Working Toward Zero  Infection Rate <ul><li>Maureen Spencer, RN, M.Ed, CIC </li></ul><ul><li>Infection Control Manager </l...
Topics: <ul><li>New England Baptist Hospital and Orthopedics </li></ul><ul><li>Multidisciplinary Team Work </li></ul><ul><...
NEBH SSI Rates 2003 – 2010 (outpatient and inpatient infections)
Orthopedic Surgical Site Infection <ul><li>Orthopedic Total Joint Infections: </li></ul><ul><ul><li>Hip or Knee aspiration...
2003 - Established a Multidisciplinary Team <ul><li>The team included representatives from  </li></ul><ul><li>OR nursing, ...
Team Intent:   Zero Healthcare-associated Infections The teams:  SSI, VAP, CLABSI, UTI, MRSA, C.difficile Books:  Power Ve...
Issues Identified By Team  <ul><li>2003:  The Operating Room: </li></ul><ul><li>Traffic control </li></ul><ul><li>Surgical...
Operating Room -  2003 <ul><li>Re-training proper use of CHG/alcohol surgical scrub solution (6 hr residual activity) </li...
Operating Room -  2003 <ul><li>Reviewed orderlies - room turnover procedures </li></ul><ul><li>Improved traffic control:  ...
Lab Coat Contamination <ul><li>NEBH Lab coat study – cultured 6 coats in OR – 2 cultured Staph aureus (33%) </li></ul><ul>...
Peri-operative Environmental  Evaluation <ul><ul><li>Overall preventive maintenance schedule </li></ul></ul><ul><ul><li>HV...
Complicated Orthopedic Instruments <ul><li>Inspection of Orthopedic Instruments  </li></ul><ul><ul><li>Lumens, grooves, so...
Environmental Upgrades <ul><li>Upgraded all OR rooms to laminar flow </li></ul><ul><ul><ul><li>(although data inconclusive...
Operating Room - 2004 <ul><li>More frequent environmental safety rounds by team  </li></ul><ul><li>Infection control educa...
<ul><ul><li>Established a weekly cross-check system of patients identified with resistant organisms (MRSA/VRE) </li></ul><...
FY05 Operating Room <ul><li>Ultrasonic scrub  </li></ul><ul><ul><li>movable carts, tables, poles and equipment </li></ul><...
Environmental Disinfection <ul><li>Developed cleaning schedules for departments in Patient Care Services </li></ul><ul><li...
Environmental Disinfection <ul><li>Silver Disinfectant Spray that  </li></ul><ul><li>kills organisms up to 24 hrs on surfa...
Environmental Disinfection <ul><li>Assigning of staff to clean before each use: </li></ul><ul><ul><li>Blood pressure cuffs...
Patient Risk Factors
Prosthetic Joint Infection Risk Factors <ul><li>Obesity  </li></ul><ul><li>Diabetics and pre-diabetics </li></ul><ul><li>P...
MRSA and Staph aureus  Eradication Program <ul><li>Prescreening Process </li></ul><ul><li>Topical Decolonization Protocol ...
February 2006  Obtained Anonymous Nares Cultures To Prove to Administration They Come In With Staph aureus and MRSA <ul><l...
Implemented Decolonization Protocol <ul><ul><li>5-day application of intranasal 2% mupirocin - applied twice daily - for M...
AORN Journal –Nov 2008 Vol 88, Nov. pages 818-820 “ Dealing with Antibiotic Resistant Organisms”
AORN <ul><li>Contact Precautions in Pre-op area, OR & PACU </li></ul><ul><ul><li>Gowns and gloves throughout procedure (in...
MRSA/MSSA Eradication Results <ul><ul><li>From July 17, 2006 through July 2010 </li></ul></ul><ul><ul><li>25,025 patients ...
<ul><li>Time Period    Inpatient surgeries  # Surgical Infections  % MRSA/MSSA </li></ul><ul><li>FY06 </li></ul><ul><li>10...
<ul><li>Time Period  Inpatient surgeries  # MRSA SSI  MRSA %  #Infections/#MRSA+ </li></ul><ul><li>  FY06 </li></ul><ul><l...
<ul><li>Time Period  Inpatient surgeries  # MSSA SSI  MSSA %   #MSSA Infections/# MSSA +  </li></ul><ul><li>Historical con...
FDA Cleared “Innovative Technologies&quot; <ul><li>Antiseptic cloth 2% chlorhexidine gluconate (CHG) impregnated </li></ul...
Sample of Chlorhexidine Products for Healthcare Use   BSI = bloodstream infection; CHG = chlorhexidine gluconate; ICU = in...
New CHG Irrigation Solution  <ul><li>  Wound Debridement and Cleansing system  </li></ul><ul><ul><li>CHG concentration is ...
Antisepsis with Chlorhexidine <ul><li>2% CHG/70% alcohol skin preparation (tinted orange)  </li></ul><ul><ul><li>Has a las...
 
OR Air Current Contamination In teaching hospitals: Surgeon leaves room Resident, Physician Assistant or Nurse Practitione...
Suture with Staphylococcus colonies Air settling plates in the operating room at the last hour of a total joint case Poten...
NEBH Antibacterial Suture  Staph aureus Culture Plate Study <ul><li>A pure culture  - 0.5 MacFarland Broth - of  Staph aur...
2005 – New England Baptist Hospital One Year Prospective Study of  3800 Total Joints and Antimicrobial Sutures <ul><li>In ...
IRGACARE ®  MP (triclosan) Properties <ul><li>IRGACARE MP </li></ul><ul><ul><li>2,4,4′-tri-chloro-2′-hydroxydiphenyl ether...
<ul><li>Compared with controls, IRGACARE MP-coated polyglactin 910 sutures produced </li></ul><ul><ul><ul><li>Substantial ...
IRGACARE ®  MP (triclosan): Mode of Action <ul><li>Chlorinated phenolic biocide— </li></ul><ul><li>a “phenol” with multi-t...
Why IRGACARE ®  MP (triclosan)? <ul><li>Able to withstand the manufacturing process </li></ul><ul><li>Cost-effective </li>...
IRGACARE ®  MP (triclosan): Pharmacokinetics <ul><li>Well absorbed </li></ul><ul><li>Well distributed in the body </li></u...
IRGACARE ®  MP (triclosan) and Microbial Resistance <ul><li>IRGACARE MP is very effective against  S aureus ,  S epidermid...
Articles Related To Antibacterial Sutures <ul><li>*Justinger, C, et al. Antibiotic coating of abdominal closure sutures an...
Protect OR Staff: ETHIGUARD* Blunt Point Needles <ul><li>ETHIGUARD Blunt Point Needles provide blunt point geometry that a...
