SSI Prevention: Bundle

Amber Wood, MSN, RN, CNOR, CIC, FAPIC

• Discuss evidence-based practices to prevent surgical site infections (SSI)

• Develop a plan for implementing a SSI bundle

Objectives

How to Build a Bundle

No two bundles are the same…

Gap Analysis

• New• Improve

Procedure Specific Compliance Your

Bundle

Risk Assessment

Implementation Science

• Behavior (Human Factors)• Change management• Leadership Support• Resources (Equipment, Staff)• Teamwork & Communication

• TeamSTEPPS (AHRQ)• CUSP/SUSP (Johns Hopkins)

Atul Gawande

http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine#t-1128716

Bundle Elements

Core Practices(not procedure-specific)

• Only when indicated• Select agent based on clinical practice guidelines• Time the dose to be in tissue at time of incision

• Within 1 hour• Dosing

• Weight based• Re-dosing

Antimicrobial Prophylaxis

Order Sets,

Time OutCDC HICPAC Draft Guideline for Prevention of SSI

SHEA Compendium SSI Guideline

Strategies corner

• Maintain normothermia (35.5°C) perioperatively• Before, during, and after surgery

• Best method unresolved• Active & Passive• Patient assessment• Temperature monitoring• Selection of method

Normothermia

CDC HICPAC Draft Guideline for Prevention of SSI, SHEA Compendium SSI Guideline,AORN Guideline for Prevention of Unplanned Patient Hypothermia

Pre-warming,Products

General anesthesia with endotracheal intubation• Increase FiO2

• Intraop and post-extubation

Tissue oxygen delivery also needs…• Normothermia• Adequate volume replacement

Oxygenation

Anesthesia

Champion

CDC HICPAC Draft Guideline for Prevention of SSISHEA Compendium SSI Guideline

• Target blood glucose levels <200 mg/dL• SHEA: <180 mg/dL

• All patients• Diabetic and non-diabetic

Glycemic Control

Order sets,

Equipment

CDC HICPAC Draft Guideline for Prevention of SSISHEA Compendium SSI Guideline

• Patient bathing• At home & preop holding• CHG liquid & cloths

• Staphylococcus aureus screening & decolonization• MRSA & MSSA• SHEA Compendium: High-risk procedures (ortho, cardiac)

Bathing & Decolonization

Patient Reminder

s (electroni

c)SHEA Compendium SSI Guideline

• Patient bathing may reduce the microbial flora• Limitations/Gaps

• Optimal bathing procedures• Antiseptics vs soaps (ie, plain, antimicrobial) • Whole body or only the surgical site• Optimal timing before surgery • Optimal number of baths or showers

• Benefits outweigh harms

Evidence Review

AORN Guideline for Preoperative Patient Skin Antisepsis

I.a. The patient should be instructed to bathe or shower before surgery with either soap or a skin antiseptic on at least the night

before or the day of surgery. [1: Strong Evidence]

I.b. A multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists should develop a

mechanism for evaluating and selecting products for preoperative patient bathing. [2: Moderate Evidence]

AORN Recommendations

AORN Guideline for Preoperative Patient Skin Antisepsis

• S. aureus screening prior to surgery• MSSA & MRSA

• CHG baths for 5 days prior to surgery• Ten (10) dose mupirocin regimen• Use vancomycin in MRSA positive and some high risk patients

who cannot be screened• Continue current SCIP Measures

Institute for Healthcare Improvement (IHI)PROJECT JOINTS

“Project Joints, Joining Organizations in Tackling SSI’s”; sponsored by the Institute for Healthcare Improvement (IHI); Kathy D. Duncan, Institute for Healthcare Improvement Faculty, Presented at the AFMC Quality Conference on May 10, 2011.

• Alcohol-based skin antiseptic• Hair removal with clippers vs razor

Skin Antisepsis & Hair Removal

Preferred AntisepticTechnique

(IFU)SHEA Compendium SSI Guideline

Prevent SSI!!!

• Remove soil • Rapidly and persistently remove transient microorganisms at

the surgical site• Reduce resident microorganisms to subpathogenic levels • Minimal skin and tissue irritation

Effective Skin Antisepsis

AORN Guideline for Preoperative Patient Skin Antisepsis

• Organization level & Patient care team• FDA-Approved antiseptic• Alcohol-based antiseptics may be more effective than aqueous-

based antiseptics when not contraindicated

Selection

Maiwald M, Chan ES-Y. The Forgotten Role of Alcohol: A Systematic Review and Meta-Analysis of the Clinical Efficacy and Perceived Role of Chlorhexidine in Skin Antisepsis. PLoS ONE. 2012;7(9).

• Eye• 5% Povidone-iodine

• Gynecologic• 10% Povidone-iodine• 4% CHG recommended in ACOG position statement

• Orthopedic• Conflicting• Alcohol-based antiseptics

Procedure Specific

AORN Guideline for Preoperative Patient Skin Antisepsis

• All available FDA-approved products might be contraindicated • Allergy, Anatomical Location, Wound

• Evaluate the risks and benefits of alternative solutions• Soaps (baby shampoo, castile soap)• Saline

Contraindications

AORN Guideline for Preoperative Patient Skin Antisepsis

• Isopropyl alcohol 70% NOT approved for preoperative patient skin antisepsis

• Injections (eg, IV start)• Select an alcohol-based antiseptic product

• Mixing is compounding (USP 797)• “Painting” is a fire risk (flammable and clear)

• Multi-dose bottle• FDA advises single use containers • Alcohol is not sterile, Bacillus cereus

