Cuts Like a New Knife - Current Practice and Emerging Evidence in Preventing Surgical Site Infections

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Cuts Like a New Knife - Current Practice and Emerging Evidence in Preventing Surgical Site Infections

  1. 1. www.saferhealthcarenow.ca Cuts Like a New Knife - Current Practice and Emerging Evidence in Preventing Surgical Site Infections
  2. 2. www.saferhealthcarenow.ca Did you Join the Call Correctly? You Joined Correctly! There IS a phone icon beside your name. You Joined Incorrectly! There is NO phone icon beside your name. If you joined incorrectly and there is NO phone icon beside your name, click the audio button on the right- hand side of the screen, below the participant list Please join the audio conference using a phone for better audio quality. 1. For direct lines, choose “Call me at a new number” 2. For lines with extension , choose “I will call in” and dial the audio conference toll-free number found on the Session Info tab, and when prompted, enter the access code and attendee ID
  3. 3. www.saferhealthcarenow.ca WebEx Please use the chat to ask questions during the presentation, or raise hand when we pause for questions.
  4. 4. www.saferhealthcarenow.ca
  5. 5. www.saferhealthcarenow.ca Host and Presenters Marlies van Dijk Dr. Claude Laflamme Paule BernierAnne MacLaurinNadine Glenn Dr. Giuseppe Papia
  6. 6. Greetings from CPSI 6 Kim Stelmacovich, Senior Director
  7. 7. Patient Safety Forward with Four • The Canadian Patient Safety Institute has a new 2013-2018 Business Plan • Four goals to move us forward • Four Clinical Priority Areas • http://www.patientsafetyinstitute.ca/English/About/PatientSafety ForwardWith4/Pages/default.aspx?utm_source=CPSI&utm_medium =HomeSideAd&utm_campaign=ForwardWithFour
  8. 8. Forward with Four Four goals  Provide leadership on the establishment of a National Integrated Patient Safety Strategy  Inspire and sustain patient safety knowledge within the system, and through innovation, enable transformational change  Build and influence patient safety capability at organizational and system levels  Engage all audiences across the health system in the national patient safety agenda Four Clinical Priority Areas 1. Medication safety 2. Surgical care safety 3. Infection Prevention & Control 4. Home care safety
  9. 9. SSI Prevention Emerging Evidence Claude Laflamme MD, FRCPC, MHSc Medical Director, Cardiac Anesthesia Sunnybrook Health Sciences Centre Assistant Professor University of Toronto
  10. 10. Disclosure • Charles E. Edmiston Jr., PhD., CIC, Milwaukee • Frank Mazza, Vice President/Chief Patient Safety Officer Associate Chief Medical Officer Seton Family of Hospitals, Austin • Paula Mendes, RN, CPN(c) Perioperative Professional Services Specialist, 3M, London
  11. 11. © 3M 2013. All Rights Reserved
  12. 12. AIPI 2013
  13. 13. Updated Recommendations for SSI Prevention • Annals of Surgery June 2011 • Recommendations from CDC 1999 • Review of current literature has been done to update the recommendations • Adherence to the proposed guidelines could reduce wound infections significantly. – Target of less than 0.5% in clean wounds – Target of less than 1% in clean-contaminated wounds – Target of less than 2% in highly contaminated wounds – Decrease costs to less than one-half of the current amount Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  14. 14. Multiple factors play a Role in SSI (CDC) • Reduction in contamination (asepsis) OR environment • Preoperative bathing with antiseptic agents • Hair Removal • Skin decontamination • Incise drapes • Reduction in consequences of contamination (antisepsis) sutures – Suture composition • Tissue damage and foreign bodies – Use of electrocautery • Drains – Drains that exit through a working incision increases SSI Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  15. 