mpspence@nebh.org

New England Baptist HospitalOrthopedic Center of Excellence

Acute inpatient discharges are divided among 3 service lines:

Orthopedic =75%Medical =17%

(Cardiology, Pulmonary, Gastroenterology, Nephrology)General Surgery = 8%

>10000 cases/yr: 7000 inpatient surgeries~4500 joints ~2500 spines/sports

NEBH Goal: Zero Healthcare-Acquired Infections

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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

Establishing an Intention for Zero Infection Rate

• A multidisciplinary team was formed to address an increase in the infection rate in FY03 and implement control measures.

• Administration established intent for zero tolerance for adverse patient outcomes, including surgical site infections. 

The Patient as a SourceRisk factors leading to colonization and infection

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Prosthetic Joint InfectionRisk Factors

Revision surgery Malignancy Steroid Use Rheumatoid Arthritis Chronic Renal Insufficiency Malnutrition Blood Transfusion

Berbari E. et al: Clinical Infectious Diseases 1998;27:1247–54

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Patient Risk Factors High rate of overweight or

obese patients among those who developed infections

Glycemic control in diabetics and pre-diabetics can impact surgical outcomes and the potential for infection

Poor patient hygiene and nutrition can impact surgical outcomes

Obesity and Surgical Incision Incision collects fluid – serum,

blood - growth medium for organisms

Spine incisions - close to the buttocks

Perspiration - diaphoresis Body fluid contamination from

bedpans/commodes Friction and sliding - skin tears

and blisters Itchy skin - due to pain

medications - skin breakdown

Skin Issues in Orthopedic Surgery

Postop Dressings

Leaving Incisions Open To Air

We discourage this practice – bacteria feed off of blood (and sugar), incisions are in first few days of wound healing – “exudative stage” and need protection

Postop Dressings - ABD with Paper TapePreviously done by residents and PAs

ABD tends to fall off easily

Paper tape can cause skin tears – obese patient sweat and tape absorbs in pores and then pulls off skin upon removal

Antimicrobial Dressing (AMD) and Sterile ABD dressing with MeFix Tape

MicroFoam Dressing with AMDs

Some surgeons apply Microfoam over steristrips, adaptic, gauze, ABD until day 2 postop

Tends to wrinkle and lose adhesion

Total Knees and Hips with Dermabond

Apply one layer of Dermabond Allow to dry - ~ 2-5 minutes

Can apply telfa – but not necessaryApply transparent dressing over telfa

Dermabond and AMD DressingLeft- Incision covered with with AMD gauze (hip)

Below - AMD telfa (knees) and a tegaderm Healed incision

Knee Dressings with Ace

ABD over knee incision

Ace bandage one day postop with blood strikethrough after drain removed – “reinforce”

AMD gauze are in postop dressing kits so they are offering protection to the incision in first two days

Spine Service and Shoulders

Aquacel, AMD, Tegaderm left on until discharge

AMD Island dressing – left on until discharge

Incision sealed with Dermabond and covered with AMD gauze and tegaderm until discharge

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The Beginning: February 2006 Nares Colonization the Source

133 patients were screened for MRSAand Staph aureus in the operating room before surgery to determinerate of MRSA and Staph aureus colonization

Results:38 – Staph aureus (29%)

*5 - MRSA ( 4%)n *all MRSA undiagnosedn *no precautions used in OR or postop

nursing unitn *all received Cefazolin for surgical

prophylaxis (not Vancomycin)!

Topical DecolonizationTopical Decolonization ProtocolProtocol

Intranasal 2% mupirocin ointment (Bactroban) BID x 5 days

Shower with 2% chlorhexidine (Hibiclens) daily x 5 days

Call from PASU to initiate treatment protocol Repeat call to document compliance MRSA carriers re-screened prior to surgery Contact precautions if 2nd MRSA screen positive Vancomycin preop antibiotic prophylaxis for all patients with 1st positive MRSA or MRSA

history of infection in past

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What were the outcomes?

