Establishing a culture of safety april 2012


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Establishing a culture of safety april 2012

  1. 1. Establishing a Culture of Safety: Working Toward Zero Orthopedic SSIs Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant Boston, MA Email:
  2. 2. Example of Working Toward Zero Team Members The teams:  Surgical Site Infections: Director Surgical Services, OR Manager, SPD Director, Infection Control Manager, Two Surgeons, VP Patient Care Services, Director of Nursing, Nursing Manager, Clinical Educator, Microbiology Lab Director  Ventilator Associated Pneumonia: ICU Hospitalist, ICU Nurse Manager, ICU Nurse, Director of Anesthesia, ICU Clinical Educator, Respiratory Therapy, Infection Control Manager, Micro Lab  Central Line Assoc Bloodstream Infections: Surgeon who inserted most central lines, ICU Manager, Director of Anesthesia, ICU Clinical Educator, ICU Nurse, Infection Control Manager  Catheter Assoc UTI: Clinical Educator, Infection Control Manager, Chief Urology, Lab Director  MRSA Elimination: Infection Control Manager, Pre-admission testing, OR Director, Microbiology Lab Director, Two Surgeons, Director of Nursing, Patient Access Director,  Information Technology, ID physician  C.difficile: Chiefs of Surgery and Gastroenterology, ICU Nurse Manager, Micro Lab Director, Infection Control Manager2
  3. 3. Post-op: Irrigation? Incisional Patient adhesive should education is Consider using be the number extremely Intraoperative: saline or new one consideration important since CHG/alcohol CHG (0.05%) for wound many patients skin prep, irrigant and closure – are discharged antibacterial eliminate prevents early in thePre-op: sutures, expensive and dehiscence and post-op period incisional toxic exogenous and haveScreen for MRSA bacitracin/polymiand Staph aureus adhesive contamination to incisions that are xin or antibiotic wound in the exudativeCHG pre-op irrigantshower or cleanse If not used state of woundwith impregnated consider covering healingcloths incision for lengthAssure OR meets of hospitalizationAORN standards ofpractice
  4. 4. MRSA and Staph aureus Elimination Program Before Patients Enter the Hospital for Surgery Prescreening Process Topical Decolonization Protocol Vancomycin for MRSA1. Kim D, Spencer M, Davidson S, et al. J Bone Joint Surg 2010;92:1820-62. Spencer M, Kim D, et al: AAOS, 20104
  5. 5. Provided Evidence: February 2006 Anonymous Nares Cultures To Prove to Administration Patients Are Colonized With Staph aureus and MRSA N = 133 patients anonymously surveyed and cultured in OR after anesthetized Purpose: to determine pre-op MRSA and Staph aureus colonization rates for administration Results: 38 – Staph aureus (29%) *5 - MRSA ( 4%) *all undiagnosed, no precautions used in OR, PACU, postop nursing unit *MRSA cases received Cefazolin for surgical5 prophylaxis – THE WRONG ANTIBIOTIC!
  6. 6. Implemented Decolonization Protocol • 5-day application of intranasal 2% mupirocin - applied twice daily - for MRSA and Staph aureus positive patients • Prescription called in by Nurse Practitioner in prescreening unit • Daily body wash with chlorhexidine (purchased by patient) • MRSA Patients – Unique sticker system to notify Pre-surgery Unit of Vancomycin surgical prophylaxis6
  7. 7. 7
  8. 8. Pre-op MRSA and S. aureus Decolonization  Results:  Timeframe: July 17, 2006 through September 2010  Infection rate: 20,065 patient screened 5,988 (23%) positive for Staph aureus 1,027 ( 4%) positive for MRSA  Effectiveness: Repeat nasal screens on MRSA patients revealed 77% eradication8
  9. 9. Pre-op MRSA and S. aureus Decolonization  Results: % MRSA and S. aureus SSI Inpatient # of Surgical Time Period %MRSA/MSSA Surgeries Infections FY06 10/01/05-07/16/06* 5,293* 24* 0.45%* *Historical Controls FY07 07/17/06-09/30/07 7,019 6 0.08% FY08 10/01/07-09/30/08 6,323 7 0.11% FY09 10/01/08-09/30/09 6,364 11 0.17% FY10 10/01/10-09/30/10 6,437 6 0.09%9
