Orthopedic residents orientation july 2010


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  • It is my pleasure to be here today to present to you the work at New England Baptist Hospital in working toward a zero infection rate.
  • NEBH is an orthopedic center of excellence located in downtown Boston, Ma. We have 150 beds and our inpatients services are approx 75% orthopedic surgery.
  • We conducted another anonymous surveillance culture study in Feb 2006 – 133 spine patients noses were cultured in the OR 29% grew out Staph aureus and 4% were positive for MRSA – which was undiagnosed and therefore surgical prophylaxis with Vancomycin was not administered and no precautions were used in the OR, PACU or nursing units. These patients may also Have been discharged to a rehab facility with no flagging for precautions.
  • Suture cost increased from ~ $31,000 to $37,000 Vicryl Plus sutures for all surgeries Additional annual cost: $5,572
  • “ Real World” benefits for use of DERMABOND Adhesive Physician: time savings in many situations Reduce needle stick exposure No followup needed to remove sutures more reassurance Increased patient satisfaction more difficult patients (geri, pedi, bedbound) building practice, marketing
  • Chlorhexidine antiseptic wash (Bactoshield) for pre-op shower Annual cost: $10,639 Chlorhexidine swabs for central line insertion site (Chloraprep) Use clippers rather than razors to remove hair at incision site Annual cost: $8,175
  • Orthopedic residents orientation july 2010

    1. 1. Orthopedic Residents and Fellow Orientation Maureen Spencer, RN, MEd, CIC Infection Control Manager New England Baptist Hospital Boston, Mass. 02120 [email_address]
    2. 2. New England Baptist Hospital Orthopedic Center of Excellence <ul><li>Acute inpatient discharges are divided among 3 service lines: </li></ul><ul><li>Orthopedic =75% </li></ul><ul><li>Medical =17% </li></ul><ul><li>(Cardiology, Pulmonary, Gastroenterology, Nephrology) </li></ul><ul><li>General Surgery = 8% </li></ul><ul><li>>10000 cases/yr: </li></ul><ul><li>7000 inpatient surgeries </li></ul><ul><li>~4500 joints </li></ul><ul><li>~2500 spines/sports </li></ul>
    3. 3. NEBH Goal: Zero Healthcare-Acquired Infections
    4. 4. Orthopedic Surgical Site Infection <ul><li>Orthopedic Total Joint Infections: </li></ul><ul><ul><li>Hip or Knee aspiration </li></ul></ul><ul><ul><li>If positive – irrigation and debridement </li></ul></ul><ul><ul><li>Removal of hardware may be necessary </li></ul></ul><ul><ul><li>Insertion of antibiotic spacers </li></ul></ul><ul><ul><li>Revisions at future date </li></ul></ul><ul><ul><li>Long term IV antibiotics in community or rehab </li></ul></ul><ul><ul><li>Future worry about the joint </li></ul></ul><ul><ul><li>In other words – DEVASTATING FOR THE PATIENT AND THE SURGEON </li></ul></ul>
    5. 5. Establishing an Intention for Zero Infection Rate <ul><li>A multidisciplinary team was formed to address an increase in the infection rate in FY03 and implement control measures. </li></ul><ul><li>Administration established intent for zero tolerance for adverse patient outcomes, including surgical site infections.  </li></ul>
    6. 6. The Patient as a Source Risk factors leading to colonization and infection
    7. 7. Prosthetic Joint Infection Risk Factors <ul><li>Revision surgery </li></ul><ul><li>Malignancy </li></ul><ul><li>Steroid Use </li></ul><ul><li>Rheumatoid Arthritis </li></ul><ul><li>Chronic Renal Insufficiency </li></ul><ul><li>Malnutrition </li></ul><ul><li>Blood Transfusion </li></ul><ul><li>Berbari E. et al: Clinical Infectious Diseases 1998;27:1247–54 </li></ul>