INCISIONAL SKIN ADHESIVE TO PREVENT EXOGENOUS CONTAMINATION TO INCISION DURIN G POST-OP PERIOD
Skin Issues in Orthopedics Anterior fusion with tape burns Posterior fusion with contaminated steri-strips Contaminated st...
We Do Not Recommend Incisions opened to air with contaminated steristrips Bacteria feed off blood (and sugar) Incisions ar...
Obesity and Surgical Incision <ul><li>Incision collects fluid – serum, blood - growth medium for organisms </li></ul><ul><...
Octyl-Cyanoacrylate Topical Skin Adhesive <ul><li>Cyanoacrylates were developed in 1949 </li></ul><ul><li>1970s - n-butyl-...
Mechanism of action  <ul><li>Combination of monomer and plasticizers, that polymerizes to form a flexible/pliable adhesive...
Benefits for surgeons, nurses, patients, and hospitals <ul><li>Physician, Hospital -centered Benefits </li></ul><ul><li>Pr...
Incisional Adhesive on Total Knee Incision
Incisionial Adhesive and AMD Dressing Knee : Sealed with Dermabond, covered with antimicrobial Telfa and a transparent dre...
If Incisional Adhesive is Not used:  Antimicrobial Post-op Dressings <ul><li>Antimicrobial (AMD) gauze for </li></ul><ul><...
No More Flimsy Post-op Dressings  ABD with Paper or Gauze Tape <ul><li>Check your residents and physician assistants steri...
2008  Standardization: Antimicrobial Dressing (AMD) By Nursing Staff AMD secured with MeFix tape for protection from exoge...
Knee Dressings with Ace Ace bandage one day post-op with blood strikethrough after drain removed – nurses told to “reinfor...
Spine Service and Shoulders AMD sealed with Tegaderm left on until discharge AMD Island dressing – left on until discharge...
Practices with Limited Supporting Data
  Surgical Incise Drapes <ul><li>Iodophor impregnated incise  </li></ul><ul><li>barrier drape (“sacred cow”) </li></ul><ul...
Bacitracin/Polymixin Irrigation <ul><li>Feb 2007 - stopped  routine  use of Bacitracin/Polymixin Irrigation  </li></ul><ul...
UTI Prevention <ul><li>Goal: Prevent bladder infection  </li></ul><ul><li>that would lead to seeding of  prosthetic  </li>...
Our Experience and Evidence
OR Cleanup Bundle Approach to Reducing SSI
NEBH SSI Rates 2003 – 2010 (outpatient and inpatient infections)
Creative and Fun Hand Hygiene Educational Programs Infection Control - $7000.00/year budget
Most Important Control Measure <ul><li>HAND HYGIENE – wash off the dirt! </li></ul><ul><li>Wash hands several times a day ...
Alcohol Foam, Liquid and Hand Wipes All patients receive package of alcohol wipes in admission kit – encourage them to san...
Got Soap? -  Engage Your Staff!! <ul><li>Engaged the OR staff in a  Got Soap?  Campaign </li></ul><ul><ul><li>OR Nurses </...
<ul><li>November 2005  </li></ul><ul><li>“ Partners in Hand Hygiene ” </li></ul><ul><li>January 2006 </li></ul><ul><li>“ L...
<ul><li>LUAU  </li></ul><ul><li>Let Us Always Use </li></ul><ul><li>Good Hand Hygiene </li></ul><ul><li>Cafeteria Cruise S...
Creative and Interactive   Glo-Germ   “Bug Beat” Fair   Contact    Plates
<ul><li>16 poster displays:  </li></ul><ul><ul><li>Admitting </li></ul></ul><ul><ul><li>Surgical Services </li></ul></ul><...
2007
2007
2008
 
Hand Hygiene Observations
Tools for Success <ul><li>Senior leadership and Board of Trustees involvement – “lead the effort” from top down </li></ul>...
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Periop conference working toward zero ssi - sep 11 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.
  • The topics I will be covering include a brief overview of NEBH, what’s up in the healthcare community related to infection control, A brief overview of the epidemiology of HAI and SSI, efforts to eliminate SSIs, surveillance data, problems we identified and action plans, the cost of HAI, action plans for patients, the outcomes and cost savings and future steps for NEBH
  • The next set of slides with take you on a journey into the field of infection control and all the areas of focus and investigation that Occurred from 2003-2005.
  • Cost saving measure in 2002 was to outsource EVS We worked with each department to write all the equipment that needed to be cleaned, how often and with what type of
  • © ETHICON, INC. 2009
  • 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
  • This is a picture of bacterial adherence to non –T riclosan-coated suture material.
  • Suture cost increased from ~ $31,000 to $37,000 Vicryl Plus sutures for all surgeries Additional annual cost: $5,572
  • Note: IRGACARE ® MP (triclosan) is a biocidal agent used in all Plus SUTURES products IRGACARE MP is a high-purity material that meets United States Pharmacopeia specifications for triclosan and contributes minimally to the background exposure to toxic residues It has demonstrated antibacterial efficacy and a long history of safety. IRGACARE MP is active against the most common pathogens implicated in SSIs, including S aureus , S epidermidis , and others IRGACARE MP is also a great candidate for incorporation into sutures because of its compatibility with suture processing
  • © ETHICON, INC. 2009
  • Note: The mode of action of triclosan is widely unknown The triclosan used in Plus SUTURES is the highly purified form, IRGACARE ® MP Recent studies have shown that it acts as a competitive inhibitor of an essential enzyme in fatty acid synthesis: enoyl-acyl carrier protein reductase
  • Note: IRGACARE ® MP (triclosan) withstands manufacturing processes, is cost-effective, and has excellent physical and functional properties Coated polyglactin 910 sutures with triclosan appeared to exhibit no difference from traditional polyglactin 910 sutures with respect to tactile smoothness, dry tie-down, and wet tie-down
  • Note: IRGACARE ® MP (triclosan) has favorable pharmacokinetic properties. It is well absorbed (50% – 100%) by the gastrointestinal tract and well distributed in the body It binds to serum albumin and is present as the sulfate and/or glucuronide conjugate, depending on exposure There is no indication that triclosan accumulates in plasma over time, nor is it stored after single or repeated exposure
  • Note: IRGACARE ® MP (triclosan) has favorable pharmacokinetic properties. It is well absorbed (50% – 100%) by the gastrointestinal tract and well distributed in the body It binds to serum albumin and is present as the sulfate and/or glucuronide conjugate, depending on exposure There is no indication that triclosan accumulates in plasma over time, nor is it stored after single or repeated exposure
  • Talking about the features and benefits that ETHIGUARD needles offer to surgeons. ETHIGUARD has better performance than conventional blunt needles which are used for soft tissue. Another key point is ETHIGUARD needles offer combinations with plus sutures.
