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Eisie Truter - Waiariki Institute of Technology - Infection Control in the OR: Just How Important Is It?

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Eisie Truter delivered the presentation at the 2014 Operating Theatre Management Conference. …

Eisie Truter delivered the presentation at the 2014 Operating Theatre Management Conference.

Focusing on strategies for implementing the National Safety and Quality Health Service Standards and the importance of communication to improve patient safety and clinical practice, the 2014 Operating Theatre Management Conference brought together operating room management and perioperative professionals to review current initiatives across the country.

For more information about the event, please visit: http://bit.ly/optheatremgmt14

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  • 1. Infection Control in the OR: Just how important is it? Elsie Truter Waiariki Institute of Technology Rotorua New Zealand
  • 2. Challenges in the OR Preventing Surgical Site Infections against a backdrop of; Changes to perioperative nursing practice and surgical techniques New equipment – is it safe to use? How do we sterilise or disinfect? New infectious diseases Antibiotic Resistance Staff compliance with Infection Prevention and Control practice
  • 3. Government Initiatives • Health Quality and Safety Commission New Zealand • Current Infection Prevention and Control Foci; • Hand Hygiene • CLAB prevention • Surgical Site Infection • To come – Antibiotic Stewardship
  • 4. Government Initiatives • Australian Commission on Safety and Quality in Health Care • Australian College of Operating Room Nurses (ACORN) 2014-2015 Standards for Perioperative Nursing • The common emphasis (from an IPC perspective) is the reduction of Health Care Acquired Infections
  • 5. This presentation • Will look at; • Antibiotic resistance • Pre surgical skin preparation – showering with or using Chlorhexidine impregnated cloths. • The behaviour of the multidisciplinary team in the OR
  • 6. A (very) Brief History
  • 7. Van Leeuwenhoek 1673
  • 8. Semmelweis 1847
  • 9. Louis Pasteur Lister
  • 10. Anaesthesia 1847 Sir James Simpson
  • 11. Surgical site infections
  • 12. Bacterial resistance
  • 13. Antibiotic overuse Estimated Annual Human Antibiotic Use (USA) Site Amount Correct use Hospital 190 million defined 25 - 55(%) daily doses/year Community 140 million courses/year 20- 50(%)
  • 14. Complacency with aseptic technique infection
  • 15. Global microbial resistance (WHO Global Report 2014) • Prevention of the spread and control of Multi drug – resistant organisms (MDRO’s) at a critical level. • Availability of antibiotics to treat these infections extremely limited • Worldwide the most common MDRO’s are;
  • 16. MDRO’s • MRSA - Methicillin resistant Staphylococcus aureus • ( prevalence 10% in Auckland NZ) • VRE – Vancomycin resistant Enterococci ( rare in NZ) • ESBL- Extended Spectrum b lactamase Gram –ve organisms ( increasing in NZ 157/100000) • CRE – Carbapenem resistant Enterobacteriaceae • MRAB - multi resistant Acinetobacter baumannii
  • 17. MDRO’s • Understanding the current resistance pattern influences both prophylactic and therapeutic a antibiotic use
  • 18. Antibiotic Stewardship in the OR • Key to reducing MRDO’s and Healthcare associated infections • Therapeutic antibiotics- give narrow spectrum for the shortest period of time, for 24hrs after incision only. Cardiac surgery for 48 hrs only. • Prophylactic antibiotics – within 1hr prior to skin incision. Superior efficacy between 0-30 min prior • ( Anderson, et.al., 2014)
  • 19. • Exception: • Vancomycin and fluroquinolones must be administered 2 hrs before incision
  • 20. Antibiotic stewardship in the OR • ACORN - IPC Standard 11 - recommends; 2g Cephazolin for all patients up to 80kg • 3g for pts over 120kg. Paediatric dose 30 mg/kg • Experts believe prophylactic antibiotics should be administered prior to tourniquet inflation. • Redose prophylactic antibiotics for long procedures or excessive blood loss ( Anderson, et.al., 2014)
  • 21. Antimicrobial-Resistant Pathogen Antimicrobial Resistance Antimicrobial Use Infection Prevent Transmission Prevent Infection Optimize Use Effective Diagnosis & Treatment Susceptible Pathogen Antimicrobial Resistance: Key Prevention Strategies
  • 22. Preventing Infection CDC estimates that 5% of all patients acquire an infection leading to 100.000 deaths per annum (CDC, 2010) Where do these pathogenic microbes come from? Most come from endogenous microbes – skin, intestines
  • 23. Within hours of admission the room will reflect the patient’s microbiome . These microbes will move to adjacent patients and rooms. Visitors add to this mix. (Arnold,2014)
  • 24. Preventing Infection • Patients become colonised with hospital microbes within hours – they could be resistant strains. • These can lead to infection once natural defence barriers have been broken
  • 25. Entry Points
  • 26. ______________________________________________________________________ Clinical infections Colonised patients