  10. 10. Pre-op MRSA Decolonization  Results: % MRSA SSI in Screened Patients Inpatient # MRSA #Infect/#MRSA Time Period MRSA% Surgeries SSIs + FY06 10/01/05-07/16/06 5,293 10 (NA) 0.19% NA FY07 07/17/06-09/30/07 7,019 3 (3+) 0.04% 3/309 (0.97%) FY08 10/01/07-09/30/08 6,245 4 (2+) 0.06% 2/242 (0.83%) FY09 10/01/08-09/30/09 6,336 6* (2+) 0.09% 2/234 (0.85%) FY10 10/01/10-09/30/10 6,437 1 (1+) 0.01% 1/266 (0.37%) * isolates have been sent for pulse field gel electrophoresis10 5 of the 6 isolates were available for PFGE and were not related genetically
  11. 11. Pre-op Staph aureus Decolonization  Results: % S. aureus (MSSA) SSI in Screened Patients Inpatient # MSSA #Infect/#MSSA Time Period MSSA% Surgeries SSIs + FY06 10/01/05-07/16/06 5,293 14 (NA) 0.26% NA FY07 07/17/06-09/30/07 7,019 3 (3+) 0.04% 3/1588 (0.19%) FY08 10/01/07-09/30/08 6,245 3 (1+) 0.05% 1/ 1422 (0.07%) FY09 10/01/08-09/30/09 6,336 5 (1+) 0.08% 3/1403 (0.21%) FY10 10/01/10-09/30/10 6,437 6 (1+) 0.09% 1/1450 (0.06%)11
  12. 12. OR Risk Factors: Contamination from OR Staff • Reviewed orderlies and room turnover procedures • Improved traffic control – new signage and monitoring system keep room doors closed and minimize traffic • Eliminate surgical caps – do not cover hair! • Cloth cap use – if worn, must be covered in OR room with disposable cap - hair coverage monitored – Hair harbors organisms – Staff sweat in cloth caps – How often do they get washed? Hospital laundered – Where are they stored? – Would you eat a meal with hair in it? – Why allow hair to potentially fall into surgical incisions?12
  13. 13. OR Risk Factors: Cleaning/Sterilization of Instruments • Inspection of Orthopedic Instruments – Lumens, grooves, sorting, hand cleaning, disassembly required – massive kits – Many instruments cannot be disassembled • Instituted better pre-soaking and rinsing of tissue and blood from the instruments in the operating room before decontamination • There was a recent outbreak investigated by CDC of shoulder infections - found shavers and cannulas with biofilm and tissue observed inside instruments with small camera13
  14. 14. Pathogens survive on surfaces Organism Survival period Clostridium difficile 35- >200 days.2,7,8 Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days.1,5,10 Vancomycin-resistant enterococcus (VRE) 58- >200 days.2,3,4 Escherichia coli >150- 480 days.7,9 Acinetobacter 150- >300 days.7,11 Klebsiella >10- 900 days.6,7 Salmonella typhimurium 10 days- 4.2 years.7 Mycobacterium tuberculosis 120 days.7 Candida albicans 120 days.7 Most viruses from the respiratory tract (eg: corona, Few days.7 coxsackie, influenza, SARS, rhino virus) Viruses from the gastrointestinal tract (eg: astrovirus, HAV, 60- 90 days.7 polio- or rota virus) Blood-borne viruses (eg: HBV or HIV) >7 days.51. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5. 7. Kramer et al. 2006. BMC Infect Dis. 6:130.2. BIOQUELL trials, unpublished data. 8. Otter and French. 2009. J Clin Microbiol. 47:205-7.3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2 9. Smith et al. 1996. J Med. 27: 293-302.4. Boyce. 2007. J Hosp Infect. 65:50-4. 10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4.5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200. 11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.6. French et al. 2004. ICAAC.
  15. 15. Why Better Environmental Cleaning? Prior room occupancy increases riskStudy Healthcare associated pathogen Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room)Martinez 20031 VRE – cultured within room 2.6x VRE – prior room occupant 1.6xHuang 20062 MRSA – prior room occupant 1.3x VRE – cultured within room 1.9x VRE – prior room occupant 2.2xDrees 20083 VRE – prior room occupant in previous two 2.0x weeksShaughnessy 20084 C. difficile – prior room occupant 2.4x A. baumannii – prior room occupant 3.8xNseir 20105 P. aeruginosa – prior room occupant 2.1x1. Martinez et al. Arch Intern Med 2003; 163: 1905-12.2. Huang et al. Arch Intern Med 2006; 166: 1945-51.3. Drees et al. Clin Infect Dis 2008; 46: 678-85.4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.5. Nseir et al. Clin Microbiol Infect 2010 (in press).
