Changing World: Perianesthesia and Infection Prevention

by: Doris Nordbye, RN MAInfection PreventionistAbbott-Northwestern Hospital

Objectives:

The Learner will be able to: Define resistant pathogens that may be encountered in

the Perianesthesia enviroment. Describe Isolation Practices which assist in the

prevention of transmission of disease. Outline interventions which assist in the reduction:

o Central Line Associated Blood Stream Infections (CLABSI)o Catheter Associated Urinary Tract Infections (CAUTI)o Surgical Site Infection (SSI)o C Diff

IntroductionObama signs bill to increase

antibiotic researchGov focus on Health Aquired

ConditionsPublic reporting of Central Line

infections, UTI, and SSI.No reimbursement for HAIEBOLAMERS-COVERCP Scopes and CRE

Microbiology: The Super Bugs

MRSA

Methicillin Resistant Staph Aureus (MRSA)◦ Normal flora to some.◦ Usually found nares, skin

and throat◦ Colonization vs Infection◦ Causes life-threatening

infections◦ SSI with MRSA increase

risk of death by 10%◦ Transmission unwashed

hands.

ESBL Extended Spectrum

Beta-Lactamase (ESBL)◦Seen with gram neg rods

ie E Coli, K Pneumonia, Family Enterobacteriaceae

◦Highly resistant◦Difficult to treat◦Usually seen in the

urinary tract and the gut but can cause wound and blood stream infections.

◦Transmission unwashed hands

C Diff

C Diff◦Normal intestinal flora.

◦Spore former◦C Diff has been found

to also shed from the skin.

◦Spreads on unwashed hands and contaminated surfaces.

C DiffSpore forming, gram positive rod

that produces exotoxins (toxins A & B)

New hyper virulent strain (NAP1)Produces greater levels of toxins A and B

C Diff Risk FactorsAntibiotic use

◦clindamycin, quinolones, 3rd gen cephalosporins

Nursing home or group home residence

Immunosuppressive meds Hospitalization (within last 90

days)SurgeryProton pump inhibitor use

C Diff Risk factorsNon-compliance with isolation

practices◦ gowning and gloving

Non-compliance with hand hygiene ◦ soap and water hand washing (not alcohol

foam)Inadequate environmental cleaning /

disinfection

CRECarbapenamase Resistant

Enterobacteriaceae (CRE)◦ 128 species of Bacteria

within this family◦ Highly resistant and share

resistance with others.◦ Long courses of antibiotic

therapy or devices◦ Can contibute to death in up

to 50% of infected patients.◦ Healthy people do not get

CRE.◦ Requires urgent aggressive

action.

VREVancomycin Resistant

Enterococcus (VRE)

◦ Normally found in the intestines and female genital tract.

◦ Can cause UTI, BSI or Wound Infection

◦ Risk VRE with long term antibiotic, hospitalized, weakened immune system, surgery, or medical devices.

Precautions/IsolationDesigned to prevent transmissionEnteric precautions require

handwashing with soap and water.

Airborne precautions used with small droplets i.e. TB

Droplet Precautions used for large droplet transmission. i.e. Influenza

Enteric Precautions

Bundles

Bundles

“It takes a village to prevent HAI”

BundlesQuality Improvement intervention

where multiple distinct interventions (that may or may not be individually effective) are “bundled” together during procedures that carry a high intrinsic risk of a complication in the expectation that these will result in and additive benefit to achieve a desired outcome.

Bundles

Usually consists of 3 – 5 evidence-based practices.

Infection Prevention today is the implementation of bundles to prevent infection.

CLaBSI BundleDeveloped as a result of multi-

facility double-blinded and large patient populations.

Implementation of CLABSI Bundles have reduced CLABSI by 49% across the country.

Central Line Insertion BundleUse the subclavian vein unless

contraindicated.Avoid the femoral vein.Do not routinely replace cathetersUse maximal sterile barrier protectionUse a full body drape.Use Antiseptic with AlcoholHand Hygiene before insertion Empower Health care personnel to

stop if breach in sterile technique.

Central Line Maintenance BundleHand hygiene before touching “Scrub the Hub” 10-15 seconds

and allow to dry.Use alcohol or CHG to “scrub the

hub”Do not use creams or ointments

on site.Change Dressing every 5-7 days.

Do not reinforce.Use an occlusive dressing.

Catheter Associated UTIDropped 19% across the country.Increasing attention

◦To reasons for insertion of foley catheters.

◦Insertion techniques◦Early removal

CaUTI BundleUse foleys in operative patients only

as necessary.◦Urologic or other surgery on contiguous

structures of the genitourinary tract.◦Prolonged duration of surgery◦Anticipated to receive large volumes of

fluid.◦Anticipated to receive diuretics ◦Monitoring of urinary output◦Assist in healing of sacral or perineal

wounds.

CaUTI BundleOnly properly trained individuals should

insert.Hand hygiene before and after

insertion.Pericare before insertionUse sterile technique to insertSecure the foley after insertionRemove as soon as possible.

◦SCIP protocol indicate by PO Day 2.◦Catheters inserted for prolonged duration of

surgery should be removed in PACU.

CaUTI Bundle Maintenance

Maintain a closed systemMaintain unobstructed flowPerform PericareDo not clean periurethral area

with antiseptic. Clean with soap and water.

Do not allow drainage bag to touch the floor.

CaUTI Work to be doneDevelop system of

alerts/reminders to assess for continued need.

Develop guidelines/protocols for nurse-directed removal

Develop guidelines and algorithms for appropriate peri-operative catheter management.

Reduce surgical site infection (SSI)Most common hospital aquired infectionNationally seen SSI drop 19%Difficult bundle development

◦Very few double blinded multifacility studies.◦Most studies are single facility small volume

studies.Must build consensus for development

and implementation.Improvement stems from interventions

that span the “continuum of care”.

Patient PreparationSmoking

◦Quitting as little as 3 weeks prior to elective procedure can have an impact.

Bathing:◦Reduce the bioburden◦All patients having elective surgery should

have a bath/shower before arriving.◦Some facilities are showering after patient

arrives.◦MRSA and MSSA thrive on the skin

Glycemic Control

Patient PreparationAdminister prophylactic antibiotics

within one hour of surgery.◦Over 120 kilos receive 3 grams.◦Redose after 2 half lifes of the antibiotic

during procedure. Hair Removal

◦No hair removal or clip only as necessary.◦ If necessary, done outside of the operating

room.Use an alcohol-based skin prep.Maintain normothermia

Post Op BundleHand hygiene before touching

wound.Teach patient to perform hand

hygiene before touching wound. Dressing:

◦If dressing needs to be changed, use sterile technique.

◦Dressing should remain in place for 24 to 48 hours.

Post operative If dressing needs to be changed,

cleanse wound before replacing dressing.

Maintain Post operative glucose

Hand Hygiene