  • 27. Preventing Infection: Minimising skin flora • Using Chlorhexidine Gluconate (CHG)2-4% wipes or showering with CHG has been shown to reduce surgical site infections from 3.19% - 1.59% ( Eiselt,2009) • Considered an adjunct risk reduction strategy to pre-operative skin prep with Chlorhexidine and alcohol or povidone-iodine and alcohol • Broad spectrum (Gram –ve and Gram +ve bacteria) killing effect
  • 28. Preventing infection Minimising skin flora • Higher concentrations of Chlorhexidine gluconate are rapidly bactericidal • Does not denature in the presence of serum and blood and has a longer residual effect • BUT cannot be used on periorbital sites – eyes and ears. Use of Povidone-iodine recommended • Patient compliance difficult to assess.
  • 29. 1 10 100 1000 10000 100000 1000000 Inguinal Axilla Inguinal Axilla Baseline Postwash One Wash 6911 Three Washes MeanSkinBacterialCount(logarithmicscale) 8 128352 6622 1797533808 NOTES: • Lab detection limit = 10 CFU. Those n.d were given a count of 5 for analysis • Postwash values for ‘three washes’ is after one wash. Mean counts remained below 10 after all three washes.
  • 30. Chlorhexidine Gluconate 4% pre-op washes. 2 cohorts 10/arm
  • 31. Preventing Infection: Pre-screening • May be logistically complicated and is expensive • Decide between vertical or horizontal surveillance • Consensus seems to be that riskier patients with complex surgery and co morbidities should be screened. • Each institution to set realistic policies • ( Making Health Care Safer ll , 2013)
  • 32. HAIs are SSI ( previously called SWI)Exogenous Sources of Infection
  • 33. To mask or not to mask?
  • 34. ACORN Infection Prevention Standard Statement 6 • Wear a mask; • where a sterile field is being prepared or used • to protect the health care worker against blood and body fluid spatters • To decrease the dispersals of microbial droplets from nose and mouth
  • 35. ACORN Perioperative Attire • Shall replace all outer garments and shall be worn correctly at all times when entering the operating suite • Do not wear perioperative attire outside the healthcare facility
  • 36. ACORN Infection Prevention Standard Statement 4 • The multi disciplinarary team shall comply with infection control parameters related to the environmental boundaries of the perioperative setting i.e. zone conformity
  • 37. Other Exogenous Sources • Environment - air changes, temperature and humidity • Inadequately cleaned environment
  • 38. In conclusion: Infection prevention in the OR is paramount • This presentation has highlighted a few important infection prevention methods in the OR 1. Antibiotic stewardship 2. The use of preoperative showering to decrease skin colonisation 3. The behaviour of the multidisciplinary team in the OR
  • 39. Thank you! Questions?
  • 40. REFERENCES Australian College of Operating Room Nurses. Standards in Perioperative Nursing 2014-2015 Australian College of Operating Room Nurses: Adelaide, South Australia Anderson,D.J.,Podgorney,K., Berrio-Torres,S.I.,Bratzler,D.W.,Dellinger.P.E…..(2014) Stratergies to Prevent Surgical Site infections in Acute Hospitals. Infection Control and Hospital Epidemiology www.medcape.com. Arnold,C, (2014). Rethinking Sterile: The Hospital Microbiome Environmental health Perspective 122(7) www.medscape.com. Bishop,W.J. (1960). The Early History of Surgery Barnes & Noble: New York Chlebicki,M.P.,Safdar,N.,O’Horo,J.C.,Maki,D.G. ( 2012). Preoperative chlorhexidine shower or bath for prevention of surgical site infection: A meta-analysis. American Journal of Infection Control 1-7 Coatsworth, N.R., Huntington,P.G., Giuffre,B.J.,Kotsiou,G. ( 2013). The Doctor and the Mask: Iatrogenic septic arthritis caused by Streptococcus mitis. MJA 198 (5)285- 286. Edmiston,C.E., Okoli,O., Graham, M.B., Sinski,S & Saebrook,G.R. ( 2010). Evidence for using Chlorhexine Gluconate Preoperative Cleansing to Reduce the Risk of Surgical Site infection AORN 92 (5) 509-518
  • 41. REFERENCES Eislet, D. (2009). Presurgical Skin preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical patients. Orthopaedic Nursing 28 (3) 141-145 Grayling,P. (2013). Surgical Attire Compliance for Safe patients and Practitioners AORN 97(4) 475-477 Grayling,P.R.& Vasaly,F.W. (2013). Effectiveness of2% Chlorhexidine Cloth Bathing for Reducing Surgical Site Infections, AORN 97 (5) 547-551 Haung,S. & Platt,.(2003). Risk of methicillin-resistant Staphylococcus aureus infection after previous Infection or colonization. Clinical Infectious Diseases.36(3): 281-285 Lee,G & Bishop,P. (2013) Microbiology and Infection Control for Healthcare Professionals (5th ed.). Frenchs Forest: Pearson Australia Making health Care Safer ll : An Updated Critical Analysis of the Evidence for Patient Safety Practices Agency for Healthcare Research and Quality: USA www.ahrq.gov Mayhall, C.G. (Ed.) ( 2012). Hospital Epidemiology and Infection control (4th ed.). Lippincott William and Wilkins: Philadelphia: United States of America Zywiel,M.G., Daley,J.A. Delanois,R.E.,Nazir,Q., Johnson,A.J., Mont,M.A. (2011). Advance pre-Operative chlorhexidine reduces the incidence of surgical site infections in knee Arthroscopy. International Orthopaedics , 35 1001-1006