  • © ETHICON, INC. 2009 Skin adhesives Cyanoacrylates were first manufactured in 1949. The first adhesives were noted to have extreme inflammatory effects on tissues. n-butyl-2-cyanoacrylate, which was developed in the 1970s, was the first adhesive to have negligible tissue toxicity and good bonding strength, as well as acceptable wound cosmesis. DERMABOND Adhesive (2-Octyl-Cyanoacrylate), the latest in cyanoacrylate technology, has less toxicity and almost four times the strength of n-butyl-2-cyanoacrylate.
  • © ETHICON, INC. 2009 “ 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
  • Iodophor/alcohol surgical prep is used – we evaluated the tinted CHG but surgeons did not like the product due to Its green color and inability to adhere the barrier drapes to the skin as well as the iodophor product – this is a big Issue for orthopedic surgeons
  • warmer patients less likely to develop infection and silver/silicone urinary catheters are used to prevent postop UTIs
  • Partners in Hand Hygiene: June-November – baseline data collected for the Partners in Your Care – Program out of Univ of Penn – 300 hospitals participating in patient education campaign November – cafeteria displays for staff to market the program, distribute scripts to staff in response to patients asking if they washed their hands, staff received small bottles of Cal Stat with a “own a bug” attached to it. December – posters in admitting office, brochures for each inpatient, small finger puppets of “bugs” distributed to patients Every two months data is collected on amount of product used by staff January – Let It Snow – gave out small snowmen in cafeteria displays April – Do the H.O.P. – raffled off bunnies, gave out small bunnies attached to Cal Stat
  • Periop conference working toward zero ssi - sep 11 2010

    1. 1. Working Toward Zero Infection Rate <ul><li>Maureen Spencer, RN, M.Ed, CIC </li></ul><ul><li>Infection Control Manager </li></ul><ul><li>New England Baptist Hospital, </li></ul><ul><li>Boston, Mass. 02120 </li></ul><ul><li>617 754-5332 </li></ul><ul><li>[email_address] </li></ul>Disclosure: Ethicon and Cardinal Health Speaker’s Bureau
    2. 2. Topics: <ul><li>New England Baptist Hospital and Orthopedics </li></ul><ul><li>Multidisciplinary Team Work </li></ul><ul><li>Identifying Problems: </li></ul><ul><ul><li>OR Environment </li></ul></ul><ul><ul><li>Central Supply </li></ul></ul><ul><ul><li>Housekeeping </li></ul></ul><ul><ul><li>Hand Hygiene </li></ul></ul><ul><li>Action Plans: </li></ul><ul><ul><li>Innovative Technologies </li></ul></ul><ul><li>The Evidence: </li></ul><ul><ul><li>What Were The Outcomes </li></ul></ul>
    3. 3. NEBH SSI Rates 2003 – 2010 (outpatient and inpatient infections)
    4. 4. Orthopedic Surgical Site Infection <ul><li>Orthopedic Total Joint Infections: </li></ul><ul><ul><li>Hip or Knee aspiration under fluoroscopy </li></ul></ul><ul><ul><li>If positive – irrigation and debridement – liner exchange or </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: </li></ul></ul><ul><ul><li>DEVASTATING FOR THE PATIENT AND THE SURGEON </li></ul></ul>
    5. 5. 2003 - Established a Multidisciplinary Team <ul><li>The team included representatives from </li></ul><ul><li>OR nursing, CSS </li></ul><ul><li>Orthopedic surgeons (Joint, Spine) & Anesthesia </li></ul><ul><li>Managers from infection control, healthcare quality, facilities and environmental services  </li></ul><ul><li>Evaluated </li></ul><ul><li>Procedures and Practices </li></ul><ul><li>Facility design and Environment of Care Issues </li></ul><ul><li>Patient Risk Factors </li></ul><ul><li>Infection Rates </li></ul><ul><li>Innovative Infection Prevention Products and Practices </li></ul><ul><li>Spencer M, et al. A Multidisciplnary Team Working Toward Zero Infection Rate. Poster presented </li></ul><ul><li>AORN 2006; March 19-23, 2006; Washington DC. </li></ul><ul><li>Spencer M., et al. A Multidisciplinary Team working toward Zero Orthopedic Infection Rate. Global </li></ul><ul><li>Infectious Disease Conference, Tufts Medical School, Boston, MA October 2009 </li></ul>
    6. 6. Team Intent: Zero Healthcare-associated Infections The teams: SSI, VAP, CLABSI, UTI, MRSA, C.difficile Books: Power Versus Force – David Hawkins, MD 48 Laws of Power – Robert Greene
    7. 7. Issues Identified By Team <ul><li>2003: The Operating Room: </li></ul><ul><li>Traffic control </li></ul><ul><li>Surgical attire </li></ul><ul><li>Operating room cleaning </li></ul><ul><li>Processing of instruments </li></ul><ul><li>Air handling system and laminar flow </li></ul><ul><li>Surgical hand scrub </li></ul><ul><li>2004: </li></ul><ul><li>Surgical infection prevention (SIP) core measures </li></ul><ul><li>Silver postoperative dressings for Spine Service </li></ul><ul><li>CHG for central line care </li></ul><ul><li>2005: </li></ul><ul><li>Antibacterial sutures – full year evaluation </li></ul><ul><li>2006-2007 </li></ul><ul><li>MRSA and MSSA Eradication Program - 2 ½ year process </li></ul><ul><li>CHG biopatch for central lines and Maximal Barrier Kits </li></ul><ul><li>2008 </li></ul><ul><li>Chlorhexidine preop, intraop, postop </li></ul><ul><li>Clostridium difficile – room decontamination and bleach </li></ul><ul><li>V.A.P. checklist and prevention guidelines </li></ul><ul><li>2009-2010: </li></ul><ul><li>Post-op anitmicrobial dressings – all incisions covered </li></ul><ul><li>Central line checklist and patient education on prevention of HAIs </li></ul>
    8. 8. Operating Room - 2003 <ul><li>Re-training proper use of CHG/alcohol surgical scrub solution (6 hr residual activity) </li></ul><ul><ul><li>2006 changed to an 80% alcohol based waterless hand scrub (6 hr residual activity also) </li></ul></ul><ul><li>Distribution of 4 oz chlorhexidine (eg Hibiclens) in prescreening for all inpatient surgeries </li></ul>
    9. 9. Operating Room - 2003 <ul><li>Reviewed orderlies - room turnover procedures </li></ul><ul><li>Improved traffic control: new signage and monitoring system </li></ul><ul><li>Cloth cap use – if worn it must be covered when in room and total hair coverage monitored </li></ul><ul><ul><li>Hair harbors organisms </li></ul></ul><ul><ul><li>Sweat in cloth caps? </li></ul></ul><ul><ul><li>How often do they get washed? </li></ul></ul><ul><ul><li>Where are they stored? </li></ul></ul><ul><ul><li>Would you eat a meal with hair in it? Why then allow hair to potentially fall into surgical incisions? </li></ul></ul>Too many in this room, hair not adequately covered