  16. 16. Rates of Surface Contamination (in hospitals) with MSRA,VRE, and C. Difficile Blood Pressure Cuff: Windowsill: VRE 14% C. Difficile 33% Commode: Overbed Table: C. Difficile 41% MRSA 40% VRE 20% Patient Gowns: MRSA 51% Bedrail: MRSA 29% Floors: VRE 28% MRSA 55% C. Difficile 19% C. Difficile 48% Bedsheets: MRSA 53% Did you know that every time you get a new roommate, there is an VRE 40% increase of 3-10% that you will acquire an HAI. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med. 2006 Oct 9;166(18):1945-51 Boyce J.M. et al.: Environmental contamination due to methicillin-resistant Staphylococcus aureus: Possible infection control implications. Infect Control Hosp Epidemiol 18:622-627, Sep. 1997. Slaughter S., et al.: A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 125: 448-456, Sep 15, 1996. Samore M.H., et al.: Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 100:32-40, Jan. 1996.
  17. 17. Environmental Disinfection – Joint Commission and CMS Focus on Surveys  Developed cleaning schedules for Patient Care Services – what equipment, how cleaned/disinfected, how often, by who, contact times for disinfectants?  Eliminate dirty buckets of water and string mops  institute micro fiber cloths and mops  Assure staff know proper cleaning technique:  left to right, high to low, clean to dirty with competencies  Daily check sheet for terminal cleaning of OR at night and for all precaution cases17
  18. 18. Decontamination of Portable Equipment with Contracted Services  Ultrasonic scrub  Movable carts  Tables  Poles  Small equipment  1500 pieces cleaned  OR, radiology, nursing  Cost: ~$20,000 / year APIC 2005 Poster M Spencer, at al: The E=MC2 Project: Environment = Maintaining Cleanliness: A Multidisciplinary Approach To Establish a Routine Cleaning Schedule for Medical Equipment.18
  19. 19. SSI risk can be addressed by controlling risk factors  Precautions are already in place to control the risk of bacterial contamination throughout the peri-operative period  However, additional controllable risk factors remain – wound closure provides an opportunity to address these risks Controlled Risks Potentially Uncontrolled Risks  Scrubbing in ☐ Bacterial colonization of the suture  Gowning ☐ Contamination of the incisional site  Skin antisepsis after the wound is closed  Controlling OR environment ☐ Entry of bacteria from the skin during  Sterilizing instruments wound closure  Using minimally invasive techniques ☐ Bacterial infiltration due to dehiscence19
  20. 20. Uncontrolled Risk Factor: Bacterial colonization of the suture  Like all foreign bodies, sutures can be colonized by bacteria:  Implants provide nidus for attachment of bacteria1  Bacterial colonization can lead to biofilm formation1  Biofilm formation increases the difficulty of treating an infection2 On an implant, such as a suture, it takes only 100 staphylococci per gram of tissue for an SSI to develop3 Contamination Colonization Biofilm Formation 1. Ward KH et al. J Med Microbiol. 1992;36: 406-413. 2. Kathju S et al Surg infect. 2009;10:457-46120 3. Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27:97-134..
