3M Infection Prevention Division

SURGICAL SITE INFECTION

CATS

Every Day Practices + 3M Solutions =

Positive Patient Outcomes
ROAZALINA HASANUDDIN Manager, Clinical RN, BSc (Hons), Post Basic Peri-Operative
1

Infection Prevention Division

3M Malaysia

3M Infection Prevention Division

OBJECTIVES

SSI Overview Understand the Best Practices in Prevention of SSI

3M Infection Prevention Division

WHAT IS SURGICAL SITE INFECTION (SSI)?

SSI is the infection that occurs after

24 hours of surgery

3M Infection Prevention Division

SURGICAL SITE INFECTION

SSI usually occurs between _________ surgery. 24 hours to 30 days (non Implant). 24 hours to a Year for Implant Surgery SSI CITERIA
SKIN

Superficial Incisional SSI

SUBCUTANEOUS TISSUE DEEP SOFT TISSUE (MUSCLE)

ORGAN
4

Deep Incisional SSI Organ /Space SSI

3M Infection Prevention Division

SSI % vs other HAIs %

Other 24%

Surgical Site 15%

Blood Stream 13%

Respiratory 16% Urinary Tract 32%

3M Infection Prevention Division

INFECTIONS

Infections cause patients condition to worsen

Infections increase a patients risk of death

Infections result in prolonged hospital stays

Longer stays and more serious problems that must be treated result in higher costs

Facts about Surgical Site Infections: 3M Infection Prevention Division

SSI account for 14 % to 16% of all nosocomial infections among hospitalized patients Estimated added cost per SSI:
Average cost of an infection: $3,152 7.3 additional days in hospital

Number of deaths: ~10,000 due to SSI Surgical site infections:

Increase patients length of stay Increase need for powerful antibiotics Decrease positive outcome of surgery

Additional cost must be absorbed by the hospital

*CDC Guideline for the Prevention of SSI, 1999

3M Infection Prevention Division

CDC Guidelines for Prevention of Surgical Site Infection (1999) Symptoms: Irritative Fever

Purulent Drainage
Overwhelming Sepsis Death
Thus to reduce the risk of SSI, a systematic and realistic approach must be applied with the awareness that this risk is influenced by characteristics of the patient, operation, personnel, and hospital.

3M Infection Prevention Division

http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf
9

GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

3M Infection Prevention Division

How do we start to prevent SSI

Use CATS to prevent SSI

10

IHI

3M Infection Prevention Division

Describe the Best Practices to Prevent SSIs

SURGICAL SITE INFECTION PREVENTION C: Hair Removal

A: Use Antibiotics Appropriately

T: Maintain Normal Body temperature S: Maintain Normal Blood Glucose
http://www.cdc.gov/hicpac/pdf/guidelines/SSI_1999.pdf
11

GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

3M Infection Prevention Division

Describe Clinical Care Protocols and Best Practices to Prevent SSIs

Hair Removal

12

Hair follicles contain bacteriareleased through friction, micro abrasions, cuts created by shaving with razors Recommendations include: No hair removal at all Clipping (AORN 2011) has remove recommendation of depilatory use. Inappropriate Razors Depilatory use

3M Infection Prevention Division

Interventions for Hair Removal

Do not remove hair unless it will interfere with surgical procedure If removal necessary only use clippers Maintain the skin integrity Remove hair as close to the time of surgery as possible Perform procedure outside of OT
Jepson et al SSI Rate
13

3M Infection Prevention Division

Hair Removal Methods:

No Hair Removal Razor Depilatory/Surgi-Cream

Clipper
14

3M Infection Prevention Division

Hair Removal

15

3M Infection Prevention Division

CLIPPER vs. RAZOR

Clipper
No micro-abrasions

Razor
Causes micro-abrasions

16

3M Infection Prevention Division

CLIPPER vs. RAZOR Razor

High chance of infection

Clipper
Low chance of infection

Clinical Study
At time of discharge Hair Clipping: 1.8 %. Razor shaving: 6.4 % At 30 days follow-up. Hair Clipping: 3.2% Alexander et al.
17

Razor shaving: 10%

Hair removal methods using a razor compared to an electric clipper. The study showed that for hair removal performed the morning of surgery.

