Immediate Pre-operative Decolonization Therapy  Reduces Surgical Site       Infections:     A multidisciplinary quality   ...
The TeamSurgery:                                Bas Masri                  Gary RedekopPerioperative Services:            ...
SSIs, Patient Flora and        Decolonization Strategies• Most SSIs arise from the patient’s own flora  including skin and...
VGH SSI reduction decolonization             QI projectWanted:• Consistent pre-operative decolonization  program in high r...
Our Novel Approach• Nasal Photodisinfection using MRSAid• Chlorhexidine impregnated washcloths
How Photodisinfection worksTreatment Site       Irrigation      Illumination      EradicationTissue Colonized       Apply ...
MRSAid™ Treatment Protocol       1st Illumination Cycle              2nd Illumination Cycle1. Connect nasal illuminator ti...
Chlorhexidine Washcloths      • Alcohol-free washcloth impregnated        with CHG      • FDA and Health Canada approved  ...
Advantages of this Approach•   Horizontal infection control strategy•   Eradicate antibiotic resistant bacterial strains• ...
VGH SSI reduction decolonization                  QI projectObjectives:1. To determine if immediate preoperative decoloniz...
Limitations• not a RCT• cannot sort out incremental  benefit of CHG and PDT therapy
Decolonization ProtocolSurgeries included:                        Surgeries excluded:•cardiac, thoracic, ortho-           ...
Microbiological Efficacy, Safety,              and Compliance• Microbiological Efficacy        Growth               MSSA r...
Microbiological Efficacy, Safety and             Compliance• Compliance:           125, (2%)                       303, (5...
SSI Data - Extraction                               Cases during                            study period and              ...
Determining the 4-yr Historical SSI RateFiscal Year CARDIAC NEURO ORTHO SPINAL THORACIC VASCULAR   TOTALS2007/08     866  ...
Comparing SSI rates: Treated and Historical*                                Treated                          4 year Histor...
Impact: SSI Case Reduction               Parameter                              SSI     SSIs/total treated patients (rate)...
Comparison of treated and not treated patients  Parameter         Treated (n=3068)     Not Treated       p value          ...
Treated vs Not Treated Patients        Sept 1, 2011 – Aug 31 2012   SSI Status              Txd             Not Txd       ...
SSIs with S.aureus   Specialty          Treated       Not Treated        p        ORCardiovascular          4/18          ...
Not Treated Patients: Reasons             Reason for Not Treated                             Number (%)                   ...
Project to Program Transition• Goals of the Transition Team  1.   transfer oversight to perioperative services  2.   strea...
Project to program transition        Time        Time               MON                           MON                     ...
Education and Knowledge             Dissemination• Within VCH  – rounds / in-services: surgical subspecialties, peri-    o...
Conclusions• Nasal photodisinfection therapy is  microbiologically effective• Decolonization therapy reduces surgical site...
Thank you!                                     The Patients                                       Surgery                 ...
Discussion / Questions?       Our vision       We will be leaders in promoting wellness and       ensuring care by focusin...
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F4 Elizabeth Bryce - Immediate Pre-operative Decolonization Therapy Reduces Surgical Site Infections

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  • Audience for participation and attentionUBC-VGH hospital foundation for funding the projectOndine Biomedical Carolyn Cross, ShelaghWeatherill for developing the technology, ongoing support and professional working relationship VGH Senior Leaders and Operations- for supporting the project and approving the adoption of the programPerioperative Services - for supporting the project and being the real 'battleground' for the programMedical Microbiology - project microbiology technologistsSurgeons - for supporting the project, and freely sharing their dataProject Personnel: Our project LPNS (T. Thandi, L. Haas, L. Allocca, P. Goundar, D. Breedveld) and data entry clerksInfection Control - Leslie Forrester for her tireless work with Chandi in helping with the data extraction and analysis.