15. Multiple factors play a Role in SSI • Prophylactic topical antimicrobials – Topical antibiotics are effective – Using other antimicrobials (PI/CHG) to decontaminate wounds are not effective and has been shown to inhibit wound healing and increase SSI. • Systemic prophylactic antibiotics – Preoperative antibiotics is among the most important of the currently available methods to prevent SSI. – 30 min before incision except for vancomycin (1-2 hours before incision) – Redosing is important (short acting, body size, and renal function) • Improvement of host defense influence of body temperature Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  16. 16. Multiple factors play a Role in SSI • Effect of oxygen therapy – O2 should start with induction, but optimal concentrations and duration of therapy have not been established. Current data suggests it should be given at least 2 hrs after closure. • Glucose control – Hyperglycemia is a risk factor for SSI independent of diabetes. – Close monitoring is essential. • Transfusions and fluid management – Blood transfusions increase the risk of infection in surgical patients. • Smoking – Increases surgical wound infection • Delayed primary closure – Benefit of delayed primary closure in highly contaminated wounds Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  17. 17. Reduction in Contamination (Asepsis) OR Environment • CDC guidelines and regulations from various accrediting agencies are good resources for providing details related to effective techniques – Air handling (HEPA filters, Laminar Air flow) – Cleaning of environmental surfaces – Sterilization techniques – Activities of surgical team members (limit traffic and idle conversations) – Surgical attire (perforations of surgical gloves are major source of contamination, and gown strike-through – sleeves/abd area also a potential source) – Drapes – Asepsis • The above should be regarded as recommendations set in stone. Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  18. 18. Preoperative Bathing with Antiseptic Agents • Infections in clean surgery are most often caused by skin organisms • Preoperative bathing with chlorhexidine – Reduces pathogenic organisms on the skin but has a non-significant reduction in wound infections • Chlorhexidine – Shown to reduce the number of organisms at the incision site better than using povidone iodine or soap and water – Showering the night before and the morning of surgery is more effective in colony reduction than a single shower • Cleansing with a chlorhexidine impregnate cloth just before operation will provide additional removal of dirt and further reduction in skin bacteria Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  19. 19. Presurgical Skin Preparations as a Pathway to Improving Surgical Outcomes • Reducing the risk of SSI in orthopaedic surgery • Standardized precleansing initiative (CHG cloths) in total joint patients (night before/morning of surgery) • SSI rate prior to intervention – 3.2% (N=727) • SSI rate post intervention – 1.6% (N=824) 50% reduction Eiselt – Orthopaedic Nursing 2009;28:141-145 • Bundling risk reduction strategies – Quality initiative • MRSA prescreening in orthopaedic, obstetric, bariatric patients – decolonization • Presurgical antisepsis (CHG cloths) prior to surgery • Preintervention SSI rate 1.6% (N=17/1,095) vs postintervention SSI rate 0.57% (N=7/1,225 ) >60% reduction • MRSA SSI rate 0.73% vs 0.16% >75% reduction Lipke VL, Hyott AS. AORNJ 2010’;62:288-296
  20. 20. Best Practice # 1: All patients undergoing an elective surgical procedure will take at least 2 CHG antiseptic shower/cleansings using a standardized regimen
  21. 21. Hair Removal • NOT removing hair is associated with least infection • When it is deemed by the surgeon that hair should be removed, shaving should never be used • Clipping the hair with care to avoid skin damage is to be the most satisfactory method • Most studies support hair removal done immediately before operation – Associated with lower infection rate Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  22. 