3M Infection Prevention Division

THE FACTS We know what AORN 2010 says about hair removal Interpretive Statement 4: If hair is to be removed, it should be done in a manner

that preserves skin integrity.

Rationale: Hair removal by shaving can disrupt skin integrity Discussion: An electric or battery powered clipper with a disposable or reusable head that can be disinfected between patients is acceptable
18

3M Infection Prevention Division

Describe Clinical Care Protocols and Best Practices to Prevent SSIs

Use Antibiotics AppropriatelyPreoperative Antibiotic Prophylaxis

Antibiotics administered within specific time frames Give initial dose of the IV antibiotic to provide a bactericidal level of drug in the serum and tissues when incision is made (within 30 minutes prior to the incision) Provides concentration of the drug in serum and tissues that is at a bactericidal level when the incision is made
19

3M Infection Prevention Division

Use Antibiotics AppropriatelyPreoperative Antibiotic Prophylaxis

Antibiotics present in the tissue at the time of the incision and for a specified period of time after surgery support existing host defenses in killing microorganisms present in the wound For colon surgery, oral non-absorbable antibiotics may ALSO be used to reduce the counts of bowel microorganisms

20

Doses may be in the upper range for obese patients, and repeat doses of antibiotics may be necessary for long operations Discontinue antibiotics within 24 hours after surgery except for cardiothoracic procedures in adult patients (as per ordered by doctors)

Describe Clinical Care Protocols and Best Practices to Prevent SSIs Maintain Normal Body temperature

3M Infection Prevention Division

Core: 37C Normothermia: the bodys ideal thermal state Core temperature:3 37.0C (98.6F) Temperature gradient: 2-4C between the core and periphery
3.Sessler DI. Current concepts: Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.
21

Periphery: 2-4C cooler

2011 Arizant Healthcare Inc. All Rights Reserved.

3M Infection Prevention Division

Normal responses to temperature change

Interthreshold range:3 Core temperature is normally tightly regulated by the body When external factors push core temperature outside this range, the body takes corrective steps Bodys response to Behavioral changes Vasoconstriction Non Shivering Thermogenesis (NST) Shivering Bodys response to heat:3 Vasodilation
22

Interthreshold Range
Vasoconstriction NST Shivering Vasodilation Sweating

cold:3

33C

35C 37C

39C

41C

0.2C

Sweating

Characteristic Patterns of General Anesthesia-Induced Hypothermia

An average core temperature drop of 1.6C can occur in the first hour of general anesthesia1
81% is from core-to-periphery heat redistribution due to anesthesia-induced vasodilation1
Core Temp (C)

3M Infection Prevention Division

Characteristic Patterns of General Anesthesia-Induced Hypothermia

0

-1.6C
-1

-2

1hr

-3

0
1. Matsukawa T, et al. Heat Flow and distribution during induction of general anesthesia. Anesthesiology 1995;82:662-73
23

2 4 Elapsed Time (h)

Adapted from: Sessler, Anesthesiology 2000

Evolution of forced-air warming: pre-warming

3M Infection Prevention Division

Problem: prevent hypothermia before it starts

Answer: active pre-warming

1980s: Post-op

1990s: Intra-op

Now: Pre-op
Warm periphery before induction to prevent redistribution temperature drop

24

3M Infection Prevention Division

How to Maintain Normal Body temperature Use warmed forced-air blankets preoperatively, during surgery, and in the post anesthesia care unit (PACU). Use warming blankets under patients on the operating table.

