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APIC Decennial March 18-22, 2010


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APIC Decennial March 18-22, 2010

  1. 1. Inter Regional General Surgery Meeting April 11, 2010 Surgical Site Infection Prevention Bundle and Plus Measures Steve Parodi, MD, Chair KP NCal Regional Infectious Disease Chiefs, Chief ID Vallejo, CA [email_address] Sue Barnes, RN, CIC, National Leader, KP Infection Prevention and Control - National Office - Oakland, CA [email_address]
  2. 2. Overview <ul><li>Bundle vs. Plus Measures and supporting evidence </li></ul><ul><li>Success stories for top 3 Plus Measures </li></ul><ul><li>Definitions, detection and reporting (including NSQIP vs. NHSN definitions) </li></ul><ul><li>Public reporting mandates by region </li></ul><ul><li>PAB guidelines supporting infection prevention </li></ul>
  3. 3. Bundle Measures vs. Plus Measures <ul><li>The Care Bundle concept created in 2002 by VA/IHI when vent bundle was developed </li></ul><ul><li>Per IHI definition a bundle = 3-5 practices designed to be performed all at once every time – each is based on RCTs </li></ul><ul><li>Plus Measures = prevention efforts supported by less than category 1 level evidence – see KP Plus Measures Toolkit (pg 7-9): </li></ul>
  4. 4. Success stories for top 3 Plus Measures <ul><li>Chlorhexidine impregnated bathing cloths or showers pre-operatively </li></ul><ul><li>Normothermia </li></ul><ul><li>Dual agent skin prep – i.e. Chloraprep or Duraprep </li></ul>Time since last SSI Med Centers performing all 3 1 SSI in 30 months Hospital 3 15 mo Hospital 2 12 mo Hospital 1 Time since last SSI Med Centers performing 2/3 1 SSI in 15 months Hospital 6 9 mo Hospital 5 24 mo Hospital 4
  5. 5. Plus measures – SSI Prevention (in addition to SCIP measures) <ul><li>ensure for ortho cases that pre op antibiotic is infused 20 minutes prior to tourniquet application. </li></ul><ul><li>3 rd party observation of surgical cases using standard IC checklist </li></ul><ul><li>cover staff hair (beard, chest, head); clip patient hair (and remove clipped hair) before entering OR; teach female patients no leg shaving for pre op total knee replacement </li></ul><ul><li>pre op antiseptic bathing – impregnated cloths vs. shower </li></ul><ul><li>post op antiseptic dressings </li></ul><ul><li>consider: 3 gms ancef pre op as standard at least for bariatric </li></ul><ul><li>decolonization MRSA pre op high risk procedures </li></ul><ul><li>antiseptic impregnated post op dressings </li></ul>
  6. 6. Revisiting the Preadmission (Preoperative) Shower <ul><li>Conclusion: No evidence-based benefit </li></ul><ul><li>6 sentinel studies – legitimate concerns </li></ul><ul><ul><li>No routine standard of practice </li></ul></ul><ul><ul><li>Some individuals showered once, other multiple times </li></ul></ul><ul><ul><li>Heterogeneous study population </li></ul></ul><ul><ul><li>No evidence of patient compliance </li></ul></ul><ul><li>Cochrane Collaborative </li></ul><ul><ul><li>Eyers PS, et al. Cochrane Database 2006;3: CD003073 </li></ul></ul><ul><ul><li>Edwards et al.. Cochrane Database 2006;3: CD003949. pub 2 </li></ul></ul>
  7. 7. CHG Concentration (PPM) Skin Sites Left Elbow Right Elbow Abdominal Left Knee Right Knee Pilot Data – Skin Concentration of 4% Chlorhexidine Gluconate (CHG) Following Shower - “Evening” and “Morning” (N = 10) MIC 90 = 4.8 ppm Note: 3 subject in “Evening” and 2 subjects in “Morning” groups recorded no CHG concentration at 1 or more skin sites “ Morning” Group (AM)” CHG Shower “ Evening” Group (PM)”