22. Skin Decontamination • Alcohol – Used as a skin disinfectant for more than 150 years – Remains the most effective short-term antimicrobial but it is highly flammable – Provides no persistent antimicrobial activity • Chlorhexidine is more effective in reduction of skin bacterial vs. povidone iodine – Chlorhexidine and alcohol provide even better reduction of bacteria • Hand scrubs – Using a chlorhexidine/alcohol based product will provide the greatest reduction in skin bacteria • The best reduction in microbes at the operative site seems to be with an iodine povacrylex/alcohol or chlorhexidine/alcohol based products Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  23. 23. Antiseptic Skin Preparation SHN RECOMMENDATIONS • To maximize its efficacy, CHG alcohol skin prep should not be washed off following surgery. • In order to prevent a fire hazard, it is imperative that CHG- alcohol skin prep be allowed to air dry for at least 3 minutes, or longer if there is excessive hair insitu. • Povidone-iodine should be used as a skin preparation in emergent cases when there is not enough time to allow CHG- alcohol solution to completely dry before incision. • Chlorhexidine-alcohol solutions must not be used for procedures involving the ear, eye, mouth or neural tissue. Safer Healthcare Now, Getting Started Kit: Prevent Surgical Site Infections, How to Guide, May 2007/2010
  24. 24. Incise Drapes • Use of an adhesive antimicrobial incise drape may or may not decrease the incidence of wound infection; – Depending upon the composition of the drape – Preparation of the skin and adherence to the wound edges. • Technique is important • With proper application of the incise drape to prevent lifting from the skin edge, contamination of the wound with skin organisms is not possible. Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  25. 25. Antibiotic doses and redosing Am J Health-Syst Phar- Vol 70 Feb 1, 2013 p.195-283
  26. 26. Effect of Maternal Obesity on Tissue Concentration Of Prophylactic Cefazolin During Cesarean Delivery Pevzner L, Edmiston CE, et al. Obstet & Gynecol 2011;117:877-882
  27. 27. Best Practice # 2: All surgical patients will receive a minimum dose of 2 gr unless their BMI is >30 – Then the correct dose is 3 gr
  28. 28. Improvement of Host Defense Maintaining Normothermia • Mild hypothermia 34-36 degrees celcius has a large number of adverse effects – Increased blood loss and transfusion requirements – Prolonged ICU and hospital LOS – Increase in morbid myocardial events – Increase in wound infection • Hypothermia increases the development of wound infection due to the adverse effects on the physiological and immunologic functions necessary to kill contaminating bacteria Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 1999;67(2):155-164.
  29. 29. Hypothermia and SSI
  30. 30. *Adapted from: Sessler, Anesthesiology 2000 1hr 0 -1 -2 -3 0 2 4 6 ΔCoreTemp(°C) Elapsed Time (h) -1.6°C Anesthesia-Induced Hypothermia Characteristic Patterns of General Anesthesia-Induced Hypothermia
  31. 31.  Impaired thermoregulation under anesthesia  Heat redistribution  Heat loss:  Convection  Conduction  Evaporation  Radiation Culprits of Perioperative Hypothermia
  32. 32. American College of Surgeons Vol. 209 No 4 October 2009
  33. 33. Perioperative Normothermia Normothermia (core temperature 36⁰C–38⁰C) should be maintained preoperatively, intraoperatively, and in PACU by implementing any combination of the following: • Warmed forced-air blankets when surgery is expected to last >30 minutes • Warmed Intravenous fluids for abdominal surgeries of >1 hour duration • Fluid warming is an important adjunct therapy. • Warmed lavage liquids for colorectal surgery • Increase the ambient temperature in the operating room to 20⁰C-24⁰C • Hats and booties on patients during surgery • Pre-warming should be initiated between 30 minutes to 2 hours prior to major surgery. Safer Healthcare Now, Getting Started Kit: Prevent Surgical Site Infections, How to Guide, May 2007/2010
  34. 34. Best Practice # 3: Core temperature less then 36 degree celsius at the end of surgery is a failure
  35. 35. Cutting Edge Evidence