Use hats and foot covers on patients perioperatively. Adjust engineering controls so operating rooms and patient areas are not permitted to become excessively cold overnight when many rooms are closed
Designate responsibility and accountability for thermoregulation.
25

Comparing active warming modalities

3M Infection Prevention Division

Convective (forced-air)

Conductive (water mattress)

Limited recruitment Risk of warming pressure points

Recruits more skin surface area to warm (at relatively low temperatures) No risk of warming pressure points
26

Area warmed (patients back)

Adverse effects of unintended hypothermia

There are many documented adverse effects of unintended hypothermia2 including:
Surgical site infection Morbid myocardial outcomes

3M Infection Prevention Division

Blood loss and tranfusion requirement

Prolonged and altered drug effect Prolonged recovery

Shivering and patient discomfort

General or regional anesthesia
2. Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28.
27

3M Infection Prevention Division

Surgical Wound Infections

Hypothermic colorectal surgical patients with mild hypothermia have:7
Infection Rate
7

Length of Hospital Stay

25 20 15 10 Days 5 0 Patients with wound infections Patients without wound infections
7

20% 15% 10% 5% 0%

Hypothermic

Normothermic

Adapted from: Kurz et al., New Engl J Med, 1996

7. Kurz A, Sessler DI, et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334:1209-1215. 28 2011 Arizant Healthcare Inc. All Rights Reserved.

3M Infection Prevention Division

Describe Clinical Care Protocols and Best Practices to Prevent SSIs

Maintain Normal Blood Glucose

SSI Host Factor: Diabetes Mellitus Increased risk for SSIs because of impaired host defenses from the disease Diabetes mellitus has long been considered a risk factor for SSI, studies inconclusive. Postoperative medical complications more common in patients with diabetes mellitus
29

3M Infection Prevention Division

Blood Sugar Concentration Level: Normal blood sugar ranges

For the majority of healthy individuals, normal blood sugar levels are as follows: The normal blood glucose level in humans is about 4 mmol/L (72 mg/dL) The body, when operating normally, restores the blood sugar level to a range of about 4.4 to 6.1 mmol/L (82 to 110 mg/dL) Shortly after eating the blood glucose level may rise temporarily up to 7.8 mmol/L (140 mg/dL)
30

3M Infection Prevention Division

Describe Clinical Care Protocols and Best Practices to Prevent SSIs Interventions for Diabetes Mellitus

Poor glycemic control is an independent risk factor for SSIs in a variety of surgical procedures. Many patients may have had undiagnosed diabetes mellitus Vigorous efforts to ensure patients with diabetes are well controlled and glucose levels are carefully managed prior to, during, and following the surgical procedure

High-risk patients should be screened to stabilize and to control bloodglucose levels prior to the surgery. Staff should set goals with the patient and family, such as lowering hemoglobin A1c levels to less than 7% before the surgical procedure
31

3M Infection Prevention Division

Institute for Healthcare Improvement (IHI) Recommendations for Management of Glucose and A1c Levels in Coronary Artery Bypass Graft Patients
Develop a single protocol for use on all surgical patients. Use a glucose control protocol, implementing a sliding scale or insulin drip as appropriate. Check preoperative glucose levels on a regular basis on all patients to identify hyperglycemia. Time the risk assessment to provide time for adequate treatment. Designate a person responsible and accountable to monitor blood glucose and control.
32

www.IHI.org

3M Infection Prevention Division

Remember CATS remember SSI Preventions..

C A T S

33

IHI

3M Infection Prevention Division

Other Best Practices to Prevent SSIs

OR & CSSD Characteristics/Environment

34

3M Infection Prevention Division

Other Prevention of SSI

OR: Hand Hygiene CDC: Hand Hygiene in Health-Care Settings Surgical hand antisepsis using either an antimicrobial scrub or an alcoholbased hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures

35

3M Infection Prevention Division

Surgical Hand Preparation

Optimum antiseptic
Broad-spectrum activity Fast acting Persistent

Use agents that have been found to have greatest residual activity For first scrub of the day - clean under nails
It is not clear that such cleaning is necessary for subsequent scrubs
CDC GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999
36

