١١

SSI17%

PNEU14%

UTI33%

BSI14%

Other22%

Healthcare Associated Healthcare Associated Infections Due to SSIInfections Due to SSI

Klevens RM, et al. Public Health Reports. 2007

BSI Bloodstream InfectionPNEU PneumoniaSSI Surgical Site InfectionUTI Urinary Tract Infection

290,485 infections8,205 deaths

248,678 infections30,655 deaths

561,667 infections13,088 deaths

250,205 infections35,967 deaths

٢٢

Impact of SSIImpact of SSISSI are associated with:SSI are associated with: Increased length of stay by Increased length of stay by 77--10 10 daysdays Increased cost per episode of up to Increased cost per episode of up to

$$3030,,000000 Increased readmission rate of up to Increased readmission rate of up to

4040%% Up to ~ Up to ~ 10 10 times increased risk of times increased risk of

death compared to surgical patients death compared to surgical patients without SSIwithout SSI

7777% attributable mortality% attributable mortality $$10 10 billion in annual US healthcare billion in annual US healthcare

expenditureexpenditure٣٣

SSI is a Global Public Health SSI is a Global Public Health PriorityPriority

22ndnd Global Patient Global Patient Safety Safety ChallengeChallenge

Clean surgeryClean surgery Safe anesthesiaSafe anesthesia Safe operatorsSafe operators Measurement and Measurement and

quality assurancequality assurance٤٤

Surgical Site Classification

• No inflammation• No involvement of pulmonary, GIT orGU systems• Primarily closed and when drain isinvolved it is closed drainage• Only blunt trauma are included in thiscategory

٥٥

Surgical Site Classificationcont……

• Pulmonary, GIT or GU systeminvolvement, but under controlledconditions• For example: biliary tract, appendix,vagina, and oropharynx• No break in the technique

٦٦

• Fresh open injuries• Operation with major break in steriletechnique• Spillage from GI tract• Entry into the genitourinary tract withinfected urine• Entry into the biliary tract with infectedbile• Non-purulent inflamed surgical site

Surgical Site Classification cont…

٧٧

• Old traumatic wounds with retaineddevitalized tissues, foreign body orfecal contamination• Surgical procedures involved bowlperforation• Surgical procedures involved pusdrainage

Surgical Site Classification cont…

٨٨

Purulent drainage from the site or the drainage

Positive culture fromthe fluid of thedrainage

The surgeon diagnose infection

SS requires re-openingDiagnosed when

you seepus at the site

٩٩

From the skinS. aureusCoagulase-negative staphylococciFrom the pulmonary system

, GIT or GUSNormal flora e.g. E. coli,

Enterococci, P.aeruginosa …

PersonnelHands, hair, scalp, nose and mouth

EnvironmentContaminated solutions, antiseptics

or dressingsSurfacesAirVentilation systemPositive pressure

Sources of pathogens

١٠١٠

Etiological Agent

Pseudomonas aeruginosa

Escherichia coli

Enterococci

Coagulase-negativestaphylococci

Enterobacter spp.

Staphylococcusaureus

١١١١

Risk FactorsSurgical site classification

Prolonged preoperative stay

Length of the operation

Preoperative shaving

Surgical technique

Abdominal drains١٢١٢

SSI PreventionSSI Prevention

Pathogen• Degree of contamination• Virulence• Antimicrobial resistance

Procedure• Duration• Preparation• Type and technique• Equipment sterilization• OR characteristics• Introduction of foreign material

Patient• Co morbid conditions• Immune status• Colonization

١٣١٣

Prevention of SSI

PreoperativeMeasures

Preoperativestay

Host factorsPreoperative

showerHair removalPreoperative

antibiotics

IntraoperativeMeasures

Preparation of theincisional site

Surgical scrubBarrier devicesMasks, Caps,Gowns

and drapesReduction of air-borne

contamination in the OROperative technique

Postoperative PhasePostoperative PhaseChanging DressingsChanging DressingsPostoperative CleansingPostoperative CleansingTopical Antimicrobial Topical Antimicrobial Agents for Wound Agents for Wound Healing by PrimaryHealing by PrimaryIntentionIntentionDressings for Wound Dressings for Wound Healing by SecondaryHealing by SecondaryIntentionIntentionAntibiotic Treatment ofAntibiotic Treatment ofSurgical Site Infection Surgical Site Infection and Treatment Failureand Treatment Failure

١٤١٤

Risk PreventionRisk Prevention Patient CharacteristicsPatient Characteristics

–– DiabetesDiabetes–– Nicotine useNicotine use–– Steroid UseSteroid Use–– MalnutritionMalnutrition–– Prolonged Hospital StayProlonged Hospital Stay–– PrePre--operative nares colonization with operative nares colonization with

Staph aureusStaph aureus–– PeriPeri--operative Transfusionsoperative Transfusions

