Today’s Webinar will begin at 11:00 PST

12/18/12

Welcome from Barb DeBaun, RN, MSN, CIC

Introduction

• Please do not put your phone on hold; use the mute function or *6

• Please type questions or comments into text box

• Interactive question session• If time permits, we will open up the phone

lines at the conclusion of the presentation

Introducing Sue Barnes, RN, CIC

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SSI Prevention - How Are We Doing? Direct OR Observations

Sue Barnes, RN, BSN, CICNational IP Leader, Kaiser Permanente

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IP Before Holiday Break

Overview and objectivesOVERVIEW: This session will describe how inpatient and outpatient surgery centers are doing relative to surgical infection prevention based on a small number of direct case observations. Prevention in all phases of the surgical journey will be addressed: pre-operative, intra-operative and Post-operative. The uncharted arena of surgical technique and infection

risk will also be considered.

OBJECTIVES1. Share project overview2. Review observed compliance with standard infection prevention

efforts, share best practices and challenge areas3. Share my ongoing dialogue with surgeons and periop staff – what do

they know that we don’t know about surgical procedures and infection risk?

Project overviewPreparation

• Request permission to observe cases from surgeon colleagues• Schedule with OR managers – inform local IP – request time for debrief• View UTube video clips of procedures

Observations• Use checklist to guide observations – take notes: best practices, questions,

opportunities for improvement• Ask surgeons and periop staff their perspective regarding aspects of surgical

procedure, technique and SSI risk – their concerns

After the case• Debrief post op with OR manager and IP (separately or together at their

convenience)• Sent thank you to surgeon, team and their supervisors with summary of best

practices• Sent private list of challenge areas – “your eyes only” to surgeon, IP and OR

manager – professional courtesy

My next steps• 4 cases observed to date (general, OB/GYN, cardiac, plastics). I plan to continue

next year with other high risk procedures including: bariatric, ortho, eye, spine

OR Observations

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“Almost no matter what experimental conditions were imposed, increases in output occurred….The investigators had obviously influenced the subjects’

behavior merely by studying that behavior, and this phenomenon has become known as the Hawthorne effect.”

(Kelly Shaver, Principles of Social Psychology, 2nd ed., Winthrop, 1981)

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Questions posed 1. Pre Op: • Hair removal• Skin prep• Hand scrub

2. Intra Op:• Aseptic technique• Antibiotic weight based dosing and

re-dosing• Irrigation• What are you concerned about?

3. Post Op:• Skin closure• Patient education• Drains, dressings

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Observation focus1. Anesthesia: Foley on floor? Scrub the hub?

Mask over nose and mouth? Hair coverage?2. Aseptic technique movement front to front,

hands above waist, sterile field3. Attire full hair coverage (including chest), long

sleeves, mask4. Environment OR room design and cleaning,

clutter, supplies covered/behind closed doors, equipment, instruments

5. Hand degermer outside/inside OR rooms6. Scrub sinks brushless scrub, no refillable bottles7. Traffic in OR rooms during case.

Lap hysterectomy + hernia repair

Breast reduction

Laparoscopic colectomy

CABG

My primary take away

Also

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A couple of these moments

Pre-operative

Surgical hand scrubWith brush: CHG or PVIBrushless: Alcohol +/- CHG

Jarral OA, McCormack DJ, Ibrahim S, Shipolini AR. Should surgeons scrub with chlorhexidine or iodine prior to surgery? Interac Cardiovas Thorac Surg. 2011 Jun;12(6):1017-21.

Lai KW, Foo TL, Low W Naidu G. Surgical hand antisepsis-a pilot study comparing povidone iodine hand scrub and alcohol-based chlorhexidine gluconate hand rub. Ann Acad Med Singapore 2012 Jan;41(1):12-6.

Pre-operative antibiotics

Ho VP, Barie PS,Stein SL, Trencheva K, Milsom JW, Lee SW, Sonoda T Antibiotic regimen and the timing of prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery. Surg Infect 2011 Aug;12(4):255-60.

Bowater RJ, Stirling SA, Lilford RJ Is antibiotic prophylaxis in surgery a generally effective intervention? Testing a generic hypothesis over a set of meta-analyses. Ann Surg. 2009 Apr;249(4):551-6.

Glucose control

Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative glycemic control in general surgery: a report from the surgical care and outcomes assessment program. Ann Surg. 2013 Jan;257(1):8-14.

Normothermia

Moola S, Lockwood C. Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment. Int J Evid Based Healthc 2011 Dec;9(4):337-45

Lista F, Doherty CD, Backstein RM, Ahmad J. The impact of perioperative warming in an outpatient aesthetic surgery setting. Aesthet Surg J. 2012 Jul;32(5):613-20.

Yeung LL, Grewal S, Bullock A, Lai HH, Brandes SB. A comparison of chlorhexidine-alcohol versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a randomized controlled trial. J Urol. 2013 Jan;189(1):136-40.

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Skin Antisepsis

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MRSA Decolonization high risk cases

Vonberg RP, Gastmeier P. Prevention of surgical site infections in bone and joint procedures. Curr Infect Dis Rep 2012 Oct;14(5):576-84.

Craft RO, Damjanovic B, Colwell AS. Evidence-based protocol for infection control in immediate implant-based breast reconstruction. Ann Plast Surg. 2012 Oct;69(4):446-50.

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Hair Removal

Grober ED, Domes T, Fanipour M, Copp JE. Preoperative Hair Removal on the Male Genitalia: Clippers vs. Razors J. Sex Med 2012 Aug 21.

Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011 Nov 9;(11):CD004122.

CHG cloths for pre-op antiseptic bathing

Webster J, Osborne S. “Home-based preoperative chlorhexidine bathing cloths to prevent surgical site infection” ICHE 2011 Oct;32(10):1047.

Intra-operative

Aseptic technique

Blanchard, Byron Burlingame, Bonnie Denholm, Sharon Giarrizzo-Wilson, Mary Ogg, and Sharon A. Van Wicklin. Perioperative Standards and Recommended Practices. Vol. 1, 2012.

Traffic control intra-operatively

Al-Benna S. Infection control in operating theatres. J Periop Pract 2012 Oct;22(10):318-22.

Staff hair coverage

Alicia J. Mangram GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Vol. 20 No. 4 247. “Wear a cap or hood to fully cover hair on the head and face when entering the operating room.” (CDC category IB).

Foley on floor - Anesthesia

Gould C et al. CDC HICPAC GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 “Do not rest the bag on the floor.” (Category IB) .

Scrub the hub - Anesthesia

Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a post insertion care bundle. AJIC. 2010 Aug;38(6):430-3.

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Hand hygiene - Anesthesia

Henderson DM, et al. “A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-line-associated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections.” J Healthc Qual . 2012 Sep-Oct;34(5):39-47.

Red cap: Version1: visitors Version 2: patient pre-op checklist pending

Change gloves before closing

Partecke LI, Goerdt AM, Langner I, Jaeger B, Assadian O, Heidecke CD, Kramer A, Huebner NO. Incidence of microperforation for surgical gloves depends on duration of wear. ICHE 2009 May;30(5):409-14.

Use of disposables – hard to clean items

Brown DQ. Disposable vs. reusable electrocardiography leads in development of and cross-contamination by resistant bacteria. Crit Care Nurse. 2011 Jun;31(3):62-8.

Post-operative

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Patient teaching – S & S Infection

Hari M, Rosenzweig M. Incidence of preventable postoperative readmissions following pancreaticoduodenectomy: implications for patient education. Oncol Nurs Forum. 2012 Jul;39(4):408-12.

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High dusting, de-cluttering, cleaning OR

Munoz-Price LS, Birnbach DJ, Lubarsky DA, Arheart KL, Fajardo-Aquino Y, Rosalsky M, Cleary T, Depascale D, Coro G, Namias N, Carling P. “Decreasing operating room environmental pathogen contamination through improved cleaning practice.” ICHE 2012 Sep;33(9):897-904.

UV light as adjunct to manual cleaning

Boyce JM, Havill NL, Moore BA. “Terminal decontamination of patient rooms using an automated mobile UV light unit”. ICHE. 2011 Aug;32(8):737-42.

Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis. 2010 Jul 8;10:197.

Antimicrobial post-op dressing

Epstein NE. “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections.” Surg Neurol Int. 2011 Feb 21;2:17.

Krieger BR et al. “The use of silver nylon in preventing surgical site infections following colon and rectal surgery”. Dis Colon Rectum. 2011 Aug;54(8):1014-9.

Antimicrobial dressing for pins and drains

Egol KA et al. “Treatment of external fixation pins about the wrist: a prospective, randomized trial.” J Bone Joint Surg Am. 2006 Feb;88(2):349-54.

D/C instructions with surgeon cell #

Surgical technique and SSI risk:Questions posed to and by

surgeons

Electronic devices that discharge air, or are designed to blow air in OR – a risk?

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Intra-operative Irrigation Pour? Bulb syringe? Jet?

Intra-operative Irrigation NS, RL, CHG, antibiotics?

What about the operative wound – size of incision, dead space, exposed adipose tissue?

What’s the benefit of the wound edge protector – when to apply?

What about wound closure and care – what’s best?

What I have added to my checklist this year

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From the News: Lumen cleaning - Instrument reprocessing

Eaton, J. “Filthy surgical instruments: The hidden threat in America's operating rooms Danger in dirty instruments”. The Center for Public Integrity I Watch. February 22, 2012.

Medl, N., Guerrero, T. G., Hölzle, L., Hässig, M., Lochbrunner, S. and Montavon, P. M. (2012), “Intraoperative Contamination of the Suction Tip in Clean Orthopedic Surgeries in Dogs and Cats.” Veterinary Surgery, 41: 254–260.

From case observations: Skin prep prior to epidural anesthesia

Bedoya A, Gentilesco B. Prosthetic valve endocarditis: a complication of spinal epidural abscess. Case Report Med. 2010;2010:105426.

From a conference: Pain control and infection risk

Sacerdote P, Franchi S, Panerai AE. Non-Analgesic Effects of Opioids: Mechanisms and Potential Clinical Relevance of Opioid-Induced Immunodepression. Curr Pharm Des. 2012 Jun 28.

De Oliveira GS Jr, Fitzgerald P, Streicher LF, Marcus RJ, McCarthy RJ. Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery. Anesth Analg. 2012 Aug;115(2):262-7.

Grogan BF, Cranston WC, Lopez DM, Furbee C, Murray CK, Hsu JR; Skeletal Trauma Research Consortium. Do protective lead garments harbor harmful bacteria? Orthopedics. 2011 Nov 9;34(11):e765-7.

From an ASC: Cleaning and disinfection of lead gowns in OR

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Sue Barnes Sue.Barnes@kp.org 510-267-4871

www.cynosurehealth.org

Thanks for joining us today