Standardizes Procedure for Hand Hygiene

Hand wash: Application technique, length of exposure to product, correct concentration of product Use of soap and water for at least 15 seconds Hand rub: Application technique, length of exposure to product, correct concentration of product Use of alcohol-based antiseptic hand rub when soil is not present on hands At least 15 seconds Surgical hand scrub: Application technique, length of exposure to product, correct concentration of product Use of either an antimicrobial surgical scrub agent or an alcohol-based antiseptic surgical hand scrub
37

3M Infection Prevention Division

3M Infection Prevention Division

SURGICAL HAND RUB Formulations (CDC)

Studies have demonstrated that formulations containing 60%95% alcohol alone or 50%95% when combined with limited amounts of a quaternary ammonium compound, hexachlorophene, or chlorhexidine gluconate (CHG), lower bacterial counts on the skin immediately post scrub more effectively than do other agents. .(Table 4)

38

3M Infection Prevention Division

Other Prevention of SSI

OR: Surgical Solution (Skin Prep)
It is important to choose the proper and correct solution which its reduce the potential of skin microbes to contaminate the surgical wound. Every surgical solutions should provides rapid bacteria kill and persistent antimicrobial activity.

39

3M Infection Prevention Division

Selection of Skin Prep Agent

Desirable qualities
Nonirritating chemical

Broad spectrum activity

Ability to act fast Persistent effect

Difficult to wash away or inactivate by blood/saline

40

3M Infection Prevention Division

Antimicrobial Agents Key Terms

Persistent Activity
Single application Ability to lower bacterial count Maintain low count over specified period of time Cumulative Activity

Repeated use
Lower overall resident bacterial count Count continues to decrease over time

41

3M Infection Prevention Division

Patient Preoperative Skin Preparation

Selecting Antiseptic Products
When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent.
AORN Recommended Practice

Use an appropriate antiseptic agent for skin preparation.

Category IB

42

3M Infection Prevention Division

Other Prevention of SSI

OR: Use of Surgical Barrier (Drapes) Sterile Surgical Drapers protect the patient form infection by preventing microorganisms form making their way into the skin opening created during surgery. If the drape gapes or moves, contamination can be introduced into the sterile field and an infection can arise because everything under the sterile surgical drape is a source of contamination.

43

3M Infection Prevention Division

6 PRINCIPLES OF DRAPING
STERILE FIELD FLUID CONTROL

ISOLATION

Drapes used before surgery to wall off dirty areas or equipment. These can be sterile or non-sterile drapes.

Any sterile drape applied to a surface in a sterile manner creates a sterile field.

44

Fluid collection pouches collect blood and body fluids. An absorbent drape that does not allow fluid strike -through also controls fluids by absorbing spills and splatters.

3M Infection Prevention Division

6 PRINCIPLES OF DRAPING
BARRIER
EQUIPMENT STERILE SURFACE

Sterile drapes used during the draping process to create a barrier layer to blood and body fluids.

Incise drapes provide a sterile surface up to the wound edge.

45

Drapes that isolates and non-sterile equipment from the surgical site and protects expensive equipment.

3M Infection Prevention Division

SURGICAL DRAPES AND GOWNS

46

3M Infection Prevention Division

Surgical Drapes are designed to establish and maintain a sterile field. It is very important to select a surgical drape that provides reliable performance and protection.

NOT SUITABLE

BEST PRACTICE

47

3M Infection Prevention Division

Other Prevention of SSI

CSSD Characteristics Proper Instrument management in CSSD which include the proper Sterilization Monitoring Process

48

3M Infection Prevention Division

Questions?

49

3M Infection Prevention Division

Q&A
SURGICAL SITE INFECTION (SSI) SSI usually occurs between _____________after Operation.

And
Occurs between a Year for Implant Surgery

50

3M Infection Prevention Division

Q&A

Maintain Normal Body temperature

Core:___C

Periphery: 2-4C cooler

51

2011 Arizant Healthcare Inc. All Rights Reserved.

3M Infection Prevention Division

Q&A When is the best time to do Hair Removal as to Reduce/Prevent SSI?

52

3M Infection Prevention Division

53