  21. 21. Why Plus Suture?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 and Visitors may leave room
  22. 22. Potential for Contamination of Sutures at End of Case Air settling plates in the operating room at the last hour of a total joint caseSuture with Staphylococcus colonies
  23. 23. Plus Antibacterial Sutures: Impact in a Real-World Setting  Plus sutures not only kill bacteria on the suture, but also create an inhospitable environment around the suture  NEBH studied the “zone of inhibition” around the suture  A pure culture—0.5 MacFarland Broth—of S. aureus was prepared on a culture plate  An antibacterial suture was aseptically cut, planted on the culture plate, and incubated for 24 hrs Traditional suture Antimicrobial suture23 5 day zone of inhibition 10 day zone of inhibition
  24. 24. Plus Antibacterial Sutures: Impact in a Real-World Setting  NEBH One Year Prospective Study of 3800 Total Joints and Antimicrobial Sutures  In July 2005, implemented a full-year evaluation of antibacterial sutures usage in an orthopedic setting  Changed product over July 4th holiday and did not tell all surgeons (only those involved with study)  At the end of the year-long trial period:  45% reduction in SSIs caused by Staph aureus and MRSA  Infection rate dropped from 0.5 0.4 0.44% to 0.33% with three less infections 0.2 0.3 Series1 0.1 0 FY05 FY06 NAON Poster Presentation - 201024  Spencer M, et al: Reducing the Risk of Orthopedic Infections: The Role of Innovative Suture Technology
  25. 25. Articles Related To Antibacterial Sutures *Justinger, C, et al. Antibiotic coating of abdominal closure sutures and wound infection. Surgery 2009;145:330-4. (*RCT) 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 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. 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
  26. 26. Innovative wound closure technologies can address risk factors for SSIs  Topical Skin Adhesive provides a microbial barrier during the critical wound healing period SSI Risk Factor Innovative Technology  Bacterial colonization of the suture  Antibacterial Sutures  Contamination of the incisional site after the  Chlorhexidine/alcohol skin prep wound is closed  Prevention of Dehiscence and  Entry of bacteria from the skin during Exogenous Contamination with wound closure Topical Skin Adhesive or  Bacterial infiltration due to dehiscence Antimicrobial Dressings26
  27. 27. Antisepsis with Chlorhexidine 2% CHG/70% alcohol skin preparation (tinted orange)  Has a lasting effect on the skin  ~ 2 days postop  Iodophors are fast kill but no long term effect  CHG dry time is 3 minutes (to prevent fires)• Evidence that chlorhexidine/alcohol achieves better skin antisepsis than iodophor Darouiche et al NEJM 2010 Ostrander et al JBJS Am 2005 Saltzman et al JBJS Am 2009 27
  28. 28. Post-op Skin Issues in Orthopedics Anterior fusion with tape burns Contaminated steri-stripsPosterior fusion with contaminated steri-strips Staples increase infection rate
  29. 29. Associated Wound Infection or Separation AfterCesarean Delivery: Sutures vs Staples Prospective, randomized study of 435 c-section patients1  197 patients: staples  219 patients: 4-0 MONOCRYL™ (poliglecaprone 25) Suture on PS2 needle – Wound separation rate: 17% (staples) vs. 5 % (sutures) – Wound complication rate: 22% (staples) vs. 9% (sutures) – Staple closure was a significant independent risk factor for wound separation after adjustment for all other factors (GDM, BMI >30, incision type, etc) Meta-analysis of 6 studies with a total of 1487 c-section patients2  803 patients: staples  684 patients: subcuticular suture closure – Staple closure was associated with a two-fold increase in risk of wound infection or separation 1. Basha et al. Am J Obstet Gynecol. 2010;203:285.e1. 2. Tuuli et al. Obset Gynecol. 2011;117:682.
  30. 30. The risk for infection after joint surgery is higher with staples vs traditionalstitches, according to the results of a meta-analysis reported in the March16 2010 issue of the BMJ. In 6 publications reporting on a total of 683 wounds, 332 patients underwent wound closure with sutures, and 351 underwent closure with staples. Compared with suture closure, staple closure was associated with more than triple the risk for the development of a superficial wound infection after orthopaedic surgery (RR, 3.83; 95% CI, 1.38 – 10.68; P = .01). When hip surgery was analyzed as a separate subgroup, the risk for the development of a wound infection was 4 times greater with use of staples vs use of sutures (RR, 4.79, 95% CI, 1.24 – 18.47; P = .02). Suture closure and staple closure did not differ significantly in development of inflammation, discharge, dehiscence, necrosis, or allergic reaction. “The Medical Journal of Australia” has recently updated its guidelines for skin closure in the treatment of hip fractures, and they state that superficial wound complication rates are higher for wounds closed with metallic staples than for wounds closed with subcuticular vicryl.