  36. 36. Making an Evidence-Based Argument for Antimicrobial (Triclosan) Coated Sutures 1. Ford et al. Pediatric surgery- Surg Infect 2005;3:313 2. Rozzelle et al. Cerebro-spinal shunt surgery – J Neurosurg Pediatr 2008;2:111-1117. 3. Mingmalairak et al. Appendectomy – J Med Assoc Thai 2009;92:770-775. 4. Zhuang et al. Abdominal surgery – J Clin Rehab Tiss Eng Res 2009;13:4045-4048. 5. Zhang et al. Radical mastectomy – Chin Med J 2011;124:719-724. 6. Galal et al. General, GI surgery - Am J Surg 2011;202:133-138. 7. Rasic et al. Colorectal surgery – Colleg. Antropologicum 2011;35:439-443. 8. Williams et al. Breast CA surgery – Surg Infect 2011;12:469-474. 9. Barac et al. Colorectal surgery – Surg Infect 2011;12:483-489. 10.Isik et al. Cardiac surgery – Heart Surg Forum 2012;15:E40-E45. 11.Turtainen et al. Lower limb revascularization surgery – World J Surgery 2012; May 23 [Epub ahead of print]. 12.Seim BE et al. Cardiac surgery – Interact Cardiovasc Thorac Surg 2012: June 12 [Epub ahead of print]. 13.Nakamura T, et al. Colorectal surgery – Surgery 2013 [Epub ahead of print]. 14.Laas E, et al. Breast surgery – Int J Breast Cancer 2012 [Epub ahead of print].
  37. 37. Edmiston, Daoud, Leaper, Submitted: 2012 Surgery
  38. 38. Checklist /Recommendation 1. The guidelines provided by the CDC and accrediting agents such as JACO have been followed. These include effective techniques for asepsis, air handling, cleaning of environmental surfaces, sterilization techniques, activities of surgical team members and surgical attire. 2. All members of the operative team have double gloved and changed gloves when any perforation is identified. Gowns and drapes have been used which prevent liquid penetration. 3. Preoperative showering with chlorhexidine within a few hours of the operation and the night before has been done and preoperative cleansing of the operative site with a chlorhexidine-impregnated cloth just before entering the operating room. Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  39. 39. Checklist /Recommendation 4. When hair removal is done, clippers have been used shortly before operation. 5. Reduction of skin organisms of both the surgical team and patient have been done using a combination of alcohol and chlorhexidine although other effective products including alcohol with iodophors are acceptable. 6. An antimicrobial incise drape has been used at operative sites where it is technically feasible to get good adherence to the skin. 7. Suture material has been selected which resists infection. 8. Dead spaces have been obliterated, where possible. Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  40. 40. Checklist /Recommendation 9. Minimal trauma to the wound itself by gentle handling of tissues and limited use of electrocautery has been accomplished. 10. Conduit drains and drainage through a working incision have not been used. 11. Prophylactic topical antibiotic solution have been used vigorously by pressure irrigation several times during an operation and before closure in all but the simplest cases to remove clots and devitalized tissues and to ensure high- tissue levels of antibiotic. Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  41. 41. Checklist /Recommendation 12. Prophylactic systemic antibiotics have been used according to guidelines in all surgical cases where the incidence of infections exceeds approximately 0.5% or when any foreign body is implanted. 13. Core temperature has been maintained at 36°C or higher throughout the perioperative period. 14. Inspired oxygen has been given at a sufficient concentration to maintain subcutaneous oxygen concentrations of approximately 100 mm Hg and pulse oxygen readings above 96. 15. All diabetic and hyperglycemic patients have received tight glucose control during the perioperative period and for 2 to 3 days afterward in high-risk patients. Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins
  42. 42. Where? Newfoundland - 2 Quebec - 1 Ontario - 3 British Columbia – 24 Coming!? Alberta Saskatchewan Atlantic Canada
  43. 43. What’s Next! • Lots of opportunity in the system • Obligation • Reducing SSIs is doable • New Evidence Emerging • Successful strategies focus on front line/clinician ownership
  44. 44. www.saferhealthcarenow.ca Surgical Safety Checklist
  45. 45. www.saferhealthcarenow.ca Merci - Questions?
  46. 46. www.saferhealthcarenow.ca Poll Poll

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