١٥١٥

Risk PreventionRisk Prevention

Operative Characteristics: Operative Characteristics: Preoperative IssuesPreoperative Issues–– Preoperative antiseptic showeringPreoperative antiseptic showering–– Preoperative hair removalPreoperative hair removal–– Patient skin prep in the ORPatient skin prep in the OR–– Preoperative hand/forearm antisepsisPreoperative hand/forearm antisepsis–– Management of infected or colonized Management of infected or colonized

surgical personnelsurgical personnel–– Antimicrobial prophylaxisAntimicrobial prophylaxis

١٦١٦

Preoperative Preparation

١٧١٧

Risk Reduction: Risk Reduction: Antimicrobial Antimicrobial PrePre--Operative ShowerOperative Shower

Chlorhexidene Gluconate Chlorhexidene Gluconate –– Primary Primary choicechoice

IodophorIodophor

HexachloropheneHexachlorophene

١٨١٨

Risk PreventionRisk Prevention Operative characteristics: IntraOperative characteristics: Intra--operative issuesoperative issues

–– Operating Room environmentOperating Room environmentVentilationVentilationEnvironmental surfacesEnvironmental surfacesMicrobial sampling Microbial sampling –– do not do routinely do not do routinely Conventional sterilization of surgical instrumentsConventional sterilization of surgical instrumentsFlash sterilization of surgical instrumentsFlash sterilization of surgical instruments

–– Surgical attire and drapesSurgical attire and drapesScrub suitsScrub suitsMasksMasksSurgical caps/hoods and shoe coversSurgical caps/hoods and shoe coversSterile glovesSterile glovesGowns and DrapesGowns and Drapes

–– Asepsis and surgical techniqueAsepsis and surgical techniqueAsepsisAsepsisSurgical techniqueSurgical technique ١٩١٩

Intraoperative Intraoperative -- OR EnvironmentOR Environment

VentilationVentilation–– Positive pressure to corridorsPositive pressure to corridors–– A minimum of A minimum of 2020--25 25 air exchanges per air exchanges per

hourhour–– Filter air Filter air –– Ceiling supply vents and exhaust near Ceiling supply vents and exhaust near

floorfloor HumidityHumidity

–– 3030--6060%% Temp Temp 6868--7373°°FF

٢٠٢٠

Dress Codes & DrapesDress Codes & DrapesGlovesGlovesMasksMasksSterile Gowns Sterile Gowns –– determine the determine the

level of impermeability needed level of impermeability needed per procedureper procedure

Shoe covers Shoe covers –– not infection not infection prevention for SSI but prevents prevention for SSI but prevents blood contaminationblood contamination

Drapes Drapes –– impervious!impervious!

٢١٢١

Cleaning, Disinfection & Cleaning, Disinfection & SterilizationSterilization

Environmental cleaningEnvironmental cleaning–– EPA approved hospital disinfectantEPA approved hospital disinfectant

Patient care equipment and instrumentsPatient care equipment and instruments SterilizationSterilization

–– Sterilize all surgical instruments according to Sterilize all surgical instruments according to published guidelinespublished guidelines

–– Perform flash sterilization only for patient care Perform flash sterilization only for patient care items that will be used immediatelyitems that will be used immediatelyDo not use flash sterilization for convenience Do not use flash sterilization for convenience

or for inventory controlor for inventory control

Biological monitoring for sterilizersBiological monitoring for sterilizers–– Rapid readoutsRapid readouts–– 48 48 hour testhour test–– SterisSteris

٢٢٢٢

Gloving Aspects of Hand HygieneGloving Aspects of Hand Hygiene

Wear gloves when Wear gloves when contact with blood or contact with blood or other potentially other potentially infectious materials, infectious materials, mucous membranes, mucous membranes, & nonintact skin & nonintact skin could occur. could occur.

Change gloves during Change gloves during patient care if patient care if moving from a moving from a contaminated body contaminated body site to a clean body site to a clean body site. site.

Remove gloves after Remove gloves after caring for a patient. caring for a patient. –– Do not wear the Do not wear the

same pair of gloves same pair of gloves for the care of more for the care of more than one patient, than one patient,

–– Do not wash gloves Do not wash gloves between uses with between uses with different patients. different patients.

٢٣٢٣

Sterile TechniqueSterile Technique Adhere to principles of asepsisAdhere to principles of asepsis Assemble sterile equipment and solutions Assemble sterile equipment and solutions

immediately prior to use. immediately prior to use. Handle tissues gently, maintain homeostasis, Handle tissues gently, maintain homeostasis,

minimize devitalized tissues and foreign bodies minimize devitalized tissues and foreign bodies and eradicate dead space at the surgical siteand eradicate dead space at the surgical site

Use delayed primary skin closure or an incision Use delayed primary skin closure or an incision open to heal by secondary intention if the open to heal by secondary intention if the surgeon considers the surgical site to be surgeon considers the surgical site to be heavily contaminatedheavily contaminated

If drainage is necessary, use a closed suction If drainage is necessary, use a closed suction drain. Place a drain through a separate drain. Place a drain through a separate incision distant from the operative incision. incision distant from the operative incision. Remove the drain as soon as possible.Remove the drain as soon as possible.

