Preventing Surgical Site Infections in the OR

Kerri A. Thom, MD, MSAssistant Professor, UM School of Medicine

Key Point

•Up to 60% of surgical site infections may be preventable and there are multiple strategies aims at reducing infection

Key Points – SSI Prevention

•Up to 60% of SSI are preventable •Antibiotic prophylaxis is very important •Be aware of your own bioburden•Be aware of impact of traffic/door openings

Key Points

•Surgical antimicrobial prophylaxis is the most important intervention in the prevention of SSI

•Essential elements include: ▫Selection of appropriate agent▫Timing (within 1 hour of incision) ▫Dose (weight-based, re-dosing) ▫Minimizing adverse events

•Recognize modifiable risk factors for surgical site infection

•Provide safe care by applying key measures to preventing infections in the OR

•Optimize antibiotic prophylaxis by selecting the most appropriate agent and giving the optimal dose at the optimal time

Objectives

•Background ▫Modifiable risks for SSI

•Antibiotic Prophylaxis, What Matters ▫Agent, dose, time

•Other important measures▫Optimizing modifiable risk factors▫Use of the surgical checklist ▫Hand hygiene▫Limiting traffic and door openings

Overview

Surgical Site Infections (SSI)

•Most Common Healthcare infection1

▫21% of all HAIs

HAP14%

CLABSI

14%

20%, SSI

22%, Other

36%, UTI

11%, BSI

11%, PNA

Magill S et al. N Engl J Med, 2014

Surgical Site Infections (SSI)

•Most Common Healthcare infection1

▫21% of all HAIs

HAP14%

CLABSI

14%

20%, SSI

22%, Other

36%, UTI

11%, BSI

11%, PNA

Magill S et al. N Engl J Med, 2014

15 million inpatient surgeries per year

Surgical Site Infections (SSI)

•Most Common Healthcare infection1

▫21% of all HAIs

HAP14%

CLABSI

14%

20%, SSI

22%, Other

36%, UTI

11%, BSI

11%, PNA

Magill S et al. N Engl J Med, 2014

15 million inpatient surgeries per year

2-5% (300-500K) develop SSI

Surgical Site Infections (SSI)

•Most Common Healthcare infection1

▫21% of all HAIs

HAP14%

CLABSI

14%

20%, SSI

22%, Other

36%, UTI

11%, BSI

11%, PNA

Up to 55% of SSIs are

preventable!

Up to 55% of SSIs are

preventable!

1Magill S et al. N Engl J Med, 20142Umscheid et al. Infect Control Hosp Epidemiol, 2011

Surgical Site Infections (SSI)

•Prolong hospital stay (7-10 days)• Increased Mortality

▫Risk of death, 2-11 times greater ▫77% of deaths are attributable to SSI

•More expensive than other complications (e.g., sternal wound infections most expensive complication of CABG)

Kirckland et al, Infect Control Hosp Epi, 1999Managram et al, Infect Control Hosp Epi, 1999

Hollenbeak et al, Chest, 2000Wenzel et al, Clin Infect Dis, 2007

SSI

Microbial Characteristics

Surgical Characteristics

Host Characteristics

e.g. Virulence, Dose

e.g. Host Defense, Immunity

e.g. Duration, Implant

Anderson. Infect Dis Clinics North Am 2011

Pathogenesis

SSI

Microbial Characteristics

Surgical Characteristics

Host Characteristics

e.g. Virulence, Dose

e.g. Host Defense, Immunity

e.g. Duration, Implant

Anderson. Infect Dis Clinics North Am 2011

Pathogenesis

Sources of Microbial Contamination

Endogenous Exogenous

• Most Common• Gram-positive (Skin Flora)

• Air, Instruments, etc…• Post-operative Dressing

Staphylococcus aureus 30.0%Coag-negative Staphylococci 13.7%Enterococcus spp. 11.2%Escherichia coli 9.6%Pseudomonas aeruginosa 5.6%

Rest: Other gram negative bacteria, Candida

Hidron, Infect Control Hosp Epidemiol 2008

Organisms Causing SSI

SSI

Glucose ControlWound Care

Wound ClassProphylactic AntibioticsPre-op CleansingPre-op ScreeningPre-op Hair RemovalSurgical Technique Surgical DurationOR environmentHypothermia

Post-Op

Surgical

Age UndernutritionInfection at Remote SiteProlonged Pre-op StayPrior OperationsImmunesuppressionCancerDiabetesObesitySmoking

Patient

Use for surgeries that require: entering a hollow viscus, insertion of prosthesis,

or if development of SSI would pose catastrophic risk

Prophylactic Antibiotics

One of the most important interventions to prevent

SSI

The Ideal Agent?

The Ideal Agent?