  31. 31. Obesity and Surgical Incision  Incision collects fluid – serum, blood - growth medium for organisms  Spine fusions -incisions close to the buttocks or neck  Heavy perspiration common  Body fluid contamination from bedpans/commodes  Friction and sliding - skin tears and blisters  Itchy skin - due to pain medications - skin breakdown31
  32. 32. Topical Skin Adhesive: A Proven Microbial Barrier  Provides a flexible, protective microbial barrier that moves with the patient, preventing breakage and acting like a temporary “skin”1,2  Adhesive demonstrates inhibition of gram-positive bacteria (MRSA and MRSE) and gram-negative bacteria (E coli) in vitro2-4  Provides greater than 99% protection for 72 hours against organisms commonly responsible for SSIs2,3:  S. epidermidis  E. coli  S. aureus  Pseudomonas aeruginosa  Enterococcus faecium No fractures, 1. Quinn et al. JAMA. 1997;277:1527-1530 wound failure 2. Bhende et al. Surg Infect (Larchmt). 2002;3:251-257. or dehiscence 3. Narang et al. J Cutan Med Surg. 2003;7:13. 4. World Health Organization. WHO Guidelines for Safe Surgery 2009. 2009.32
  33. 33. Topical Skin Adhesive: Benefits Beyond Risk Reduction For Hospital Staff  No time spent removing staples or sutures  Reduced hospitalization costs  Reduces number of suture set ups  Simplifies post-op wound checks  Reduces number of wound dressings For Patients  7 days of wound healing strength in less than 95 seconds of application  Shower immediately  Outstanding cosmesis  Reduced follow-up  Less pain and anxiety33
  34. 34. Incisional Adhesive on Total Knee Incision
  35. 35. Clinical Use of Incisionial Adhesive Hip: Sealed with adhesive covered with gauze and transparent dressing for incision protection Knee: Sealed with incisional adhesive, covered with Telfa and a transparent dressing Healed incision for incision protection
  36. 36. Incisional Adhesive and TotalShoulder Replacements Total Shoulder Rates 2.5 2 1.5 1 0.5 0 2003 2004 2005 2006 2007 2008 2009 2010• Propionibacterium acnes related total shoulder infections (TSR)• Eliminated the use of staples for TSR• Instituted the use of incisional adhesive• Covered dressing until day of discharge for protection
  37. 37. Selected Publications: DERMABOND® Topical Skin Adhesive in Orthopedic Surgery Procedure Reference No. of Patients Key Findings • Patients followed for >7 months Primary hip arthroplasty1 Khurana et al. 2008 93 • No infections • 1 wound dehiscence • Patients followed for >5 months Lumbar and cervical spine 200 Hall and Bailes. 2005 • Only 1 documented SSI procedures2 Retrospective • High patient satisfaction • Surgeon preference to reduce urinary Total hip arthroplasty for Kregor et al. 2008 and fecal contamination of wound Retrospective femoral neck fracture3 and allow patients to shower immediately1. Khurana et al. Acta Orthop Belg. 2008;74:349.2. Hall and Bailes. Neurosurgery. 2005;56(suppl 1):147.3. Kregor et al. Techniques Ortho. 2008;23:312.
  38. 38. DERMABOND ADVANCED™ Topical Skin Adhesive A protective barrier that adds strength and reduces bacteria • Has been shown in ex vivo studies to have superior tensile strength versus other octyl and butyl based products • Creates a microbial barrier against organisms commonly responsible for SSIs * Innovative *Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, Enterococcus faecium and Pseudomonas aeruginosaData on File. Ethicon, Inc.
  39. 39. Comparison of TSA Components Among Currently Available Agents DERMABOND ADVANCED™ Topical Skin derma+flex® QS™ Histoacryl® Components Adhesive SurgiSeal™ (octylseal™) INDERMIL® (Repara) LiquiBand® Skinstitch®OctyladhesivePlasticizers ?Inert storagevial,stabilizer, andnorefrigerationInitiator andheat-dissipatingagentHigh-viscosityformulationThe third-party trademarks used herein are trademarks of their respective owners.Data on file: Ethicon Inc.
  40. 40. Evidence-Based Performance  The largest randomized clinical trial database of any TSA  8x the number of patients vs the leading competitor Total Number Total Number of Product of RCTs Patients Treated DERMABOND® 40 4075 Topical Skin Adhesive Histoacryl® 6 534 INDERMIL® 2 150 LiquiBand® 1 78 SurgiSeal® 0 0 derma+flex® QS™ 0 0 (octylseal™)No RCTs identified for any other competitors.RCTs only; reasons for exclusion were language of publication other than German or English, nonhuman studies, case series orcase reports, and inappropriate indication.The third-party trademarks used herein are trademarks of their respective owners.RCT = randomized controlled trials.Data on file: Ethicon Inc, Literature Search 2/2011 PubMed
  41. 41. New, innovative, minimally invasive DERMABOND™ PRINEO™ Skin Closure System  A unique combination of 2 components • A 2-octyl cyanoacrylate topical skin adhesive for proven strength and microbial protection1,2 – Sets in approximately 60 seconds when applied to mesh – 2-hour working time3 • A flexible, self-adhesive polyester mesh for superior approximation and healing1,3 – Contains initiator that accelerates polymerization of liquid adhesive – Each dispenser contains 60 cm of tape 1. DERMABOND™ PRINEO™ IFU. PM72449C. STATUS 6/2010.41 2. Shapiro AJ et al. Am Surg. 2001;67(11): 1113‐1115. 3. Data on file. Ethicon, Inc.