    10. 10. Lab Coat Contamination <ul><li>NEBH Lab coat study – cultured 6 coats in OR – 2 cultured Staph aureus (33%) </li></ul><ul><li>visibly soiled, pockets stuffed with books, food, scissors – even prescription pads! </li></ul><ul><li>Now offer fee for service cleaning physician lab coats in Environmental Services </li></ul><ul><li>Fellows/Residents/PA – provide weekly lab coats </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: </li></ul></ul><ul><ul><li>23% Staph aureus, </li></ul></ul><ul><ul><li>18% MRSA </li></ul></ul>
    11. 11. Peri-operative Environmental Evaluation <ul><ul><li>Overall preventive maintenance schedule </li></ul></ul><ul><ul><li>HVAC – filters and calibration of system, air quality & exchanges </li></ul></ul><ul><ul><li>Laminar flow in all operating rooms </li></ul></ul><ul><ul><ul><li>(although data inconclusive that these reduce SSI rates) </li></ul></ul></ul><ul><ul><li>Terminal room cleaning procedures on night shift – </li></ul></ul><ul><ul><li>are there sufficient cleaning staff? </li></ul></ul><ul><ul><li>Autoclave maintenance, instrument processing and sterilization </li></ul></ul>
    12. 12. Complicated Orthopedic Instruments <ul><li>Inspection of Orthopedic Instruments </li></ul><ul><ul><li>Lumens, grooves, sorting, hand cleaning, disassembly required – massive kits </li></ul></ul><ul><ul><li>Many instruments cannot be disassembled </li></ul></ul><ul><li>Company contracted – disassemble and bead blast the material coagulated and hardened within lumens </li></ul><ul><li>Instituted better pre-soaking and rinsing of tissue and blood from the instruments in the operating room before decontamination </li></ul><ul><li>2009 built new CSPD – state of the art </li></ul>
    13. 13. Environmental Upgrades <ul><li>Upgraded all OR rooms to laminar flow </li></ul><ul><ul><ul><li>(although data inconclusive that these reduce SSI rates) </li></ul></ul></ul><ul><li>Annually - close the OR over the holidays - entire cleaning of the inner core and rooms </li></ul><ul><li>Traffic Control – keep room doors closed and minimize traffic </li></ul>
    14. 14. Operating Room - 2004 <ul><li>More frequent environmental safety rounds by team </li></ul><ul><li>Infection control education for </li></ul><ul><li>OR staff and surgeons </li></ul><ul><li>Implement SCIP core measures: </li></ul><ul><ul><li>warming patient </li></ul></ul><ul><ul><li>surgical prophylaxis </li></ul></ul><ul><ul><li>hair clippers </li></ul></ul><ul><ul><li>increased oxygen </li></ul></ul>
    15. 15. <ul><ul><li>Established a weekly cross-check system of patients identified with resistant organisms (MRSA/VRE) </li></ul></ul><ul><li>Weekly email from Infection Control to: </li></ul><ul><ul><li>Pre-surgical Holding Unit </li></ul></ul><ul><ul><li>OR Surgical Scheduling </li></ul></ul><ul><ul><li>Patient Access (admitting) </li></ul></ul><ul><ul><li>Operating Room </li></ul></ul><ul><ul><li>Pre-assessment screening Unit (PASU) </li></ul></ul><ul><ul><li>PACU </li></ul></ul><ul><li>Master list of MRSA/VRE positive patients accessed on-line as a “live” file </li></ul>Infection Control - 2005
    16. 16. FY05 Operating Room <ul><li>Ultrasonic scrub </li></ul><ul><ul><li>movable carts, tables, poles and equipment </li></ul></ul><ul><li>1500 pieces cleaned </li></ul><ul><ul><li>OR, radiology, nursing units </li></ul></ul><ul><li>Cost: ~$20,000 </li></ul><ul><li>Done annually </li></ul><ul><li>APIC 2005 - Poster </li></ul><ul><li>M Spencer: The E=MC2 Project: Environment = Maintaining Cleanliness: A Multidisciplinary Approach To Establish a Routine Cleaning Schedule for Medical Equipment . APIC 2005 Baltimore Conference </li></ul>
    17. 17. Environmental Disinfection <ul><li>Developed cleaning schedules for departments in Patient Care Services </li></ul><ul><li>Eliminated dirty buckets of water – instituted micro fiber mop per OR room and wash/dry onsite </li></ul><ul><li>Daily check sheet for terminal cleaning of OR at night and for all precaution cases </li></ul>
    18. 18. Environmental Disinfection <ul><li>Silver Disinfectant Spray that </li></ul><ul><li>kills organisms up to 24 hrs on surfaces (Spectrum clene24 - (previously Agion) </li></ul><ul><li>Use in high volume areas that are cleaned once a day </li></ul><ul><ul><li>Radiology, Ambulatory Care Unit </li></ul></ul><ul><ul><li>PACU and Pre-surgery Unit </li></ul></ul><ul><li>Cubicle-curtain change policy –after each precaution discharge and </li></ul><ul><ul><li>6 months on nursing unit </li></ul></ul><ul><ul><li>3 months - ICU and Ambulatory Care </li></ul></ul>APIC 2007 – Poster Presentation: M Spencer: “Microbiologic Evaluation of a Silver Antimicrobial Disinfectant Spray” APIC San Jose, June 2007
    19. 19. Environmental Disinfection <ul><li>Assigning of staff to clean before each use: </li></ul><ul><ul><li>Blood pressure cuffs </li></ul></ul><ul><ul><li>Pulse oximeters </li></ul></ul><ul><ul><li>Thermometers </li></ul></ul><ul><ul><li>Leg tourniquets </li></ul></ul><ul><ul><li>Bar Coding equipment </li></ul></ul><ul><ul><li>Computers on Wheels </li></ul></ul><ul><li>SHEA poster March 2009 – San Diego Conference </li></ul><ul><li>Spencer M, et al: Nondisposable Blood Pressure Cuffs as a Potential Source for Cross Contamination. </li></ul>
    20. 20. Patient Risk Factors
    21. 21. Prosthetic Joint Infection Risk Factors <ul><li>Obesity </li></ul><ul><li>Diabetics and pre-diabetics </li></ul><ul><li>Poor patient hygiene </li></ul><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>Prior Infection in joint </li></ul><ul><li>Berbari E. et al: Clinical Infectious Diseases 1998;27:1247–54 </li></ul>
    22. 22. MRSA and Staph aureus Eradication Program <ul><li>Prescreening Process </li></ul><ul><li>Topical Decolonization Protocol </li></ul><ul><li>Vancomycin for MRSA </li></ul>Kim D, Spencer M, Davidson S, et al. J Bone Joint Surg Am. 2010;92:1820-6
    23. 23. February 2006 Obtained Anonymous Nares Cultures To Prove to Administration They Come In With Staph aureus and MRSA <ul><li>N = 133 patients </li></ul><ul><li>Purpose: to determine pre-op </li></ul><ul><li>MRSA and Staph aureus </li></ul><ul><li>Colonization rates </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 undiagnosed, no precautions used in OR or postop nursing unit, all MRSA cases received Cefazolin for prophylaxis </li></ul>
    24. 24. Implemented Decolonization Protocol <ul><ul><li>5-day application of intranasal 2% mupirocin - applied twice daily - for MRSA and Staph aureus positive patients </li></ul></ul><ul><ul><ul><li>Prescription called in by Nurse Practitioner in prescreening unit </li></ul></ul></ul><ul><ul><li>Daily body wash with chlorhexidine (purchased by patient) </li></ul></ul><ul><ul><li>MRSA Patients – Unique sticker system to notify Pre-surgery Unit of Vancomycin surgical prophylaxis </li></ul></ul>
    25. 25.