    8. 8. Patient Risk Factors <ul><li>High rate of overweight or obese patients among those who developed infections </li></ul><ul><li>Glycemic control in diabetics and pre-diabetics can impact surgical outcomes and the potential for infection </li></ul><ul><li>Poor patient hygiene and nutrition can impact surgical outcomes </li></ul>
    9. 9. Obesity and Surgical Incision <ul><li>Incision collects fluid – serum, blood - growth medium for organisms </li></ul><ul><li>Spine incisions - close to the buttocks </li></ul><ul><li>Perspiration - diaphoresis </li></ul><ul><li>Body fluid contamination from bedpans/commodes </li></ul><ul><li>Friction and sliding - skin tears and blisters </li></ul><ul><li>Itchy skin - due to pain medications - skin breakdown </li></ul>
    10. 10. Skin Issues in Orthopedic Surgery
    11. 11. Postop Dressings
    12. 12. Leaving Incisions Open To Air We discourage this practice – bacteria feed off of blood (and sugar), incisions are in first few days of wound healing – “exudative stage” and need protection
    13. 13. Postop Dressings - ABD with Paper Tape Previously done by residents and PAs ABD tends to fall off easily Paper tape can cause skin tears – obese patient sweat and tape absorbs in pores and then pulls off skin upon removal
    14. 14. Antimicrobial Dressing (AMD) and Sterile ABD dressing with MeFix Tape
    15. 15. MicroFoam Dressing with AMDs Some surgeons apply Microfoam over steristrips, adaptic, gauze, ABD until day 2 postop Tends to wrinkle and lose adhesion
    16. 16. Total Knees and Hips with Dermabond Apply one layer of Dermabond Allow to dry - ~ 2-5 minutes Can apply telfa – but not necessary Apply transparent dressing over telfa
    17. 17. Dermabond and AMD Dressing Left- Incision covered with with AMD gauze (hip) Below - AMD telfa (knees) and a tegaderm Healed incision
    18. 18. Knee Dressings with Ace ABD over knee incision Ace bandage one day postop with blood strikethrough after drain removed – “reinforce” AMD gauze are in postop dressing kits so they are offering protection to the incision in first two days
    19. 19. Spine Service and Shoulders Aquacel, AMD, Tegaderm left on until discharge AMD Island dressing – left on until discharge Incision sealed with Dermabond and covered with AMD gauze and tegaderm until discharge
    20. 20. The Beginning: February 2006 Nares Colonization the Source <ul><li>133 patients were screened for MRSA </li></ul><ul><li>and Staph aureus in the operating </li></ul><ul><li>room before surgery to determine </li></ul><ul><li>rate of MRSA and Staph aureus </li></ul><ul><li>colonization </li></ul><ul><li>Results: </li></ul><ul><li>38 – Staph aureus (29%) </li></ul><ul><li>*5 - MRSA ( 4%) </li></ul><ul><li>*all MRSA undiagnosed </li></ul><ul><li>*no precautions used in OR or postop nursing unit </li></ul><ul><li>*all received Cefazolin for surgical prophylaxis (not Vancomycin)! </li></ul>
    21. 21. Topical Decolonization Protocol <ul><li>Intranasal 2% mupirocin ointment </li></ul><ul><li>(Bactroban) BID x 5 days </li></ul><ul><li>Shower with 2% chlorhexidine (Hibiclens) </li></ul><ul><li>daily x 5 days </li></ul><ul><li>Call from PASU to initiate treatment protocol </li></ul><ul><li>Repeat call to document compliance </li></ul><ul><li>MRSA carriers re-screened prior to surgery </li></ul><ul><li>Contact precautions if 2nd MRSA screen positive </li></ul><ul><li>Vancomycin preop antibiotic prophylaxis </li></ul><ul><li>for all patients with 1 st positive MRSA or MRSA history of infection in past </li></ul>
    22. 23. What were the outcomes?