Alcohol

• Leave the hair and choose an aqueous, water-based antiseptic OR

• Clip the hair and choose an alcohol-based antiseptic

Hairy Patients

AORN Guideline for Preoperative Patient Skin Antisepsis

• Closing instruments• Change gloves at closing

Sterile Technique

Technique,

Resources

• Dressings• Technique, antimicrobial dressings, skin adhesive

• Postoperative wound care education

Dressings & Wound Care

Standardization,

Patient Education

Procedure-Specific

• Nasal antiseptic• Surgical Helmet Systems• Laminar Flow

Total Joints

Multiple APIC 2016 Posters

• Suture closure vs. staple• Vaginal prep with povidone-iodine• Placenta removal with traction vs. manual extraction

Cesarean Birth

Multiple APIC 2016 Posters

• Nasal antiseptic• CHG mouthwash• Disposable telemetry leads

Cardiac Procedures

Multiple APIC 2016 Posters

• Wound protectors (SHEA Compendium)• Bowel technique• Closing instruments• Change gown/gloves• Mechanical/chemical bowel prep• Triclosan coated suture (HICPAC Draft SSI Guideline)

Colon Procedures

Multiple APIC 2016 Posters

• Preop• Fasting & carbohydrate needs• Thromboembolism prophylaxis• Antimicrobial prophylaxis• Skin preparation

• Intraop• Anesthetic protocol• Surgical access• Avoid nasogastric intubation• Normothermia• Fluid management

• Postop• Nausea & vomiting• Eliminating drains• Remove urinary catheter• Prevent ileus• Multimodal analgesia• Nutrition• Glucose• Early ambulation

ERAS: Enhanced Recovery After Surgery

ERAS Society: http://erassociety.org/Hohenberger H & Delahanty K. 2015. "Patient-Centered Care—Enhanced Recovery After

Surgery and Population Health Management". AORN Journal. 102 (6): 578-583.

ElectiveColon

Environment

Temperature & Humidity

Facilities Guideline Institute, 2014AORN Guideline for a Safe Environment of Care, Part 2

Area Humidity Temperature Air Pressure

OR 20% to 60% 68° F to 75° F20° C to 24° C

Positive

Soiled/ Decontamination

< 60% *72° F to 78° F22° C to 26° C(May be too warm for personnel in PPE)

Negative

Clean/Sterile <60% 72° F to 78° F22° C to 26° C

Positive

https://www.aorn.org/guidelines/clinical-resources/position-statements

Harmonization

• Keep doors closed • Entry and exit of patients/personnel • SSIs related to door openings

Traffic

AORN Guideline for a Safe Environment of Care, Part 2

• Preplanning • Preference cards• Confirming all supplies present before the incision• Sign on the door to restrict traffic• Communication without door opening• Locks (opened from the inside only)• Taking breaks• Education

Decrease Door Openings

• High transmission risk Munoz-Price LS, Birnbach DJ, Lubarsky DA, et al. Decreasing operating room environmental pathogen contamination through improved cleaning practice. Infect Control Hosp Epidemiol. 2012;33(9):897-904.

• 25% mean cleaning rate for objects cleaned in the OR at 6 acute care hospitals

Jefferson J, Whelan R, Dick B, Carling P. A novel technique for identifying opportunities to improve environmental hygiene in the operating room. AORN J. 2011;93(3):358-364.

Environmental Cleaning

AORN Guideline for Environmental Cleaning

• Determine which items are high touch• Clean those items more frequently

Stiefel U, Cadnum JL, Eckstein BC, Guerrero DM,Tima MA, Donskey CJ. Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients. Infect Control Hosp Epidemiol. 2011;32(2):185-187.

High Touch Objects

AORN Guideline for Environmental Cleaning

• Multidrug-resistant organisms• Enhanced cleaning may reduce MRSA and VRE contamination

& risk of transmission from prior room occupantDatta R, Platt R, Yokoe DS, Huang SS. Environmental cleaning intervention and risk of acquiring multidrugresistant organisms from prior room occupants. Arch Intern Med. 2011;171(6):491-494.

Enhanced Environmental Cleaning

Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2006.

Adapted with permission from Guidelines for Perioperative Practice. Copyright © 2016, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.

AORN Guideline for Environmental Cleaning

http://www.aorn.org/toolkits/environmentalcleaning/

Toolkit

Surgical Attire

AORN Guideline for Surgical Attire

• Home laundering vs. health care-accredited laundering

• Evidence conflicting• Risk for pathogens being carried on the

scrub attire if home laundering

Laundering

AORN Guideline for Surgical Attire

• 3 postoperative Gordonia bronchialis sternal infections after CABG• Nurse anesthetist colonized: scrub attire, axilla, hands, and purse• Roommate also colonized• Home washing machine likely reservoir• Biofilms • Recommended hospital laundered scrub attire• First to demonstrate a causal relationship between home laundering

and human disease

Case Report

Wright SN, Gerry JS, Busowski MTet al. Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery: intraoperative transmission from a healthcare worker. Infect Control Hosp Epidemiol. 2012;33(12):1238–1241.

• Completely cover arms• Long-sleeved jacket or scrub top

• Restricted areas• Skin prep• Packaging items in sterile processing

Long Sleeves

AORN Guideline for Surgical Attire

• Clean or single-use• Evidence does not support wearing cover apparel to protect

scrub attire from contamination• Lab coats can be contaminated with large numbers of pathogens

Cover Apparel

AORN Guideline for Surgical Attire

• A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn.

• Hair colonized with bacteria & hair sheds• Significantly more bacteria on the ears than foreheads and

eyebrowsOwers KL, James E, Bannister GC. Source of bacterial shedding in laminar flow theatres. J Hosp Infect. 2004;58(3):230–232.

Hair!!

AORN Guideline for Surgical AttireBoyce JM. 2014. "Evidence in support of covering the hair of OR personnel". AORN Journal. 99 (1): 4-8.

Evidence Tables

https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-tables