SURGICAL SITE INFECTION (SSI) PREVENTIONMedicaid re-imbursement starting in 2011. • Goal: Reduce...

36
SURGICAL SITE INFECTION (SSI) PREVENTION during Abdominal Hysterectomy and Cesarean Section ANDREW P. SOISSON, MD DIVISION OF GYNECOLOGIC ONCOLOGY UNIVERSITY OF UTAH/HUNTSMAN CANCER HOSPITAL

Transcript of SURGICAL SITE INFECTION (SSI) PREVENTIONMedicaid re-imbursement starting in 2011. • Goal: Reduce...

  • SURGICAL SITE INFECTION (SSI) PREVENTION during Abdominal Hysterectomy

    and Cesarean SectionANDREW P. SOISSON, MD

    DIVISION OF GYNECOLOGIC ONCOLOGY

    UNIVERSITY OF UTAH/HUNTSMAN CANCER HOSPITAL

  • Surgical site infection definition (Vaginal contamination)

  • • Purulent drainage from the wound.

    • Positive culture from wound fluid.

    • Attending surgeons diagnosis.

    • One of the following signs or symptoms.

    Surgical site infection definition: Wound infection.

    • Pain or localized tenderness.• Localized swelling.• Erythema.• Incision opened by attending surgeon unless culture negative.

  • • Purulence from the deep portion of the incision.

    • Wound dehiscence or wound opened by attending

    surgeon for fever, localized pain or tenderness,

    unless culture negative.

    • Radiographic evidence of abscess.

    • Infection diagnosed by attending surgeon.

    Surgical site infection definition: Deep space infection.

  • Surgical site infection definition: (Center for Disease Control)

    Definition = An infection associated with a

    surgical procedure within 30 days of the surgery

    (12 months if surgical implant used)

    • Observed rate = your # of SSI/your # of surgeries x 100

    • Observed/expected rate = #SSI/Expected number: Expected # = probability for SSI

  • • Surgical Care Improvement Project (SCIP) introduced in 2002 by the Centers for Medicare and Medicaid services. Initial goal was to reduce the incidence of surgical complications/infection by 25% by the year 2010.

    • Adherence to SCIP protocols would affect Medicare and Medicaid re-imbursement starting in 2011.

    • Goal: Reduce rates of postoperative infections.• 1) Antibiotics within one hour of incision, 2) Appropriate

    antibiotics, 3) Discontinue antibiotics within 24 hours of the procedure.

    Surgical site infection definition: (Center for Disease Control)

  • • Centers for Medicare and Medicaid Services (CMS) analyzed 34,133 abdominal surgeries.

    Surgical site infection definition: (Center for Disease Control)

    Surgical parameter Outcome

    Administration of ABS within 1 hr. of surgery

    56%

    Administration of appropriate ABS 93%

    Discontinuation of ABS within 24 hr. of surgery

    41%

  • Study parameter Pre-study Post-study

    Administration of ABS within 1 hr. of surgery

    72% 92%

    Administration of appropriate ABS

    90% 95%

    Discontinuation of ABS within 24 hr. of surgery

    67% 85%

    Surgical site infection definition: (Center for Disease Control)

    • Centers for Medicare and Medicaid Services (CMS) initiated a national collaboration study involving 56 hospitals in 5o states.

  • SSI: Incidence in Abdominal Hysterectomy

    Category Incidence of SSIAbdominal hysterectomy/benign

    4%

    Abdominal hysterectomy/benign/obese

    3-9%

    Abdominal hysterectomy/endometrial cancer

    10%

    Abdominal hysterectomy/ovarian cancer

    9-17%

  • • In US academic hospitals (2419 patients):

    5.5% developed a surgical site infection

    after C-section.

    • In overweight US women: 23% developed a

    surgical site infection after C-section.

    SSI: Incidence in Cesarean section patients

  • • 75% of US women gain too much weight during pregnancy.

    • 51% of women in Utah gained excessive weight during pregnancy.

    • 68% of overweight women in Utah gained excessive weight during pregnancy.

    • In the US 43% of pregnant women are obese.

    • In the US 6-10% of pregnant women have AODM.