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MRSA/MSSA Eradication Results

From July 17, 2006 through April 2010

23,439 patients screened 5412 (23%) positive for Staph aureus 969 ( 4%) positive for MRSA

Repeat nasal screens on MRSA patients revealed 78% eradication

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Time Period Inpatient surgeries # Surgical Infections Percent

FY06 10/01/05-07/16/06 5293* 24 0.45%

FY0707/17/06-09/30/07 7019 13 0.18%

FY08 10/01/07-09/30/08 6323 7 0.11%

FY09 10/01/08-09/30/09 6364 11 0.17%

*historical controls

% MRSA and Staph aureus SSI

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Time Period Inpatient surgeries # MRSA SSI MRSA % #Screen + (%SSI) FY06

10/01/05-07/16/06 5293* 10 (NA) 0.19% NA

FY0707/17/06-09/30/07 7019 3 (3+) 0.04% 3/ 309 (0.97%)

FY08 10/01/07-09/30/08 6245 4 (2+) 0.06% 2/ 242 (0.83%)

FY09 10/01/08-08/31/09 6364 6* (2+) 0.09% 2/ 234 (0.85%)

*isolates have been sent for pulse field gel electrophoresis 5 of the 6 isolates were available for PFGE and were not related genetically

% MRSA SSI in MRSA + Screened Patients

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Time Period Inpatient surgeries # MSSA SSI MSSA % #Screen + (%SSI) Historical controls

FY06 10/01/05-07/16/06 5293* 14 (NA) 0.26% NA

Screened PatientsFY0707/17/06-09/30/07 7019 3 (3+) 0.04% 3/1588 (0.19%)

FY08 10/01/07-09/30/08 6245 3 (1+) 0.05% 1/ 1422 (0.07%)

FY09 10/01/08-08/31/09 6364 5 (3+) 0.08% 3/1403 (0.21%)

% Staph aureus (MSSA) SSI in MSSA Screen + Patients

Staff Items as Sources for Cross Contamination

Lab Coats, Stethoscopes, Otoscopes, Gloves, Gowns, Pagers, Cell Phones – contamination with Staph aureus, MRSA and VRE

Infect Control Hosp Epidemiol. 2001 Sep;22(9):560-4. Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci. Zachary KC, Bayne PS, Morrison VJ, Ford DS, Silver LC, Hooper DC. Infectious Disease Division Massachusetts General Hospital, Boston RESULTS: VRE were isolated from at least 1 examiner site (gloves, gowns, or stethoscope) in 33 (67%) of 49 cases. Gloves were contaminated in 63%, gowns in 37%, and stethoscopes in 31%.

  J Hosp Infect. 2001 Aug;48 Suppl A:S64-8.

Stethoscopes and otoscopes--a potential vector of infection? Cohen HA, Amir J, Matalon A, Mayan R, Beni S, Barzilai A. RESULTS: All the stethoscopes and 90% of the otoscope handles were colonized by microorganisms. Staphylococci were isolated from 85.4% of the stethoscopes and 83.3% of the otoscopes, with 54.5% and 45.2% respectively being S. Aureus. Methicillin-resistant S. aureus were found in four each of the stethoscopes (7.3%) and otoscopes (9.5%)

Docs' Cell Phones May Spread Hospital Infections - screened 124 hospital personnel for the germ Acinetobacter baumannii - 12 percent of healthcare providers' cell phones were contaminated with the bug not only on phones but also on 24 percent of the hands of the people tested, who included 71 physicians and 53 nurses.

Infect Control Hosp Epidemiol. 2002 May;23(5):274-6. Bacterial contamination of hospital pagers. Singh D, Kaur H, Gardner WG, Treen LB. Microorganisms were isolated from all pagers; 21% yielded Staphylococcus aureus, of which 14% were methicillin resistant. Cleaning with alcohol reduced the total colony count by an average of 94%.

Lab Coat Contamination

NEBH Lab coat study – cultured 6 coats in OR and two were growing Staph aureus (33%) – visibly soiled and pockets stuffed with books, food, scissors, etc.