    26. 26. AORN Journal –Nov 2008 Vol 88, Nov. pages 818-820 “ Dealing with Antibiotic Resistant Organisms”
    27. 27. AORN <ul><li>Contact Precautions in Pre-op area, OR & PACU </li></ul><ul><ul><li>Gowns and gloves throughout procedure (in addition to Mask already worn) by Circulator ad Anesthesia </li></ul></ul><ul><ul><li>Circulator removes gown and gloves before leaving OR to retrieve supplies/equipment </li></ul></ul><ul><ul><li>Enhanced environmental cleaning after precaution cases – therefore last case in room or scheduled last case of day </li></ul></ul><ul><ul><li>Use outside runner or circulator if possible to prevent contamination of perioperative environment </li></ul></ul><ul><ul><ul><li>MRSA – survives from 22-90 days on polyethylene </li></ul></ul></ul><ul><ul><ul><li>Enterococci – 11 days </li></ul></ul></ul><ul><ul><ul><li>Clostridium difficile – five months </li></ul></ul></ul>
    28. 28. MRSA/MSSA Eradication Results <ul><ul><li>From July 17, 2006 through July 2010 </li></ul></ul><ul><ul><li>25,025 patients screened </li></ul></ul><ul><ul><ul><li>5770 (23%) positive for Staph aureus </li></ul></ul></ul><ul><ul><ul><li>1027 ( 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>
    29. 29. <ul><li>Time Period Inpatient surgeries # Surgical Infections % MRSA/MSSA </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 6 0.08% </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>FY10 </li></ul><ul><li>10/01/10-07/31/10 5397 5 0.09% </li></ul><ul><li>*historical controls </li></ul>% MRSA and Staph aureus SSI
    30. 30. <ul><li>Time Period Inpatient surgeries # MRSA SSI MRSA % #Infections/#MRSA+ </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>10/01/08-09/30/09 6366 6* (2+) 0.09% 2/234 (0.85%) </li></ul><ul><li>FY10 </li></ul><ul><li>10/01/10-07/31/10 5397 0 0.00% 0/208 (0%) </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
    31. 31. <ul><li>Time Period Inpatient surgeries # MSSA SSI MSSA % #MSSA Infections/# MSSA + </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><ul><li>FY10 </li></ul><ul><li>10/01/10-07/31/10 5397 5 (4+) 0.07% 4/1232 (0.32%) </li></ul>% Staph aureus (MSSA) SSI in Screen + Patients
    32. 32. FDA Cleared “Innovative Technologies&quot; <ul><li>Antiseptic cloth 2% chlorhexidine gluconate (CHG) impregnated </li></ul><ul><li>Urologic devices - Foley catheters-hydrogel/silver, Ureteral stents-triclosan eluting, Implantable prostheses—antibiotic </li></ul><ul><li>Central venous catheters - CHG-impregnated disk (dressing), Silver alone, Silver sulfanilamide (SS), SS/CHG, Minocycline/rifampin </li></ul><ul><li>Peritoneal catheters Silver-coated </li></ul><ul><li>Vascular catheters Silver/antibiotic-coated </li></ul><ul><li>Orthopedic devices external fixation pins- Silver Antibiotic-impregnated polymethylmethacrylate (PMM) </li></ul><ul><li>Surgical sutures - Braided and monofilament with triclosan </li></ul><ul><li>Topical Skin Adhesives - proven microbial barriers </li></ul>
    33. 33. Sample of Chlorhexidine Products for Healthcare Use BSI = bloodstream infection; CHG = chlorhexidine gluconate; ICU = intensive care unit; SSI = surgical site infection Product Format CHG Concentration Healthcare Uses Topical solution Sponge applicators Swab sticks Ampules 2% or 3.15% With 70% isopropyl alcohol Skin preparation for surgery, invasive procedures, central lines to prevent SSI and BSI Scrub solution Liquid detergent (sudsing base) 2% or 4% aqueous Preoperative showering/bathing General skin cleansing Washcloth Impregnated single-use washcloth/wipe 2% aqueous Daily bathing in ICU patients Dental solution Oral rinse 0.12% Decontaminate oral cavity (ventilator-associated pneumonia prevention protocols) Gauze dressing Cotton-weave gauze dressing 0.5% with paraffin Wounds or burns Catheter dressing CHG pad or integrated with semi-permeable transparent dressing 2% gel pad or foam disk Peripherally inserted central catheters Central line dressings Hand rub Waterless antiseptic hand gel 1% alcohol based with emollients Hand sanitizer for healthcare personnel (nonsoiled hands)
    34. 34. New CHG Irrigation Solution <ul><li> Wound Debridement and Cleansing system </li></ul><ul><ul><li>CHG concentration is 0.05%, lowest FDA-cleared concentration of this antiseptic </li></ul></ul><ul><ul><li>Testing shows that this concentration kills and inhibits Staphylococcus, CA-MRSA, HA-MRSA, Coagulase negative Staphylococcus, Pseudomonas aeruginosa, E. Coli and Aspergillus niger </li></ul></ul><ul><ul><li>IrriSept passed the FDA-required safety testing for irritation, immune response and cytoxicity. </li></ul></ul><ul><ul><li>There are only three limitations to use: (1) it should not be used on the eyes; (2) near the ear canal; or (3) on individuals sensitive to CHG. </li></ul></ul>
    35. 35. Antisepsis with Chlorhexidine <ul><li>2% CHG/70% alcohol skin preparation (tinted orange) </li></ul><ul><ul><li>Has a lasting effect on the skin </li></ul></ul><ul><ul><ul><li>~ 2 days postop </li></ul></ul></ul><ul><ul><li>Iodophors are fast kill but no long term effect </li></ul></ul><ul><ul><li>CHG dry time is 3 minutes (to prevent fires) </li></ul></ul><ul><li>Evidence that chlorhexidine/ alcohol achieves better skin antisepsis than iodophor </li></ul><ul><li> Darouiche et al NEJM 2010 </li></ul><ul><li>Ostrander et al JBJS Am 2005 </li></ul><ul><li>Saltzman et al JBJS Am 2009 </li></ul>
    36. 37. OR Air Current Contamination In teaching hospitals: Surgeon leaves room Resident, Physician Assistant or Nurse Practitioner work on incision Circulating Nurse counts sponges and starts room breakdown Scrub Technician starts breaking down tables and preparing instruments for Central Processing Anesthesia move in and out of room Instrument representative might leave room Visitors may leave room