    SSI: Weight gain and AODM in pregnancy

  • Incidence of Surgical Site Infection

    • Clean case: No contamination by gastro-intestinal or respiratory tract.

    • Clean contaminated: Gastro-intestinal and respiratory tract entered but no gross spillage.

    • Contaminated: Acute inflammation (no pus) or gross spillage.

    • Dirty: Pus encountered or perforation of a viscus.

    Cruse PJ: Analyzed 23,649 surgical wounds in Calgary Canada.

  • Parameter Outcome

    Clean 1.8%

    Clean-contaminated 9%

    Contaminated 22%

    Dirty 38%

    Surgeon hand prep ND

    Preoperative shower ND

    Shaving 2.3%

    No shaving .9%

    AODM/Obesity/malnutrition Increased

    Cloth versus plastic drapes ND

    Subcutaneous drains ND

    Skin diathermy Increased by 30-50%

  • • Know diabetic patient.• Age greater than 45.• BMI greater than 35.

    SSI reduction: Glucose controlPreoperative HBA1C measurement:

    • Preoperative glucose measurement greater than 130 mg/dl.• Monitor glucose every hour during surgery.• Administer insulin if glucose greater than 180 mg/dl.

    Intraoperative management:

    Postoperative management:• Target glucose of 150-180 mg/dl.• Administer insulin for glucose greater than 180 mg/dl.

  • • Not well studied as a clinical parameter associated with SSI reduction.

    • Most studies that have been done indicated that it is NOT a significant clinical parameter.

    • However, hypothermia has been associated with impaired drug metabolism, cardiac dysfunction, and coagulopathy.

    • Therefore, thermoregulation should be part of any surgical bundle.

    SSI reduction: Temperature control

  • • Cefazolin 2 gm IV, 3 gm if greater than 120 kg.• Patients with cephalosporin or penicillin allergy:

    Clindamycin 900 mg IV.

    • GI tract involvement: Metronidazole 500 mg IV.• Re-dose if case greater than 3 hour or EBL greater than

    1,500 ml.

    • Alternatives: Clindamycin + Gentamycin, Clindamycin + Quinolone, Clindamycin + Aztreonam.

    • 18,255 hysterectomies: Cefazolin + metronidazole superior to Cefazolin alone.

    • Should be given 30-60 minutes before skin incision.

    SSI reduction: Antibiotic prophylaxis/hysterectomy

  • • Multiple studies have demonstrated that proper antibiotic prophylaxis is the most significant parameter associated with SSI reduction.

    • Multiple studies have shown that utilization of surgical bundles will reduce SSI rates by 50-75%.

    • Reduction in SSI rates will reduce cost and length of hospital stay.

    • 26,593 surgical cases evaluated: of those with SSI, 11% required evaluation in the ER, 11% required re-admission to the hospital, and each infection was associated with greater than $8,500 cost.

    SSI reduction: Antibiotic prophylaxis/hysterectomy

  • • RCT study in women undergoing C-section -Azithromycin + cefazolin versus cefazolin alone: Reduced rate of endometritis (3.8 vs 6.1%) and wound infection (2.4 vs 6.6%).

    • Long-term antibiotic prophylaxis in obese women undergoing C-section (n = 403): cefhalexin + metronidazole versus placebo -6.4 versus 15.4% SSI.

    SSI reduction: Antibiotic prophylaxis/C-section

  • • Clean and clean-contaminated cases (200): No difference.

    • Cochrane data-base: Mixed results.• Upper GI surgery (534): No difference.• Laparotomy (388): No difference.• Laparotomy (351): No difference.• Clean and clean contaminated (849): 4.2% vs 8.6%

    SSI reduction: Skin preparation

    Chlorhexidine versus povidone-iodine skin preparation in open (laparotomy) cases RCT:

  • • 932 cases at multiple hospitals: No difference.

    • 1404 cases: No difference.• 1147 cases: 4% versus 7%.

    SSI reduction: Skin preparation

    Chlorhexidine versus povidone-iodine skin preparation in Cesarean section RCT:

  • • Cochrane review of 23 studies demonstrated that betadine is superior to chlorhexidine before C-section to prevent endometritis. No adverse events.

    • PREPS RCT trial (320): No difference in incidence of endometritis after C-section.