  • F4 Elizabeth Bryce - Immediate Pre-operative Decolonization Therapy Reduces Surgical Site Infections

    1. 1. Immediate Pre-operative Decolonization Therapy Reduces Surgical Site Infections: A multidisciplinary quality improvement projectDr. Elizabeth BryceDr. Titus Wongon behalf ofthe VGH decolonization teamSurgery and Orthopaedics Combined Grand Rounds12 December, 2012 1
    2. 2. The TeamSurgery: Bas Masri Gary RedekopPerioperative Services: Debbie Jeske Claire Johnston Kelly Barr Shelly Errico Anna-Marie MacDonald Tammy Thandi, Lorraine Haas Pauline Goundar Lucia Allocca Dawn Breedveld Steve KabanukInfection Control: Elizabeth Bryce Chandi Panditha Leslie Forrester Diane Louke Tracey WoznowMedical Microbiology: Diane Roscoe Titus WongPatient Safety: Linda DempsterOndine Biomedical: Shelagh Weatherill et al Special Thanks: microbiology technologists, and perioperative staff
    3. 3. SSIs, Patient Flora and Decolonization Strategies• Most SSIs arise from the patient’s own flora including skin and head/neck distant from wound• Decreasing the bacterial load prior to surgery can decrease risk of SSIs• Traditional decolonization strategies consist of chlorhexidine (CHG) +/- intranasal mupirocin
    4. 4. VGH SSI reduction decolonization QI projectWanted:• Consistent pre-operative decolonization program in high risk surgeries• High degree of compliance with program• Minimal risk of antibiotic resistance• Must be effective
    5. 5. Our Novel Approach• Nasal Photodisinfection using MRSAid• Chlorhexidine impregnated washcloths
    6. 6. How Photodisinfection worksTreatment Site Irrigation Illumination EradicationTissue Colonized Apply Illuminate the “Activated”with Pathogenic Photosensitizer Treatment Site Photosensitizer Bacteria that binds to Using Non- creates reactive bacterial Thermal Light oxygen species, surfaces Energy killing bacteria
    7. 7. MRSAid™ Treatment Protocol 1st Illumination Cycle 2nd Illumination Cycle1. Connect nasal illuminator tips to laser cable port via fiber-optic connector2. Illuminate for 2 minutes with tips placed as shown above (directed into inner tip of nose for 1st cycle and posterior for 2nd cycle)
    8. 8. Chlorhexidine Washcloths • Alcohol-free washcloth impregnated with CHG • FDA and Health Canada approved • Used below the neck day of or night prior to surgery • Left on the skin (not rinsed off) • Equivalent to 4% CHG on skin http://www.sageproducts.com/lit/20778C.pdf
    9. 9. Advantages of this Approach• Horizontal infection control strategy• Eradicate antibiotic resistant bacterial strains• No generation of bacterial resistance• No/minimal effect on human tissues• Rapid action – maximally effective in minutes• Increased compliance 9
    10. 10. VGH SSI reduction decolonization QI projectObjectives:1. To determine if immediate preoperative decolonization using nasal photodisinfection therapy + CHG wipes reduces SSI rates in elective non-general surgeries.2. To assess the feasibility of integration of a decolonization program in the pre-operative areaTarget Population: all elective surgical procedures that were normally followed for SSI as part of the Infection Prevention and Control surveillance program 10
    11. 11. Limitations• not a RCT• cannot sort out incremental benefit of CHG and PDT therapy
    12. 12. Decolonization ProtocolSurgeries included: Surgeries excluded:•cardiac, thoracic, ortho- •open fractures, dirty/contaminatedrecon, ortho- cases, duplicate cases, cases in 6trauma, vascular, neuro/spine, and week introductory periodbreast cases. Photodisinfection CHG within 24h Nasal Culture Therapy (MRSAid) Perform Document SSI Surveillance Surgery Compliance, AE
    13. 13. Microbiological Efficacy, Safety, and Compliance• Microbiological Efficacy Growth MSSA reduction MRSA reduction n = 1286 (%) n=51 (%) Heavy 105/109 (96.3%) 8 /10(80%) Moderate 348/383 (90.9%) 13/16 (81.3%) Scant 598/794 (75.3%) 18/25 (72%) Total 1051/1286 (81.7%) 39/51 (76.4%)*unpaired data was excluded** reduction defined as complete or partial bioburden reduction
    14. 14. Microbiological Efficacy, Safety and Compliance• Compliance: 125, (2%) 303, (5%) 96, (2%) Complete Tx CHG only PDT only No Tx 5566, (91%)
    15. 15. SSI Data - Extraction Cases during study period and study hours N=5176 Total Eligible for Not eligible for SSI SSI surveillance surveillance N= 3264 N = 1912 Cases treated Cases not treatedpreop with PDT N = 196 N = 3068
    16. 16. Determining the 4-yr Historical SSI RateFiscal Year CARDIAC NEURO ORTHO SPINAL THORACIC VASCULAR TOTALS2007/08 866 507 515 334 231 262 27152008/09 818 492 647 287 316 291 28512009/10 776 532 815 271 282 257 29332010/11 874 621 867 714 528 284 3888 Total 3334 2152 2844 1606 1357 1094 12,387 Number of SSIs over the past 4 years: Average Historical SSI Rate: 339 infections/12,387 = 0.027 339