  8. 8. CHG Concentration (PPM) Skin Sites Left Elbow Right Elbow Abdominal Left Knee Right Knee 4% Chlorhexidine Gluconate (CHG) Shower - Skin Surface Concentration (N=60) MIC 90 = 4.8 ppm Group 2A “Morning (AM)” Group 3A “ Both (AM and PM)” CHG Shower Group 1A “Evening (PM)” p < 0.05 NS P<0.001 Edmiston et al, J Am Coll Surg 2008;207:233-239
  9. 9. CHG Concentration (PPM) Skin Sites Left Elbow Group 1B “Evening (PM)” Group 2B “Morning (AM)” Right Elbow Abdominal Left Knee Right Knee 2% Chlorhexidine Gluconate (CHG) Impregnated Cloth Application – Skin Surface Concentration (N = 60) Group 3B “ Both (AM and PM)” MIC 90 = 4.8 ppm CHG Cloth Application p < 0.05 p < 0.001 Edmiston et al, J Am Coll Surg 2008;207:233-239
  10. 10. Efficacy of Preoperative CHG Wipes <ul><li>Observational non-randomized use of 2% CHG impregnated cloths on orthopedic total joint patients - SSI Rates dropped 50.1% (3.2% to 1.6%) </li></ul><ul><li>Need randomized studies </li></ul><ul><li>Need to make sure patients adhere to protocol for application </li></ul>Eiselt, Ortho Nurs 2009;28:141-5
  11. 11. A PROSPECTIVE, RANDOMIZED, MULTICENTER CLINICAL TRIAL OF 2% CHLORHEXIDINE GLUCONATE / 70% ISOPROPYL ALCOHOL (Alc-CHG) VS POVIDONE-IODINE (PI) FOR PREVENTION OF SSI <ul><li>Patients > 18 years, undergoing clean/clean-contaminated procedures (gastrointestinal, thoracic, urologic and gynecologic) </li></ul><ul><li>N = 820 surgical patients: 400 Alc-CHG vs. 420 PI :1 randomization </li></ul><ul><li>Patients monitored for 30 days post-op </li></ul><ul><li>Overall rate of SSI was significantly reduced in Alc-CHG vs. PI groups: 9.8 vs. 16.9, p<0.003 </li></ul><ul><li>Significant difference (p<0.01 ) in superficial incisional site rate: 4.3% (A-CHG) v. 8.6% (PI) – rate for deep incisional 1% v. 3% </li></ul><ul><li>No significant difference for organ space infection </li></ul><ul><li>No significant adverse events noted during the study in either group </li></ul><ul><li>Alc-CHG superior to PI in reducing the risk of SSI in clean/clean-contaminated procedures </li></ul>Dairouche, NEJM 2010;362:18-26
  12. 12. What to do about MRSA? <ul><li>Conflicting Studies Regarding Preop Screening </li></ul><ul><ul><li>Large randomized crossover trial using universal screening of specialty v. general surgical patients for MRSA. MRSA patients received decolonization and periop vanco. No difference in SSI rates. </li></ul></ul><ul><ul><li>Smaller controlled trial screened patients, treated with decolonization and daily CHG baths. Excluded “simple procedures.” Reduced S. aureus SSI rates by 60%. </li></ul></ul><ul><li>Screening generally restricted to more complex procedures ( i.e. implants, CV surgery) </li></ul>Harbath JAMA 2008;299:1149 Bode NEJM 2010;362:9
  13. 13. Percent Serum/Tissue Concentrations Achieving Therapeutic levels at a 2 gm (N = 38) and 3 gm (N = 40) Perioperative Dosing Regimen 2-gm a 3-gm b Organism N Serum Tissue N Serum Tissue S. aureus 70 68.6% 27.1% 92 87.5% 68.5% S. epidermidis 110 34.5% 10.9% 156 64.5% 49.6% E. coli 85 75.3% 56.4% 101 92.4% 86.5% Kl. pneumoniae 55 80% 65.4% 49 96.8% 90.4% a period covering 2001-2003 b period covering 2006-2008 a Edmiston et al, Surgery 2004;136:738-747 b Edmiston et al., Submitted for publication 2009 Perioperative Antimicrobial Prophylaxis in Higher BMI ( > 40) Patients: Do We Achieve Therapeutic Levels?