    • ACOG opinion 571: Vaginal chlorhexidine is safe.• Vaginal chlorhexidine in 117 women undergoing vaginal

    surgery: No adverse effects.

    • Vaginal chlorhexidine in 5377 women undergoing vaginal surgery: No adverse effects.

    SSI reduction: Vaginal preparationChlorhexidine vaginal preparation in Cesarean section and gynecologic surgery:

  • • Meta analysis of 400 studies/2,684 patients undergoing abdominal surgery: Potential benefit.

    • Meta analysis in 12 RCT/3,029 patients undergoing lower GI surgery: Significant benefit.

    • 198 women undergoing C-section: reduction in SSI from 8 to 1%

    • 301 obese women undergoing C-section: No benefit.

    SSI reduction: Wound protectors (Alexis Device)

  • • Multiple meta analysis studies have demonstrated reduction in SSI rates in obese women undergoing C-section.

    • Negative pressure drains are cost-effective.• Danish RCT study involving 876 women with BMI

    > 30 showed reduction in SSI from 9.2% to 4.6%.

    • Not well studied in hysterectomy patients.• Dialkylcarbanmoxyl chloride impregnated surgical

    dressings RCT in C-section: 5.2% versus 1.8% SSI.

    SSI reduction: Negative Pressure Wound Dressings /C-section

  • • Screening and treatment for bacterial vaginosis.• Screening or treatment for MERSA.• Preoperative bathing or showering with anti-septic

    agents.• Hair removal: Clipping better than shaving.• Irrigation fluids.• Subcutaneous drains.• Changing gown and gloves prior to fascia and skin closure.• Different instruments for fascia and skin closure.• Subcutaneous tissue closure.• Type of skin closure (staples versus suture).• Early versus later removal of surgical dressings.

    SSI reduction: Non-significant clinical factors

  • • Oral antibiotics and fleet enema prior to surgery if bowel resection a possibility.

    • Preoperative AODM evaluation.• Preoperative warming.• Appropriate preoperative antibiotics (Cefazolin +

    metronidazole).

    • Chlorhexidene skin prep/iodine vaginal prep.• Glucose monitoring.• Intraoperative thermoregulation.• Wound protector.

    SSI reduction: Suggested protocol abdominal hysterectomy

  • SSI reduction: Suggested protocol C-section

    • Preoperative AODM evaluation.• Preoperative warming.• Appropriate preoperative antibiotics (Cefazolin +

    azithromycin).

    • Chlorhexidene skin prep/iodine vaginal prep.• Glucose monitoring.• Intraoperative thermoregulation.• Wound protector.• Negative pressure dressing if obese.• Extended antibiotics (cefhalexin + metronidazole) if obese.

  • SURGICAL SITE INFECTION (SSI) PREVENTION during Abdominal Hysterectomy and Cesarean SectionSlide Number 2Surgical site infection definition (Vaginal contamination)Slide Number 4Surgical site infection definition: Wound infection.Surgical site infection definition: Deep space infection.Slide Number 7Surgical site infection definition: (Center for Disease Control)Surgical site infection definition: (Center for Disease Control)Surgical site infection definition: (Center for Disease Control)Surgical site infection definition: (Center for Disease Control)SSI: Incidence in Abdominal HysterectomySSI: Incidence in Cesarean section patientsSSI: Weight gain and AODM in pregnancySlide Number 15Incidence of Surgical Site Infection Slide Number 17Slide Number 18SSI reduction: Glucose controlSSI reduction: Temperature controlSSI reduction: Antibiotic prophylaxis/hysterectomySSI reduction: Antibiotic prophylaxis/hysterectomySSI reduction: Antibiotic prophylaxis/C-sectionSSI reduction: Skin preparationSSI reduction: Skin preparationSSI reduction: Vaginal preparationSlide Number 27SSI reduction: Wound protectors (Alexis Device)Slide Number 29Slide Number 30SSI reduction: Negative Pressure Wound Dressings /C-sectionSSI reduction: Non-significant clinical factorsSlide Number 33SSI reduction: Suggested protocol abdominal hysterectomySSI reduction: Suggested protocol C-sectionSlide Number 36