Annie Laberge, R.N., M.Sc. (c) Marie-Claude Roy , M.D. Centre hospitalier affilié universitaire de Québec (CHA de Québec) ...
Agenda <ul><li>Introduction  </li></ul><ul><ul><li>Physiopathology and microbiology of implant-related  surgical site infe...
Physiopathology and Microbiology of  Implant-related SSIs <ul><li>Surgery or the placement of implants is conducive to the...
Impact of a SSI Following Implant Orthopedic Surgery <ul><li>Prolongs hospital stay by 14 days on average </li></ul><ul><l...
Why develop these guidelines? <ul><li>High post-surgical SSI rates at the CHA de Québec:  intervention to reduce these rat...
Literature Retrieval Method: BTEC <ul><li>This guide was created at the Bureau de transfert et d’échange des connaissances...
Method: Research Questions <ul><li>In order to prevent post-surgical infections in patients undergoing orthopedic surgery ...
Method: Inclusion Criteria <ul><li>Our inclusion criteria for obtaining evidence-based data:  </li></ul><ul><ul><li>Experi...
Results: Practice Guidelines  <ul><li>101 references were chosen based on our criteria </li></ul><ul><li>A 21-page practic...
Key Recommendations: Before surgery, by the nursing staff Recommendations Strength of Evidence Recognizing SSI risk factor...
Key Recommendations: Before surgery, by the medical team Recommendations Strength of Evidence Admit the patient the evenin...
Key Recommendations: Before and  during  surgery, by all staff in the room Recommendations Strength of Evidence Ensure the...
Key Recommendations: During surgery, by the medical team  Recommendations Strength of Evidence If diabetes is poorly contr...
Key Recommendations: After surgery, for the medical staff  Recommendations Strength of Evidence Maintain patient’s blood s...
Key Recommendations: After surgery, by the infection prevention team Recommendation Strength of Evidence Conduct SSI monit...
Conclusion <ul><li>These practice guidelines prove to be a reference for staff involved in the prevention of SSIs. </li></...
Post-surgical Orthopedic Implant Infections 2005 2006   2007   2008 Open reduction internal fixation (ORIF) infections cur...
Acknowledgments <ul><li>Infection Control Department (ICD) nurses from the Centre hospitalier affilié universitaire (CHA) ...
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Annie Laberge, R.N., M.Sc. (c)

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Annie Laberge, R.N., M.Sc. (c)

  1. 1. Annie Laberge, R.N., M.Sc. (c) Marie-Claude Roy , M.D. Centre hospitalier affilié universitaire de Québec (CHA de Québec) Françoise Côté, R.N., Ph.D. Johanne Gagnon, inf., Ph.D. Sc. Inf. Université Laval CHICA-AIPI, June 3, 2008 PRACTICE GUIDELINES SURGICAL SITE INFECTIONS (SSI) RELATED TO ORTHOPEDIC IMPLANTS: KNOWING HOW TO RECOGNIZE AND PREVENT THEM
  2. 2. Agenda <ul><li>Introduction </li></ul><ul><ul><li>Physiopathology and microbiology of implant-related surgical site infections (SSI) </li></ul></ul><ul><ul><li>Impact </li></ul></ul><ul><ul><li>Why develop these guidelines? </li></ul></ul><ul><li>Literature retrieval method </li></ul><ul><li>Results </li></ul><ul><ul><li>Practice guidelines </li></ul></ul><ul><ul><li>Key documented recommendations </li></ul></ul><ul><li>Conclusion </li></ul>
  3. 3. Physiopathology and Microbiology of Implant-related SSIs <ul><li>Surgery or the placement of implants is conducive to the development of infections: </li></ul><ul><ul><li>A limited amount of bacteria inoculum (10 2 microorganisms/g rather than 10 5 ) is needed for development of a SSI. </li></ul></ul><ul><ul><li>A larger spectrum of microorganisms can cause SSIs (minimally pathogenic bacteria such as Staphylococcus albus ). </li></ul></ul><ul><ul><li>The host’s immune response encourages the development and persistence of infections. </li></ul></ul>