  42. 42. Minimally invasive closure that distributes tension away from the wound Traditional closure DERMABOND™ PRINEO™ Skin Closure System  Gently and evenly disperses tension across the entire area of the incision, without penetrating the skin42
  43. 43. DERMABOND™ PRINEO™ removalPatient is shown 2 weeks after circumferential body lift and immediately after removal of DERMABOND™ PRINEO™ Skin Closure System.
  44. 44. Areas for Cost Savings
  45. 45. Surgical Incise Drapes Iodophor- impregnated incise barrier drape  No data to support these drapes reduce SSI – although do reduce bacteria on skin  Surgeon preference based on adhesion to skin and drapes  Consider using non- impregnated drapes and using cost savings for other innovative technologies 45
  46. 46. Use of plastic adhesive drapes during surgeryfor preventing surgical site infectionObjective: Compared the effect of adhesive drapes used during surgery on surgical site infection, cost, mortality and morbidity Five studies involving 3,082 participants comparing adhesive drapes with no drape Two studies involving 1,113 participants comparing iodine-impregnated adhesive drapes with no drapeConclusion: A significantly higher proportion of patients in adhesive drape group developed a surgical site infection when compared with no drape Iodine-impregnated adhesive drapes had no effect on the surgical site infection rate Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006353
  47. 47. Bacitracin/Polymixin Irrigation Feb 2007 - stopped routine use of Bacitracin/Polymixin Irrigation Cost: > $110,000/year reduced to $10,000 Limited use for revisions, allografts and infected cases (irrigation and debridements) New irrigant available – FDA approved for mucous membranes with 0.05% CHG - IrriseptFletcher N, et al: Prevention of perioperative infections. J Bone Joint Surg Am. 2007;89:1605-1618 47
  48. 48. IRRISEPT Finally, an alternative to saline and antimicrobial irrigation The first and only FDA-cleared cleansing and debridement system, containing 0.05% Chlorhexidine Gluconate (CHG) in Water for Irrigation IrriSept O.R. (sterile packaging)Irrigation Applicators:Custom designedapplicators facilitatecleansing for a variety ofapplications SplatterGuard® LT SplatterGuard® IrriProbe® 48
  49. 49. Review: Bundled Approach to Eliminating SSIs1. Pre-screen inpatient surgeries for MRSA and Staph aureus (MSSA) using PCR rapid molecular technology2. Decolonization protocol for MRSA/MSSA positive patients (eg mupirocin 2% ointment 2 x day, daily CHG wash x 5 days)3. Preoperative shower with CHG (eg Hibiclens) or CHG washcloths (eg Sage) night before/morning of surgery4. Assure OR standards are being met (traffic control, surgical attire, surgical hand scrub, sterilized instruments, room turnover and terminal cleaning, precautions in OR)5. Assure surgical prophylaxis is delivered for maximum tissue concentrations6. Surgical skin prep with CHG/alcohol prep7. Irrigation with CHG if necessary (eg Irrisept)8. Antibacterial sutures (eg Ethicon)9. Incisional Adhesive (octyl cyanoacrylate) (eg Dermabond and Prineo)10. Post-op incision care instructions11. Data driven, analysis and calculation of rates, communication/feedback
  50. 50. Reducing Risk Factors for SSIs: Tools for success  Institutional support  Senior leadership and “C Suite” involvement  “lead the effort” from top down  Clear goals  Structured program with clearly defined goal of zero tolerance for HAIs  Theoretical foundation to IP Program: Social Learning Theory (Role Modeling, Self Efficacy, Positive Deviance)  Communication – effective and consistent  Ongoing and creative education  Financial support to Infection Prevention program50
  51. 51. Thank You