    37. 38. Suture with Staphylococcus colonies Air settling plates in the operating room at the last hour of a total joint case Potential for Contamination of Sutures at End of Case
    38. 39. NEBH Antibacterial Suture Staph aureus Culture Plate Study <ul><li>A pure culture - 0.5 MacFarland Broth - of Staph aureus was prepared on a plate </li></ul><ul><li>A coated antibacterial suture was aseptically cut and planted and incubated for 24 hrs </li></ul><ul><li>Photo #1 shows zone of inhibition at day 5 </li></ul><ul><li>Photo # 2 shows zone of inhibition at day 10 </li></ul><ul><li>Plate on right is a non-coated suture. Staph aureus growth right over it </li></ul>5 day zone of inhibition 10 day zone of inhibition
    39. 40. 2005 – New England Baptist Hospital One Year Prospective Study of 3800 Total Joints and Antimicrobial Sutures <ul><li>In July, 2005 – implemented use of antibacterial sutures for a full year evaluation – changed product over July 4 th holiday and did not tell all surgeons (only those involved with study) </li></ul><ul><li>At the end of the year long trial period: </li></ul><ul><ul><li>45% reduction in surgical site </li></ul></ul><ul><ul><ul><li>infections caused by Staph aureus </li></ul></ul></ul><ul><ul><ul><li>and MRSA </li></ul></ul></ul><ul><ul><li>Reduction in total joint infections rate during trial period 0.44% - 0.33% </li></ul></ul><ul><li>NAON Poster Presentation - 2010 </li></ul><ul><li>Spencer M, et al: Reducing the Risk of Orthopedic Infections: The Role of Innovative Suture Technology </li></ul>
    40. 41. IRGACARE ® MP (triclosan) Properties <ul><li>IRGACARE MP </li></ul><ul><ul><li>2,4,4′-tri-chloro-2′-hydroxydiphenyl ether </li></ul></ul><ul><ul><li>High-purity material that meets USP specifications for triclosan, with minimal residue content </li></ul></ul><ul><li>IRGACARE MP is safe </li></ul><ul><ul><li>Biocompatible, nontoxic </li></ul></ul><ul><ul><li>Consumer products </li></ul></ul><ul><ul><ul><li>Mouthwash, toothpaste, soaps, cosmetics </li></ul></ul></ul><ul><li>IRGACARE MP is effective </li></ul><ul><ul><li>Active against methicillin-sensitive and methicillin-resistant S aureus and S epidermidis (most common for device infections) </li></ul></ul><ul><ul><li>Active against Escherichia coli and Klebsiella pneumoniae </li></ul></ul><ul><li>IRGACARE MP is compatible with suture processing </li></ul><ul><ul><li>Maintains excellent suture properties </li></ul></ul>USP=United States Pharmacopeia. Zurita R et al. Macromol Biosci. 2006;6:58-69. Ming Xet al. Surg Infect (Larchmt). 2007;8:201-207. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53 .
    41. 42. <ul><li>Compared with controls, IRGACARE MP-coated polyglactin 910 sutures produced </li></ul><ul><ul><ul><li>Substantial zones of inhibition (all sizes; P <.05) 1 </li></ul></ul></ul><ul><ul><ul><li>Zones of inhibition against methicillin-sensitive and methicillin-resistant S aureus and S epidermidis 1 </li></ul></ul></ul><ul><ul><ul><li>Microbial recovery of gram-positive and gram-negative organisms was significantly lower with IRGACARE MP-coated sutures vs non-coated sutures ( P <.01) 2 </li></ul></ul></ul><ul><ul><ul><li>Effective antiseptic activity of IRGACARE MP was present for at least 96 hours 2 </li></ul></ul></ul>IRGACARE MP-Coated Sutures: In Vitro Activity 1 Rothenburger S, et al. Surg Infect (Larchmt). 2002;3(suppl 1):S79-S87. 2 Edmiston CE, et al. J Am Coll Surg. 2006;203:481-489. Suture without IRGACARE MP Suture with IRGACARE MP
    42. 43. IRGACARE ® MP (triclosan): Mode of Action <ul><li>Chlorinated phenolic biocide— </li></ul><ul><li>a “phenol” with multi-targeted biocidal mechanisms </li></ul><ul><ul><li>Nonspecific effects on cell membrane activities and cell membrane integrity </li></ul></ul><ul><ul><li>Blocks active site of the enoyl-acyl carrier protein reductase —an essential enzyme in fatty acid synthesis—building cellular components and reproduction </li></ul></ul>
    43. 44. Why IRGACARE ® MP (triclosan)? <ul><li>Able to withstand the manufacturing process </li></ul><ul><li>Cost-effective </li></ul><ul><li>Safe in tissues </li></ul><ul><li>Performance/function properties </li></ul><ul><ul><li>Handling </li></ul></ul><ul><ul><li>Absorption profile, breaking-strength retention </li></ul></ul>
    44. 45. IRGACARE ® MP (triclosan): Pharmacokinetics <ul><li>Well absorbed </li></ul><ul><li>Well distributed in the body </li></ul><ul><li>Rapidly metabolized in liver to the glucuronide/sulfate conjugate </li></ul><ul><ul><li>T½=10 to 13 hours </li></ul></ul><ul><li>Excreted through kidneys </li></ul>
    45. 46. IRGACARE ® MP (triclosan) and Microbial Resistance <ul><li>IRGACARE MP is very effective against S aureus , S epidermidis and E coli , which are the 3 most important bacteria related to SSIs </li></ul><ul><li>There is no connection between the use of IRGACARE MP and significant antibiotic resistance </li></ul><ul><li>The use of IRGACARE MP may lead to the overall reduction of the antibiotic burden </li></ul><ul><ul><li>Decreases the risk of SSIs and the resulting application of stronger antibiotics against SSIs </li></ul></ul><ul><ul><li>The use of IRGACARE MP is not associated with increased bacterial virulence that raises the antibiotic burden </li></ul></ul>Ming X et al. Surg Infect (Larchmt). 2007;8:209-213. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. Ford HR et al. Surg Infect (Larchmt). 2005;6:313-321.