٢٤٢٤

Risk PreventionRisk Prevention

Postoperative IssuesPostoperative Issues–– Incision careIncision care

Protect with a sterile dressing for Protect with a sterile dressing for 24 24 to to 48 48 hours postoperatively an incision that has hours postoperatively an incision that has been closed primarily.been closed primarily.

Wash hands before and after dressing Wash hands before and after dressing changes any contact with surgical sitechanges any contact with surgical site

When an incision dressing must be changed, When an incision dressing must be changed, use sterile technique.use sterile technique.

––Discharge planningDischarge planningEducate the patient and family regarding Educate the patient and family regarding

proper incision care, symptoms of SSI, and proper incision care, symptoms of SSI, and the need to report those symptomsthe need to report those symptoms ٢٥٢٥

WHAT IS A BUNDLE?A bundle is a structured way of improving processes of care and patient outcomes.

It is a small straightforward set of practices – generally three to five that when performed collectively, reliably and continuously, have been proven to improve patient outcome.

٢٦٢٦

The Bundle1. If at all possible avoid hair removal; if hair removal is necessary, avoid the use of razors2. Ensure prophylactic antibiotic was prescribed as per local antibiotic policy guideline, for the specific operation category & Ensure the antibiotic was been administered within 60 minutesprior to the operation.3. Ensure the patient’s body temperature was normal throughout the operation (excludes cardiac patients).4. Ensure the surgical scrub & preparation of incision site was done.5. Ensure the patient’s blood glucose level was normal throughout the operation (diabetic patients only).

Surgical Site Infection Prevention Bundle

٢٧

Surgical Site Infection Prevention Bundle –Standard Operating Procedure

Surgical site infections arise when the host’s defences are overwhelmed by micro-organisms that come from the patient, disseminated from staff in the operating theatre or from inadequately decontaminated instruments.Procedures undertaken in the ward pre and post operatively, and in the theatre peri-operatively must be designed to negate, or minimise as far as is possible, the risk of surgical site infection.

Statement

Objectives:1.To optimise peri-operative care minimising the risk of surgical site infections.2.To be able to demonstrate quality peri-operative care in OUR clinical area

Objectives

Before the SSI prevention bundle is performed.Signed commitment from the clinical team: consultants; junior doctors, ward manager and nurse team to optimising SSI prevention care.The data required for this bundle should be collected and documented on every patient.Analysis of compliance can be through the analysis of data (if there is ongoing surveillance), or via a weekly analysis of a selection of patients’ peri-operative records

Requirements

For weekly analysis review of notes1.Perform hand hygiene.2.On each ward select notes from 7 patients who underwent operations.3.Check to see if the appropriate bundle criteria were recorded in the patients’ notes.4.Record findings on the SSI bundle prevention data collection sheet.

Procedure

Complete form.Give it to:Discuss and display the data when it has been returned.(Keep bundle forms for xx time).

After care٢٨

Date:

Location:

Observer:

Patient7

Patient 6

Patient 5

Patient 4

Patient 3

Patient 2

Patient1

(See overleaf for qualifying information)

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

1.If at all possible avoid hair removal; if hair removal is necessary, avoid the use of razors $

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

1.Prophylactic antibiotics were prescribed as per the local antibiotic policy/SIGN guideline for the operation category.

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

1.The antibiotic was administered 60 minutes prior to the start of the operation.

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

1.The patient’s body temperature was normal (36-37C) throughout the operation. $$

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

1.If diabetic, the patient remained normoglycaemic during the operation. $$$

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

YesNoN/A

1.The surgical scrub & preparation of incision site were done

٢٩

Comment(if required)

No.Summary Table of SSI Prevention Bundle Findings

(should be 7)Total number of patients’ case notes reviewed

Total number of patients requiring hair removal that operation sites were clipped.

Total number of patients who were given the right antibiotics

Total number of given antibiotics within 60 minutes of the start of the operation.

Total number of patients who were normothermic throughout the operation.

Total number of diabetic patients who were normoglycaemic throughout the operation.

Tick if achievedAll or None Table – Was SSI prevention Optimal

100% of patients requiring hair removal, hair was clipped.

100% of patients were given the correct antibiotics

100% of patients were given antibiotics within 60 minutes of the operation

100% of patients were normothemic throughout the operation

100% of diabetic patients were normoglycaemic throughout the operation.

100% of OR staff don surgical scrub & well prepared the incision site. ٣٠

٣١