  14. 14. Evaluation of Antiseptic Activity of Triclosan-Coated Polyglactin 910 Suture at 24, 48, 72 and 96 Hours Compared to Standard Polyglactin 910 Braided Suture Mean colony forming units (cfu)/cm suture S. aureus (10 5 ) MRSA S. epidermidis (10 5 ) RP62A Non-coated polyglactin 910 NS NS 24 hr VT 48 hr VT 72 hr VT 96 hr VT N=10 p<0.01 p<0.01 Edmiston et al, J Am Coll Surg 2006;203:481-489
  15. 15. <ul><li>Antimicrobial Suture (AMS) Wound Closure for </li></ul><ul><li>Cerebrospinal Fluid Shunt Surgery: A </li></ul><ul><li>Prospective, Double-blinded, Randomized </li></ul><ul><li>Controlled Trial </li></ul>The shunt infection rate in the study group was 4.3%, while the infection rate was 21% in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups. These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and associated with a reduced risk of postoperative shunt infection. Rozzelle et al., J Neurosurgery 2008;2:111-117
  16. 16. Definitions: NSQIP vs. NHSN <ul><li>NSQIP Definition : </li></ul><ul><li>Identifies by CPT code </li></ul><ul><li>reports SSI data in 3 procedure categories combining various procedures: general, vascular, colorectal </li></ul><ul><li>uses O/E (observed/expected) ratios instead of infections/procedures x 100 (rate) instead of infection rates </li></ul><ul><li>NHSN Definition : </li></ul><ul><li>categorized by wound severity: superficial, deep, or organ space </li></ul><ul><li>all surgical procedures reported separately </li></ul><ul><li>rates are stratified by risk index 0 – 3: one point assigned for each of the following: </li></ul><ul><li>1. Operation lasts for longer than 2 hrs </li></ul><ul><li>2. Contaminated or dirty/infected wound classification </li></ul><ul><li>3. ASA Classification of 3, 4 or 5. </li></ul>
  17. 17. Public reporting mandates by region <ul><li>NW ICU BSI, SSIs total knee and CABG </li></ul><ul><li>CO BSI in ICU, VAP, SSI in THA, TKA, Hernia, CABG, and Vag hyst. </li></ul><ul><li>HAWAII no reporting required </li></ul><ul><li>MAS MD - BSI in the ICU, SSI CABG, hips and knees; VA - BSI; DC -MRSA, SCIP measures </li></ul><ul><li>GA no reporting at this time </li></ul><ul><li>OH no reporting at this time </li></ul><ul><li>NCAL/SCAL MRSA Bloodstream Infections (BSIs), Clostridium difficile infections, VRE BSIs, Non-ICU Central line-associated BSIs not reported through NHSN, Deep or organ/space Surgical Site Infections not reported through NHSN, Orthopedic (total knee/hip), Cardiac (CABG), GI (colon resection), SCIP </li></ul>
  18. 18. PAB guidelines supporting infection prevention <ul><li>Infusion of the first antimicrobial dose should begin within 60 minutes before the surgical incision </li></ul><ul><li>Infusion antibiotic completed 20 minutes prior to inflation of tourniquet for total knee </li></ul><ul><li>Discontinue 24 hours post operatively </li></ul><ul><li>Adjust dose by weight </li></ul><ul><li>Order set </li></ul>