    23. 24. MRSA/MSSA Eradication Results <ul><ul><li>From July 17, 2006 through April 2010 </li></ul></ul><ul><ul><li>23,439 patients screened </li></ul></ul><ul><ul><ul><li>5412 (23%) positive for Staph aureus </li></ul></ul></ul><ul><ul><ul><li>969 ( 4%) positive for MRSA </li></ul></ul></ul><ul><ul><ul><li>Repeat nasal screens on MRSA patients </li></ul></ul></ul><ul><ul><ul><li>revealed 78% eradication </li></ul></ul></ul>
    24. 25. <ul><li>Time Period Inpatient surgeries # Surgical Infections Percent </li></ul><ul><li>FY06 </li></ul><ul><li>10/01/05-07/16/06 5293* 24 0.45% </li></ul><ul><li>FY07 </li></ul><ul><li>07/17/06-09/30/07 7019 13 0.18% </li></ul><ul><li>FY08 </li></ul><ul><li>10/01/07-09/30/08 6323 7 0.11% </li></ul><ul><li>FY09 </li></ul><ul><li>10/01/08-09/30/09 6364 11 0.17% </li></ul><ul><li>*historical controls </li></ul>% MRSA and Staph aureus SSI
    25. 26. <ul><li>Time Period Inpatient surgeries # MRSA SSI MRSA % #Screen + (%SSI) </li></ul><ul><li> FY06 </li></ul><ul><li>10/01/05-07/16/06 5293* 10 (NA) 0.19% NA </li></ul><ul><li>FY07 </li></ul><ul><li>07/17/06-09/30/07 7019 3 (3+) 0.04% 3/ 309 (0.97%) </li></ul><ul><li>FY08 </li></ul><ul><li>10/01/07-09/30/08 6245 4 (2+) 0.06% 2/ 242 (0.83%) </li></ul><ul><li>FY09 </li></ul><ul><li>10/01/08-08/31/09 6364 6* (2+) 0.09% 2/ 234 (0.85%) </li></ul><ul><li>*isolates have been sent for pulse field gel electrophoresis </li></ul><ul><li> 5 of the 6 isolates were available for PFGE and were not related genetically </li></ul>% MRSA SSI in MRSA + Screened Patients
    26. 27. <ul><li>Time Period Inpatient surgeries # MSSA SSI MSSA % #Screen + (%SSI) </li></ul><ul><li>Historical controls </li></ul><ul><li>FY06 </li></ul><ul><li>10/01/05-07/16/06 5293* 14 (NA) 0.26% NA </li></ul><ul><li>Screened Patients </li></ul><ul><li>FY07 </li></ul><ul><li>07/17/06-09/30/07 7019 3 (3+) 0.04% 3/1588 (0.19%) </li></ul><ul><li>FY08 </li></ul><ul><li>10/01/07-09/30/08 6245 3 (1+) 0.05% 1/ 1422 (0.07%) </li></ul><ul><li>FY09 </li></ul><ul><li>10/01/08-08/31/09 6364 5 (3+) 0.08% 3/1403 (0.21%) </li></ul>% Staph aureus (MSSA) SSI in MSSA Screen + Patients
    27. 28. Staff Items as Sources for Cross Contamination
    28. 29. Lab Coats, Stethoscopes, Otoscopes, Gloves, Gowns, Pagers, Cell Phones – contamination with Staph aureus, MRSA and VRE <ul><li>Infect Control Hosp Epidemiol. 2001 Sep;22(9):560-4. Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci. Zachary KC, Bayne PS, Morrison VJ, Ford DS, Silver LC, Hooper DC. Infectious Disease Division Massachusetts General Hospital, Boston RESULTS: VRE were isolated from at least 1 examiner site (gloves, gowns, or stethoscope) in 33 (67%) of 49 cases . Gloves were contaminated in 63%, gowns in 37%, and stethoscopes in 31%. </li></ul><ul><li>  </li></ul><ul><li>J Hosp Infect. 2001 Aug;48 Suppl A:S64-8. Stethoscopes and otoscopes--a potential vector of infection? Cohen HA, Amir J, Matalon A, Mayan R, Beni S, Barzilai A . RESULTS: All the stethoscopes and 90% of the otoscope handles were colonized by microorganisms. Staphylococci were isolated from 85.4% of the stethoscopes and 83.3% of the otoscopes, with 54.5% and 45.2% respectively being S. Aureus. Methicillin-resistant S. aureus were found in four each of the stethoscopes (7.3%) and otoscopes (9.5%) </li></ul><ul><li>Docs' Cell Phones May Spread Hospital Infections - screened 124 hospital personnel for the germ Acinetobacter baumannii - 12 percent of healthcare providers' cell phones were contaminated with the bug not only on phones but also on 24 percent of the hands of the people tested, who included 71 physicians and 53 nurses. </li></ul><ul><li>Infect Control Hosp Epidemiol. 2002 May;23(5):274-6. </li></ul><ul><li>Bacterial contamination of hospital pagers. Singh D, Kaur H, Gardner WG, Treen LB. </li></ul><ul><li>Microorganisms were isolated from all pagers; 21% yielded Staphylococcus aureus, of which 14% were methicillin resistant. Cleaning with alcohol reduced the total colony count by an average of 94%. </li></ul>
    29. 30. Lab Coat Contamination <ul><li>NEBH Lab coat study – cultured 6 coats in OR and two were growing Staph aureus (33%) – visibly soiled and pockets stuffed with books, food, scissors, etc. </li></ul><ul><li>Bacterial contamination of health care workers' white coats American Journal of Infection Control 37 : (2 ) 101-105 (March 2009) </li></ul><ul><ul><li>148 cultured: 23% Staph aureus, 18% MRSA </li></ul></ul>