    46. 47. Articles Related To Antibacterial Sutures <ul><li>*Justinger, C, et al. Antibiotic coating of abdominal closure sutures and wound infection. Surgery 2009;145:330-4. (*RCT) </li></ul><ul><li>Rothenburger S, et al. In vitro antimicrobial evaluation of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect 2002;3 Suppl 1:S79-87 </li></ul><ul><li>Ford HR, et al. Intraoperative handling and wound healing: controlled clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture). Surgical Infections. 6(3):313-21, 2005. </li></ul><ul><li>Edmiston CE, et al. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? Journal of the American College of Surgeons. 203(4):481-9, 2006 Oct . </li></ul>
    47. 48. Protect OR Staff: ETHIGUARD* Blunt Point Needles <ul><li>ETHIGUARD Blunt Point Needles provide blunt point geometry that allows soft tissue penetration with minimum force, designed to decrease the incidence of needlestick injuries. </li></ul><ul><li>ETHICON offers 97 codes on ETHIGUARD Blunt Point needles, combined with braided and monofilament suture materials including Coated VICRYL* Plus Antibacterial Suture, MONOCRYL* Plus Antibacterial Suture, and PDS* Plus Antibacterial Suture, etc. </li></ul><ul><li>ETHIGUARD Needles are available on the most frequent use needles for fascia closure. </li></ul><ul><li>The sutures combined with ETHIGUARD needle have size from 1 to 3-0. </li></ul><ul><li>ETHIGUARD needle with a ribbed and flattened body affords greater stability in the needle holder, for improved protection against slipping and for precise control. </li></ul><ul><li>ETHIGUARD Blunt Point Needles require no changes to surgical technique. </li></ul><ul><li>ETHIGUARD Blunt Point Needles are supplied in secured needle packaging. </li></ul>* Trademark TPB-1: 65 mm SHB: 26 mm CTB-1: 36 mm CTXB: 48 mm CTB-2: 26 mm CTB: 40 mm
    48. 49. INCISIONAL SKIN ADHESIVE TO PREVENT EXOGENOUS CONTAMINATION TO INCISION DURIN G POST-OP PERIOD
    49. 50. Skin Issues in Orthopedics Anterior fusion with tape burns Posterior fusion with contaminated steri-strips Contaminated steri-strips
    50. 51. We Do Not Recommend Incisions opened to air with contaminated steristrips Bacteria feed off blood (and sugar) Incisions are in exudative stage of wound healing first few post-op days Sent home on day 3- 4 with incision and underlying tissues starting proliferative stage of wound healing Wounds are susceptible to dehiscence
    51. 52. Obesity and Surgical Incision <ul><li>Incision collects fluid – serum, blood - growth medium for organisms </li></ul><ul><li>Spine fusions -incisions close to the buttocks or neck </li></ul><ul><li>Heavy perspiration common </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>
    52. 53. Octyl-Cyanoacrylate Topical Skin Adhesive <ul><li>Cyanoacrylates were developed in 1949 </li></ul><ul><li>1970s - n-butyl-2-cyanoacrylate </li></ul><ul><li>1999 - 2-Octyl-Cyanoacrylate (DERMABOND) </li></ul><ul><ul><li>1 st FDA approved Topical Skin Adhesive </li></ul></ul><ul><li>Today – over 5 million patients a year are treated with Incisional Adhesive </li></ul><ul><li>2 Octyl cyanoacrylate has the longest carbon side chain for increased flexibility and, increased breaking strength versus butyl cyanoacrylate 1 </li></ul><ul><li>In vivo and In vitro studies demonstrate a proven microbial barrier against bacteria which may cause infection. </li></ul><ul><li>24 months shelf life, stores at room temperature </li></ul><ul><li>a violet, non tattooing dye for easy observation </li></ul>1. Quinn, JV Tissue Adhesives in Wound Care, BC Decker 1998. Attached are chapters from the book.
    53. 54. Mechanism of action <ul><li>Combination of monomer and plasticizers, that polymerizes to form a flexible/pliable adhesive film </li></ul><ul><li>Sets or cures within 45-90 seconds following final layer and reaches full mechanical strength in 2.5 minutes </li></ul><ul><li>If needed, can be wiped from skin within 10 seconds after application or with a petroleum based product after setting </li></ul><ul><li>Adhesive film sloughs or falls off wound within 7-10 days as skin re-epithelializes </li></ul><ul><li>Equivalent to 7 days wound healing strength in 3 minutes 1 </li></ul><ul><ul><li>1. Singer and Hollander, Lacerations in Acute Wounds: An evidence-based guide , p.85 </li></ul></ul>OCA: 300-500 microns thick compared to other N- Butyls at : <50 microns thick
    54. 55. Benefits for surgeons, nurses, patients, and hospitals <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>
    55. 56. Incisional Adhesive on Total Knee Incision
    56. 57. Incisionial Adhesive and AMD Dressing Knee : Sealed with Dermabond, covered with antimicrobial Telfa and a transparent dressing Hip: Sealed with Dermabond, covered with antimicrobial gauze and transparent dressing Healed incision
    57. 58. If Incisional Adhesive is Not used: Antimicrobial Post-op Dressings <ul><li>Antimicrobial (AMD) gauze for </li></ul><ul><li>all post-op incisions that are not sealed with adhesive </li></ul><ul><li>Impregnated with a 0.2% PHMB </li></ul><ul><li>(Polyhexamethylene Biguanides) </li></ul><ul><li>Initial dressing and subsequent </li></ul><ul><li>dressings done by nursing staff </li></ul><ul><li>At day of discharge – dressing </li></ul><ul><li>left in place for an additional 48 hrs postop </li></ul>
    58. 59. No More Flimsy Post-op Dressings ABD with Paper or Gauze Tape <ul><li>Check your residents and physician assistants sterile technique </li></ul><ul><ul><li>ABD pads may be stuffed in lab coat pockets during rounds </li></ul></ul><ul><ul><li>Gloves may not be worn for dressing changes. </li></ul></ul><ul><ul><li>Lack of hand hygiene </li></ul></ul><ul><ul><li>Bandage scissors often used between patients with no disinfection between use </li></ul></ul><ul><ul><li>Often discard bloody dressings in regular waste rather than get red bag and bring to dirty utility room – they rush early AM rounds to get into OR </li></ul></ul>