Bacterial contamination of health care workers' white coats American Journal of Infection Control 37:(2) 101-105 (March 2009) 148 cultured: 23% Staph aureus,

18% MRSA

Prevention Measures

Precaution Material*Precaution Gowns*Gloves*Masks*Private Room*Precaution Cart *Signage – new Red signs*Dedicated Equipment (stethoscope, sphgmanometer,

commodes)*Cal Stat Alcohol Hand Rub*Red Bags for Infectious Waste

Disposal

MRSA

VRE

Abscesses

Cellulitis

Draining wound infections

Significant continence with feces

Clostridium difficile Infection

Must wash hands to remove spores and clean equipment with bleach wipes

Contaminated Hands Most Common Source

Most Important Control Measure

HAND HYGIENE

Wash hands several times a shift – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes

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. Clinical Infectious Diseases, February

2008.

Wear Gloves, Wash Hands Often, Use Alcohol Based Hand Rub/Foam

Hand Cultures – before and after the use of Cal Stat

Action Plans for Patients

Antibacterial Sutures

• Due to the number of SSI due to Staph aureus and MRSA we instituted the use of Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture

Coated VICRYL*Plus Antibacterial Suture Staph aureus Culture Plate Study

A pure culture (0.5 MacFarland Broth) of Staph aureus was prepared

A coated VICRYL*Plus 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 zone of inhibition at day 10 in plate on left. Plate on right is noncoated vicryl suture.

DERMABOND Incisional AdhesivePhysician, 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 CostsNurse, Patient -centered Benefits Reduces number of suture set ups Ease of Post Op wound checks Reduces number of wound dressings Shower immediately Excellent Cosmesis

CHG Use For Surgery

Chlorhexidine showers

2% CHG/70% alcohol skin preparation (tinted orange)

Antimicrobial dressing material for primary and secondary dressings (“AMD”)

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NEBH SSI Rates 2003 - 2010

Team Analysis of Surveillance Data:

2007 Laminectomy increase rate: case/control study confirmed it was due to the use of locally administered steroids (depomedrol)2008 Total knee infection rate increase: evaluation revealed the use of instilled pain medications in joints – preparation technique questionable2009 Total hip infection rate increase: ?due to increase in post-op hematomas – case/control study underway to evaluate risk factors

GENERAL SSI FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10(Oct-Apr)# Infections 6 1 3 4 2 2 1 0# Procedures 1073 920 780 692 567 467 137Infection Rate 0.6 0.1 0.4 0.5 0.3 0.3 0.2 0

ORTHOPEDIC SSI# Infections 63 60 49 46 39 37 28 15# Procedures 8837 9669 9216 8986 9027 8884 8890 5783Overall Infection Rate 0.7 0.6 0.5 0.5 0.4 0.4 0.3 0.26#Hip Infections 14 5 4 7 5 5 10 5 Hip Prosthesis Rate 1.0 0.3 0.2 0.4 0.3 0.3 0.5 0.39 Hip 0 Index 0.0 0.0 0.0 0.4 0.14#Knee Infections 21 14 11 7 7 11 9 4 Knee Prosthesis Rate 1.6 1.0 0.7 0.4 0.3 0.5 0.4 0.27 Knee 0 Index 0.2 0.2 0.4 0.4 0.28#Laminectomy Infec. 6 9 7 7 12 4 0 2 Laminectomy Rate 0.7 0.9 0.6 0.8 1.3 0.5 0.0 0.61#Spinal Fusions Infec. 5 15 12 12 5 5 3 1 Spinal Fusion Rate 0.8 2.0 1.4 1.1 0.4 0.4 0.3 0.2

In Summary….. Healthcare-associated infections

are a major problem in hospitals Infection control measures, such

as precaution techniques and hand hygiene have been shown to prevent the spread of nosocomial infections

Follow department-specific infection control policies and procedures

Report any problems immediately to the infection control