  4. 4. Impact of a SSI Following Implant Orthopedic Surgery <ul><li>Prolongs hospital stay by 14 days on average </li></ul><ul><li>US$24 344/infection in related costs </li></ul><ul><li>Decreases patient’s quality of life: pain, reduced physical abilities… </li></ul><ul><li>Difficult to treat </li></ul><ul><li>Risk of death doubles with a SSIs following total hip replacement (THR) surgery </li></ul><ul><li>Results in another visit to the operating room </li></ul><ul><ul><ul><li>Whitehouse et al. Infect Control Hosp Epidemiol 2002;23:183-89, </li></ul></ul></ul><ul><ul><ul><li>Jodra et al. Infect Control Hosp Epidemiol 2006, 27(12), 1299-1303. </li></ul></ul></ul>
  5. 5. Why develop these guidelines? <ul><li>High post-surgical SSI rates at the CHA de Québec: intervention to reduce these rates </li></ul><ul><li>CHA de Québec’s practice guidelines date back to 1999. Have there been any advancements? </li></ul><ul><li>Evidence-based data references for staff and students </li></ul>
  6. 6. Literature Retrieval Method: BTEC <ul><li>This guide was created at the Bureau de transfert et d’échange des connaissances (BTEC)* of Université Laval’s Faculty of Nursing Sciences. </li></ul><ul><li>BTEC provides nurses with a way to integrate scientific evidence into their professional practice </li></ul><ul><li>As part of their graduate studies, the BTEC allows students to turn their ideas into literature review questions and conduct exhaustive literature reviews </li></ul><ul><li>*Literal translation = Knowledge Transfer and Exchange Bureau </li></ul>
  7. 7. Method: Research Questions <ul><li>In order to prevent post-surgical infections in patients undergoing orthopedic surgery or initial placement of an implant, it is important to know the following: </li></ul><ul><li>What are the risk factors of a surgical site infection in orthopedics? </li></ul><ul><li>What preventative practices have demonstrated to be effective in preventing this type of infection? </li></ul>
  8. 8. Method: Inclusion Criteria <ul><li>Our inclusion criteria for obtaining evidence-based data: </li></ul><ul><ul><li>Experimental or quasi-experimental studies, descriptive studies, systematic reviews, meta-analyses or evidence-based practice guidelines </li></ul></ul><ul><ul><li>Articles on risk factors, preventative interventions and impact of SSIs, particularly in orthopedic surgery, including implant surgery </li></ul></ul><ul><ul><li>Studies based on the NNIS method or the equivalent </li></ul></ul>
  9. 9. Results: Practice Guidelines <ul><li>101 references were chosen based on our criteria </li></ul><ul><li>A 21-page practice guideline was designed and validated, consisting of: </li></ul><ul><ul><li>Key documented recommendations </li></ul></ul><ul><ul><li>Theory about SSIs and implant-related SSIs: classifications and definitions, microbiology, physiopathology and risk factors </li></ul></ul><ul><ul><li>Tables suggesting ways to control risk factors as well as other interventions that may be effective in preventing SSIs. </li></ul></ul>
  10. 10. Key Recommendations: Before surgery, by the nursing staff Recommendations Strength of Evidence Recognizing SSI risk factors IV Teach patient about risk factors, the signs and symptoms of SSIs and pre-operative bath IV Review patient’s history of bleeding, clotting disorder or use of anticoagulants IV Encourage patient to decrease or stop smoking Ib Monitor patient’s blood sugar level and glycosylated hemoglobin IV Encourage patient to lose weight and have a follow-up with a nutritionist IV Wash entire body with chlorhexidine the day before and the morning of the surgery IV Remove hair with clipper as close to the incision time as possible Ia Administer antibiotic prophylaxis 30 to 60 minutes before the incision is made or the tourniquet is applied Ib