    30. 31. Prevention Measures
    31. 32. Precaution Material <ul><li>*Precaution Gowns </li></ul><ul><li>*Gloves </li></ul><ul><li>*Masks </li></ul><ul><li>*Private Room </li></ul><ul><li>*Precaution Cart </li></ul><ul><li>*Signage – new Red signs </li></ul><ul><li>*Dedicated Equipment </li></ul><ul><li>(stethoscope, sphgmanometer, commodes) </li></ul><ul><li>*Cal Stat Alcohol Hand Rub </li></ul><ul><li>*Red Bags for Infectious Waste Disposal </li></ul>
    32. 33. MRSA VRE Abscesses Cellulitis Draining wound infections Significant continence with feces
    33. 34. Clostridium difficile Infection Must wash hands to remove spores and clean equipment with bleach wipes
    34. 35. Contaminated Hands Most Common Source
    35. 36. Most Important Control Measure <ul><li>HAND HYGIENE </li></ul><ul><li>Wash hands several times a shift – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes </li></ul>
    36. 37. Hands and Gloved Hands as Sources for Spread <ul><li>Scientists cultured the imprint of a health care worker's gloved hand after examining a patient infected with Clostridium difficile. </li></ul><ul><li>The larger yellow colonies outlining the fingers are clusters of Clostridium difficile </li></ul><ul><li>The patient had showered an hour before the  </li></ul><ul><li>specimen was collected. </li></ul>Clinical Infectious Diseases, February 2008.
    37. 38. Wear Gloves, Wash Hands Often, Use Alcohol Based Hand Rub/Foam
    38. 39. Hand Cultures – before and after the use of Cal Stat
    39. 40. Action Plans for Patients
    40. 41. Antibacterial Sutures <ul><li>Due to the number of SSI due to Staph aureus and MRSA we instituted the use of Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture </li></ul>
    41. 42. Coated VICRYL*Plus Antibacterial Suture Staph aureus Culture Plate Study <ul><li>A pure culture (0.5 MacFarland Broth) of Staph aureus was prepared </li></ul><ul><li>A coated VICRYL*Plus antibacterial suture was aseptically cut and planted on the plate and incubated for 24 hrs </li></ul><ul><li>Photo #1 shows zone of inhibition </li></ul><ul><li>at day 5 </li></ul><ul><li>Photo # 2 zone of inhibition at day 10 in plate on left. Plate on right is noncoated vicryl suture. </li></ul>
    42. 43. DERMABOND Incisional Adhesive <ul><li>Physician, Hospital -centered Benefits </li></ul><ul><li>Proven microbial barrier for lasting protection </li></ul><ul><li>7 days of wound healing strength in 3 minutes for strong closure and peace of mind </li></ul><ul><li>No time spent removing staples or sutures </li></ul><ul><li>Reduces needle stick exposure </li></ul><ul><li>Increases patient satisfaction </li></ul><ul><li>Reduced Hospitalization Costs </li></ul><ul><li>Nurse, Patient -centered Benefits </li></ul><ul><li>Reduces number of suture set ups </li></ul><ul><li>Ease of Post Op wound checks </li></ul><ul><li>Reduces number of wound dressings </li></ul><ul><li>Shower immediately </li></ul><ul><li>Excellent Cosmesis </li></ul>
    43. 44. CHG Use For Surgery <ul><li>Chlorhexidine showers </li></ul><ul><li>2% CHG/70% alcohol skin preparation (tinted orange) </li></ul><ul><li>Antimicrobial dressing material for primary and secondary dressings (“AMD”) </li></ul>
    44. 45. NEBH SSI Rates 2003 - 2010 Team Analysis of Surveillance Data: 2007 Laminectomy increase rate: case/control study confirmed it was due to the use of locally administered steroids (depomedrol) 2008 Total knee infection rate increase: evaluation revealed the use of instilled pain medications in joints – preparation technique questionable 2009 Total hip infection rate increase: ?due to increase in post-op hematomas – case/control study underway to evaluate risk factors
    45. 46. In Summary….. <ul><li>Healthcare-associated infections are a major problem in hospitals </li></ul><ul><li>Infection control measures, such as precaution techniques and hand hygiene have been shown to prevent the spread of nosocomial infections </li></ul><ul><li>Follow department-specific infection control policies and procedures </li></ul><ul><li>Report any problems immediately to the infection control </li></ul>
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