surgical site infection prevention: what’s new? · 2020-05-19 · surgical site infection...
TRANSCRIPT
Surgical Site Infection Prevention: what’s new?
Barbara DeBaun, RN, MSN, CICAlaska State Hospital and Nursing Home Association Webinar Series
March 20, 2018
Surgery and SSI’s: Current Situation
• 80 million surgeries in US/year• 1.5 million SSI’s• Most common HAI (30%)• 3% mortality rate• 75% of SSI-associated deaths are
directly attributable to the SSI• Cost $5,000-$13,000• 55% are preventable
2020: The Silver Tsunami
Prevention of Surgical Site Infection, 2017
• 1999 guidelines were primarily driven by expert opinion
• 2017 guidelines were driven by an evidence rating system
• Review of >5,000 studies published between 1998 and 2014.
HICPAC Strength of Evidence
Category IA A strong recommendation supported by high- to moderate-quality evidence suggesting net clinical benefits or harms.
Category IB A strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms, or an accepted practice, supported by low- to very low-quality evidence.
Category IC A strong recommendation required by state or federal regulation.
Category II A weak recommendation supported by any quality evidence suggesting a tradeoff between clinical benefits and harms.
No recommendation/unresolved issue An unresolved issue for which there is either low- to very low-quality evidence with uncertain tradeoffs between benefits and harms or no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention.
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SSI Resource – Supplemental Guidance
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Interventions for All Procedures
antimicrobial prophylaxis
(AMP)
glycemic control normothermia oxygenation antiseptic
prophylaxis
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Polling Question
In my facility, we:
a. Give every surgical patient the same dose of prophylactic antibioticsb. Adjust prophylactic antibiotics based on patient’s BMI or weightc. Not sure
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Polling Question
At my facility we:
a. Re-dose prophylactic antibiotics based on the drug half-life and duration of surgeryb. Do not re-dosec. Not sure
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Antimicrobial Prophylaxis
• Only when indicated• Selection• Time• No re-dosing after incision is
closed, even in presence of a drain (clean and clean-contaminated)
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Preoperative Antimicrobial Agents
HICPAC SSI Prevention Guidelines• No recommendation for weight
based dosing
• No recommendation for intra operative redosing
WDPH SSI Prevention Guidance• Follow the 2013 American
Society of Health-System Pharmacists (ASHP) guidelines
• Give based on BMI or weight in kilograms
• Base re-dosing on drug half-life and duration of surgery
Polling Question
In my facility, we:
a. Aim to maintain a hemoglobin A1C of <6.7 for all surgical patientsb. Only focus on patients with known diabetesc. Not on our radard. Not sure
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Glycemic Control
• Maintain perioperative blood glucose levels <200mg/dl in ALL surgical patients (not just diabetics)
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Glycemic Control
HICPAC SSI Prevention Guidelines• No recommendation regarding
the safety and effectiveness of lower or narrower BG target levels and SSI
• No recommendation for hemoglobin A1C target levels and risk of SSI
WDPH SSI Prevention Guidance• Avoid increased risk of
hypoglycemic events and increased mortality associated with tight glycemic control
• Maintain hemoglobin A1C level <6.7
Polling Question
In my facility, we:
a. Keep our surgical patients warm before, during, and after surgeryb. Are not focused on keeping patients warmc. Not sure
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Normothermia
• 35.5 C or more• Mild degrees of hypothermia
can increase SSI risk• Impacts circulation, coagulation,
medication metabolism and wound healing
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Normothermia
HICPAC SSI Prevention Guidelines• No recommendation regarding
safety or efficacy of normothermia strategies, ranges or duration
WDPH SSI Prevention Guidance• Consider use of forced-air
warming to reduce incidence of SSI’s
Polling Question
In my facility, we
a. Provide high oxygen supplementation to patients undergoing colon surgeryb. Do not provide high oxygen supplementation to surgical patientsc. Not sure
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Oxygenation
• Pre/intra/post• Optimizes tissue oxygenation
and reduces SSI risk• Low cost and simple
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Oxygenation
HICPAC SSI Prevention Guidelines• No recommendation for high
oxygen supplementation
WDPH SSI Prevention Guidance• Consider use of high oxygen
supplementation as an SSI risk reduction strategy during colorectal procedures
Skin Antisepsis (Pre and Peri-op)
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Polling Question
In my facility, we
a. Have reliable processes to provide pre-surgical skin antisepsis/bathing for our patientsb. No, we don’t have this in placec. Not sure
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Antiseptic Prophylaxis
HICPAC SSI Prevention Guidelines• Advise patients to shower or
bathe (full body) with either soap (antimicrobial or non-antimicrobial) or an antiseptic agent on at least the night before the operative day
WDPH SSI Prevention Guidance• Ensure that all patients
undergoing elective surgical procedures involving skin incisions undergo a standardized preadmission shower/cleansing with 4% aqueous or 2% (cloth coated) CHG
Patient Instructions
Antiseptic Prophylaxis
HICPAC SSI Prevention Guidelines• No recommendation for optimal
timing of the preoperative shower or bath, # of soap or antiseptic applications or CHG washcloths
WDPH SSI Prevention Guidance• Standardize the preadmission
shower• Specific recommendations for #
of baths
Third Time’s a Charm?
Antiseptic Prophylaxis
HICPAC SSI Prevention Guidelines• Consider use of triclosan-coated
sutures to prevent SSI’s
WDPH SSI Prevention Guidance• Use triclosan-coated
antimicrobial sutures to close surgical wounds
Additional Interventions
• Prosthetic joint• Staphylococcal screening and decolonization• blood transfusion• systemic immunosuppressive therapy, intra-articular corticosteroid injection,
anticoagulation, orthopedic space suits, and biofilms
• Colorectal• Mechanical bowel preparation with antibiotics
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Use of Surgical Care Bundles
What is on the other side of the red line?
Skin Prep
Hair removal
Nasal Decolonization
Glove Changes/New Instruments
Irrigation
Challenges
Surgical Attire: What We Wear Matters
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Head Covers
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Staff hair containment does matter
Traffic Control
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Red Cap
UV light as adjunct to manual cleaning
• Anderson DJ et al. “Decontamination of targeted pathogens from patient rooms using an automated ultraviolet-C-emitting device.” Infect Control Hosp Epidemiol. 2013 May;34(5):466-71.
• Doan L et al. “Clinical and cost effectiveness of eight disinfection methods for terminal disinfection of hospital isolation rooms contaminated with Clostridium difficile 027”. J Hosp Infect. 2012 Oct;82(2):114-21.
Antimicrobial post-op dressing
• Eberlein T et al. “Comparison of PHMB-containing dressing and silver dressings in patients with critically colonised or locally infected wounds”. J Wound Care. 2012 Jan;21(1):12, 14-6, 18-20.
• Martín-Trapero C, et al. “Surgical site infections. Effectiveness of polyhexamethylenebiguanide wound dressings.” Enferm Clin. 2013 Mar 22.
Antimicrobial dressingfor pins and drains
Blechman K, Reavey P. American Association of Plastic Surgeons Conference April 2012. ABSTRACT: “Use of the Biopatch Drain Dressing to Reduce Infection Rates in Expander/Implant-Based Breast Reconstruction.”
SSI Patient Brochure
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SSI Change Package & Top 10 Checklist
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For more SSI resources, visit http://www.hret-hiin.org/topics/surgical-site-infection.shtml
SSI Change Package SSI Top 10 Checklist
Any Questions/Comments in the Chat Box?
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Next Steps