  11. 11. Key Recommendations: Before surgery, by the medical team Recommendations Strength of Evidence Admit the patient the evening before or the day of the surgery Ib Discontinue products containing ASA 7 to 10 days before the surgery Ib Adjust anticoagulant dose to attain an INR < 3 Ib Patient’s hemoglobin level must be > 14-15 g/dL Ib Prescribe adequate antibiotic prophylaxis Ia Treat any infection and cancel surgery in the event of unexplained fever or uncontrolled infection Ib Adjust antibiotic prophylaxis based on patient’s weight IV Cover the site with an idodophor film 24 hours before the incision is made IIb
  12. 12. Key Recommendations: Before and during surgery, by all staff in the room Recommendations Strength of Evidence Ensure the air in the operating room is “ultra” clean Ib The surgical team members must perform a surgical scrub of their hands and forearms Ib
  13. 13. Key Recommendations: During surgery, by the medical team Recommendations Strength of Evidence If diabetes is poorly controlled: prescribe insulin infusion with blood sugar monitoring Ib Ensure effective hemostasis and remove any hematomas that have formed before closing the wound Ib The length of the surgery should be ≤ NNIS T time IV In cases of heavy bleeding, red blood cell recovery and reinfusion may be performed Ib Paint the skin with an antiseptic agent before the incision is made IV Perform pulsed lavage of the surgical site with 2 L of NaCl 0.9% Ib Do not use cement with the prosthesis or at least use it with antibiotics Ib Maintain normothermia of the patient Ib
  14. 14. Key Recommendations: After surgery, for the medical staff Recommendations Strength of Evidence Maintain patient’s blood sugar level < 6.1 mmol/L before meals and at 10 mmol/L after meals Ib Keep administration of homologous blood transfusions to a minimum IIa Keep sterile bandage on the site for 24 to 48 hours after surgery IV
  15. 15. Key Recommendations: After surgery, by the infection prevention team Recommendation Strength of Evidence Conduct SSI monitoring and forward results to operating room staff in a timely manner IIb
  16. 16. Conclusion <ul><li>These practice guidelines prove to be a reference for staff involved in the prevention of SSIs. </li></ul><ul><li>Most of the recommended interventions in these guidelines have been applied in the operating room of Hôpital de l’Enfant-Jésus. </li></ul><ul><li>The interventions performed have lead to decreased SSI rates in total hip replacement (THR), total knee replacement (TKR) and total shoulder replacement (TSR) surgery. </li></ul>
  17. 17. Post-surgical Orthopedic Implant Infections 2005 2006 2007 2008 Open reduction internal fixation (ORIF) infections currently being validated for 2007-2008 English Legend : ORIF TSR THR TKR
  18. 18. Acknowledgments <ul><li>Infection Control Department (ICD) nurses from the Centre hospitalier affilié universitaire (CHA) de Québec particularly Valérie Dancause, who started ORIF infection monitoring in 2005 </li></ul><ul><li>The various experts who have taken part in reviewing the guidelines include: </li></ul><ul><ul><li>Dr. Luc Bédard, Orthopedist, CHA de Québec </li></ul></ul><ul><ul><li>Claire Bégin, ICD Coordinator, Hôtel-Dieu de Lévis </li></ul></ul><ul><ul><li>Valérie Dancause, ICP, CHA de Québec </li></ul></ul><ul><ul><li>Nathalie Goulet, Operating Room Monitor, Hôpital de l’Enfant-Jésus </li></ul></ul><ul><ul><li>Dr. Alain Paradis, Microbiologist/Infectious Disease Specialist, CHA de Québec </li></ul></ul><ul><ul><li>Michèle Ricard, Risk Management Adviser, CHA de Québec </li></ul></ul>
  19. 19. Questions

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