    17. 17. Comparing SSI rates: Treated and Historical* Treated 4 year Historical Specialty SSI Procedures SSI SSI (Avg) Procedures SSI P-value Odds Rate Rate RatioCardiovascular1 18 628 0.029 21 833.5 0.025 0.5830 0.8652 Neuro2 2 502 0.004 7.75 538 0.014 0.0764 3.6539 Orthopedics3 5 892 0.006 12.5 711 0.018 0.0141 3.1747 Spine 19 475 0.04 34 201.5 0.085 0.0015 2.2204 Thoracic 2 431 0.005 3.5 1357 0.010 0.2884 2.2360 Vascular 4 140 0.029 6.25 1273.5 0.023 0.6747 0.7951 Total 50 3068 0.016 85 3097 0.027 0.0005 1.6984(1) CHG/mupirocin program in place previously (2) CHG bathing program in place previously (3) CHG/mupirocin used variably* Statistics done on the four year total numbers rather than the average
    18. 18. Impact: SSI Case Reduction Parameter SSI SSIs/total treated patients (rate) 50/3068 (0.016) Projected number of SSIs if all eligible 0.0016 x 3264 = 52 patients (n=3264) treatedFour year historical average number of SSIs 85 Potential cases avoided if all patients 33 (39% reduction) treated
    19. 19. Comparison of treated and not treated patients Parameter Treated (n=3068) Not Treated p value (n=196) Female 1392/3068 (45.4%) 103/196 (52.6%) 0.0598 Average Age 61.7 58.1 0.006 ASA 3-5 1844/3068 (60.1%) 126/196 (64.4%) 0.2779Scheduled Surgery 2869/3068 (93.5%) 165/196 (84.2%) 0.0001 Average t Time 129” (SD 122.4) 106” (SD 122.89) 0.010 Cases > 2 hours 1641/3068 (53.5%) 87/196 (44.4%) 0.0148
    20. 20. Treated vs Not Treated Patients Sept 1, 2011 – Aug 31 2012 SSI Status Txd Not Txd SSI 50 18 No SSI 3018 178 p<0.00001 OR 6.1038 Treated vs Not Treated groups may not have comparable risk factors for infection
    21. 21. SSIs with S.aureus Specialty Treated Not Treated p ORCardiovascular 4/18 2/3 0.0948 10.000 Neuro 1/2 1/2 NS NS Ortho (all) 2/5 0/4 NS NS Spine 8/19 7/7 0.0490 20.2941 Thoracic 0/2 0/1 NS NS Vascular 1/4 1/3 NS NS Total 16/50 (32%) 11/18 (61%) 0.0235 3.6667Note that these groups are not necessarily comparable re risk factors
    22. 22. Not Treated Patients: Reasons Reason for Not Treated Number (%) Short Staffed 32 (16%) After Shift 20 (10%) 46% Dr/Nurse – Not enough time 40 (20%) Technical Reasons 18 ( 9%) No illuminators 5 (3%) Straight to OR from unit 21 (11%) Allergic/Patient refused 10 ( 6%) No information 38 (19%) Miscellaneous 12 ( 6%) Total 196*percentage of ‘not done’ cases range from 3.4% - 8.3% among surgical subspecialties** No substantive differences between surgical subspecialties
    23. 23. Project to Program Transition• Goals of the Transition Team 1. transfer oversight to perioperative services 2. streamline process to maximize efficiency 3. expand coverage 4. educate and disseminate information• Transition Team – Dr. Elizabeth Bryce, Dr. Diane Roscoe, Dr. Titus Wong, Dr. Bas Masri, Leslie Forrester, Shelagh Weatherill, Shelley Errico, Anna Marie, Steve Kabanuk, Anna-Marie MacDonald, Kelly Barr
    24. 24. Project to program transition Time Time MON MON TUES TUES WED WED THU THU FRI FRI SAT SAT SUN SUN 0000 0100 0200Increased LPNs 0300 0400during AM rush; 0500 0600 Shift FOUR Shift ONE Shift ONE Expanded 3LPNs 0700 0700 0800 0800 3 3 3 3 Shift TWO 0900 Hours; Hired 0900 1000 1000 1100 1LPN 1 1100Nurse Educator2LPNs 2 2 2 2 Shift FIVE 1200 1200 1300 1300 Shift THREE 1400 1400 1500 1500 1600 1600 1700 1700 1800 1800 1900 1900 2000 2000 2100 2100 2200 2200 2300 2300 *Process streamlined by elimination of project requirements: nasal cultures, data form collection, study data entry
    25. 25. Education and Knowledge Dissemination• Within VCH – rounds / in-services: surgical subspecialties, peri- operative services, PAR, infection control, medical microbiology – newsletter / electronic media• Beyond VCH – Conference presentations: • AMMI 2012 (Vancouver), IDWEEK 2012 (San Diego), Knee Society Summer Meeting (Garden City) • upcoming: AAOS 2013 (Chicago) – Publications: pending
    26. 26. Conclusions• Nasal photodisinfection therapy is microbiologically effective• Decolonization therapy reduces surgical site infections• Decolonization programs can be integrated into perioperative work flow• Nasal and skin decolonization have high degree of compliance when performed (98.8%)• Decreases patient morbidity and is cost effective
    27. 27. Thank you! The Patients Surgery Perioperative Services Infection Control Medical Microbiology Patient Safety Operations and Senior Leaders Ondine BiomedicalSpecial Thanks: Study LPNs, data clerks, data analysts, microbiology technologists,and perioperative staff Team Awards:Special Thanks: UBC- VGH Hospital Foundation AMMI 2012 Innovation Academy Award
    28. 28. Discussion / Questions? Our vision We will be leaders in promoting wellness and ensuring care by focusing on quality and innovation. Our mission We are committed to supporting healthy lives in healthy communities with our partners through care, education and research.

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