Effective

Safe

No impact on Microbiome

•Activity against expected pathogens•Favorable safety profile (toxicities, allergies) •Favorable cost profile

Antibiotic Selection

•Weight-based•Cefazolin 2 gm for all

•RCT of 1 versus 2 gm▫1 gm decreased serum/tissue concentrations,

below necessary MICs

Dose

Forse, Surg, 1989

Successful prophylaxis relies on drug availabilityat the operative site during time of contamination

Begin administration within 1 hour of cut time• 2 hr for Vanc/FQ

Complete administration by incisionRe-dose at 3 hour intervals (and/or blood loss)Stop antibiotics after procedure

Timing

SSI rates corresponding to the temporal association between

administration of antibiotics and the start of surgery

Timing

Classen NEJM, 1992

Timing

Steinberg JP, Ann Surg, 2009

Association between the timing of prophylaxis and incidence of SSI following Cardiac Surgery, THA/TKA, Hysterectomy

Successful prophylaxis relies on drug availabilityat the operative site during time of contamination

Begin administration within 1 hour of cut time• 2 hr for Vanc/FQ

Complete administration by incisionRe-dose at 3 hour intervals (and/or blood loss)Stop antibiotics after procedure

Timing

•SCIP (Surgical Care Improvement Project)▫Appropriate selection ▫Within 1 hour ▫Stopped within 24 hours

•CMS Reporting▫SSI after CABG, THA, TKA▫Soon…SSI after Colorectal and Hysterectomy

National QI Initiatives

Other Infection Prevention Measures

Use an OR Checklist (based on WHO Surgical Checklist)

Surgical Checklist

Results of Starting Checklist

Variable % Decrease p value•Total disruptions/case 47 <0.01•Miscommunications/case 53 0.03•Time circulator gone 56 0.01

Henrickson. J Amer Coll Surgeons 2009; 208: 1115-23

Does the Checklist Impact Mortality?

•22 item checklist modeled on WHO•25,513 patients followed•Record of checklist completion:

• Not done• Partial - at least 1 of 22 done• Completed - all done

van Klei. Ann Surg 2012; 255: 44-9

Checklist Completion and Mortality

Adjusted Odds RatioMortality

All patients 0.85 (0.73-0.98)

van Klei. Ann Surg 2012; 255: 44-9

Checklist Completion and Mortality

Adjusted Odds RatioMortality

All patients 0.85 (0.73-0.98)

Completed 0.44 (0.28-0.70)

Partial 1.09 (0.78-1.52)

Not done 1.16 (0.86-1.56

van Klei. Ann Surg 2012; 255: 44-9

Reducing our own bioburden

•Hand hygiene (and/or surgical scrub) •Appropriate attire

▫Including covering hair •Monitor for skin lesions

Hand Hygiene

• In/Out of Room

•Multiple opportunities during case

Managing Air Flow

Microbial Air Counts and OR Traffic

•68% of the variance in total CFU/m3 (p = 0.001) explained by▫Traffic flow (door openings)▫Number of persons (clutter) in the OR▫Procedure duration

AE Andersson et al. AJIC 2012, Jan 28 epublished

Door Openings

•284 operations•22 pts had SSI:

▫Mastectomy (n = 5; 2.8%)▫Colon resection (n = 16; 21.6%)▫Aorta reconstruction (n = 1; 2.8%)

•Risk factors for SSI:▫Wound class: p < 0.001▫Emergency procedure: p = 0.001▫Door openings/hour 0-6 vs > 6: p = 0.02

FJ Prakken, et al. NED TIJDSCHR GENEESKD. 2011;155:A3269

Reasons for Door Openings•177 (33.5%) = necessary

▫40 = expert consultations▫137 = supplies & equipment

•184 (35.7%) = semi-necessary ▫76 = surgical team members entering or leaving▫134 = breaks

•168 (31.8%) = unnecessary▫30 = logistics, like planning other operations▫45 = social▫93 = no detectable reason

AE Andersson et al. AJIC 2012, Jan 28 epublished

Door Openings

•Number of door openings varied by specialty▫ 19-50 door openings/hour

•OR doors open: ▫~20 seconds/opening▫15-20 min/hour

•Requests for information > breaks (~25%) > supplies (~20%)

RJ Lynch, et al. Am J Med Qual 2009;24;45-52

Strategies to Reduce Door Opening

Key Point

•Up to 60% of surgical site infections may be preventable and there are multiple strategies aims at reducing infection

Key Points – SSI Prevention

•Up to 60% of SSI are preventable •Antibiotic prophylaxis is very important •Be aware of your own bioburden•Be aware of impact of traffic/door openings

Key Points

•Surgical antimicrobial prophylaxis is the most important intervention in the prevention of SSI

•Essential elements include: ▫Selection of appropriate agent▫Timing (within 1 hour of incision) ▫Dose (weight-based, re-dosing) ▫Minimizing adverse events

ANY QUESTIONS?

WASH YOUR HANDS!