    59. 60. 2008 Standardization: Antimicrobial Dressing (AMD) By Nursing Staff AMD secured with MeFix tape for protection from exogenous contamination and prevention of tape burn Allow skin/incision to create proper temperature beneath dressing to enhance wound healing Protect the incision from exogenous contamination until discharge Protect the incision from trauma Incision protected until discharge and then 48 hrs post-op
    60. 61. Knee Dressings with Ace Ace bandage one day post-op with blood strikethrough after drain removed – nurses told to “reinforce” – another reason to have antimicrobial gauze beneath the ace bandage. Initial post-op dressing is usually an ace wrap for compression. AMD gauze are in post-op dressing kits to offer protection to the incision in first two days
    61. 62. Spine Service and Shoulders AMD sealed with Tegaderm left on until discharge AMD Island dressing – left on until discharge Rotator cuff (and total shoulders) – Dermabond is being used or an AMD gauze covered by tegaderm – left on until discharge
    62. 63. Practices with Limited Supporting Data
    63. 64. Surgical Incise Drapes <ul><li>Iodophor impregnated incise </li></ul><ul><li>barrier drape (“sacred cow”) </li></ul><ul><li>Cost: >~ $60,000/year </li></ul><ul><li>Surgeon preference based on adhesion to skin </li></ul><ul><li>and theoretical reduction in skin organisms </li></ul><ul><li>beneath the drape during surgery </li></ul><ul><li>A search on MEDLINE http://www.ncbi.nlm.nih.gov/entrez/query.fcgi </li></ul><ul><li>brought up 10 studies on antimicrobial drapes for human use. All but two were published in the 1980’s. </li></ul><ul><li>Of the 10 studies concerning drapes impregnated with a disinfectant, results were mixed. Other studies pointed out that, even though the survival rate of bacteria may have been reduced by using antimicrobial drapes, it represented little or no difference in wound infection rates when compared to conventional preparations </li></ul>
    64. 65. Bacitracin/Polymixin Irrigation <ul><li>Feb 2007 - stopped routine use of Bacitracin/Polymixin Irrigation </li></ul><ul><li>Cost: > $110,000/year </li></ul><ul><li>No evidence reduces SSI </li></ul><ul><li>Cases of anaphylactic shock associated with Bacitracin </li></ul><ul><li>Approved limited use for revisions, long spine cases, allografts and infected cases (irrigation and debridements) </li></ul><ul><li>Topical irrigation with polymyxin and bacitracin for spinal surgery. Surgical Neurology [Surg Neurol] 1998 Sep; Vol. 50 (3), pp. 208-12. </li></ul><ul><li>Intraoperative anaphylactic shock after bacitracin irrigation. Anesthesia And Analgesia [Anesth Analg] 1990 Oct; Vol. 71 (4), pp. 430-3. </li></ul>
    65. 66. UTI Prevention <ul><li>Goal: Prevent bladder infection </li></ul><ul><li>that would lead to seeding of prosthetic </li></ul><ul><li>device upon catheter removal </li></ul><ul><li>Closed catheter systems </li></ul><ul><ul><li>Silver-coated latex /silicone </li></ul></ul><ul><ul><li>Prevent UTIs postoperatively </li></ul></ul><ul><ul><li>Ideally in for no more than 48 hrs </li></ul></ul><ul><ul><li>Some old literature that supports silver </li></ul></ul><ul><ul><li>catheters </li></ul></ul><ul><li>We use silver latex catheters - no longer use Bactrim prophylaxis post-op (unless re-catheterized for urinary retention) </li></ul><ul><li>New SCIP core measure – catheters removed within 48 hrs </li></ul>
    66. 67. Our Experience and Evidence
    67. 68. OR Cleanup Bundle Approach to Reducing SSI
    68. 69. NEBH SSI Rates 2003 – 2010 (outpatient and inpatient infections)
    69. 70. Creative and Fun Hand Hygiene Educational Programs Infection Control - $7000.00/year budget
    70. 71. Most Important Control Measure <ul><li>HAND HYGIENE – wash off the dirt! </li></ul><ul><li>Wash hands several times a day – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes and communicate efficiently with one another to transfer antibiotic resistance factors </li></ul>
    71. 72. Alcohol Foam, Liquid and Hand Wipes All patients receive package of alcohol wipes in admission kit – encourage them to sanitize hands Foam or liquid sanitizer In each patient room, outside rooms, cafeteria and other areas Wash hands often – before eating, before leaving work, after contamination
    72. 73. Got Soap? - Engage Your Staff!! <ul><li>Engaged the OR staff in a Got Soap? Campaign </li></ul><ul><ul><li>OR Nurses </li></ul></ul><ul><ul><li>Surgeons </li></ul></ul><ul><ul><li>Administration </li></ul></ul><ul><ul><li>Infection Control </li></ul></ul>
    73. 74. <ul><li>November 2005 </li></ul><ul><li>“ Partners in Hand Hygiene ” </li></ul><ul><li>January 2006 </li></ul><ul><li>“ Let it S.N.O.W.” </li></ul><ul><li>Stop Nosocomial </li></ul><ul><li>Organisms by Washing </li></ul><ul><li>April 2006 </li></ul><ul><li>“ Do the H.O.P.” </li></ul><ul><li>Hand washing Offers Protection </li></ul>Patient and Visitor Empowerment Routine Cafeteria Displays
    74. 75. <ul><li>LUAU </li></ul><ul><li>Let Us Always Use </li></ul><ul><li>Good Hand Hygiene </li></ul><ul><li>Cafeteria Cruise Ship </li></ul><ul><li>Alcohol hand rub to </li></ul><ul><li>enter cafeteria </li></ul><ul><li>Posters – Engage the Staff </li></ul><ul><li>Hawaiian music and food </li></ul><ul><li>Raffle table and </li></ul><ul><li>candy distributed </li></ul>Be Creative – Make it Fun
    75. 76. Creative and Interactive Glo-Germ “Bug Beat” Fair Contact Plates
    76. 77. <ul><li>16 poster displays: </li></ul><ul><ul><li>Admitting </li></ul></ul><ul><ul><li>Surgical Services </li></ul></ul><ul><ul><li>Micro Lab </li></ul></ul><ul><ul><li>EVS, Transport </li></ul></ul><ul><ul><li>Nursing Units </li></ul></ul>M.R.S.A . Fair – Program Make Resistance Stay Away
    77. 78. 2007
    78. 79. 2007
    79. 80. 2008
    80. 82. Hand Hygiene Observations
    81. 83. Tools for Success <ul><li>Senior leadership and Board of Trustees involvement – “lead the effort” from top down </li></ul><ul><li>Structured program with clearly defined goal of zero tolerance for HAIs </li></ul><ul><li>Communication – effective and consistent </li></ul><ul><li>Ongoing and creative education </li></ul><ul><li>Financial support to Infection Control program </li></ul>
    82. 84. Thank You

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