1 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention NQF-Endorsed ® Safe Practices for Better Healthcare Student Projects

2 © 2010 TMIT NQF Safe Practices: Brought to you by The Quality Choir

3 © 2010 TMIT Culture SP NQF Report

4 © 2010 TMIT Overview Key Points:  Part I – Background:  Definition and cause of a Surgical-Site Infection (SSI)  Why is there a case for concern?  What are SSI prevention recommendations?  Part II – Barriers:  What impedes implementation of SSI prevention practices?  Part III – Strategies:  How can students contribute to improving implementation of prevention practices?

© 2006 HCC, Inc. CD XX 5 © 2010 TMIT Learning Objectives Participants will be able to:  Explain criteria for defining a Surgical-Site Infection (SSI) and describe guidelines and recommendations for prevention.  Describe barriers to implementing SSI prevention practices.  Identify a strategy in the pre-, intra- and post- operative period to improve adoption of prevention practices and to decrease SSIs.

© 2006 HCC, Inc. CD XX 6 © 2010 TMIT Definition Case for Concern Prevention Guidelines and Practices Part I: Background

© 2006 HCC, Inc. CD XX 7 © 2010 TMIT Definition Associated with at least one of the following An infection that occurs at the site of an incision within the first 30 postoperative days, or within 1 year if an implant has been placed Purulent Drainage Fascial Dehiscence Abscess involving incision Isolated organisms Part I: Background Definition

© 2006 HCC, Inc. CD XX 8 © 2010 TMIT Three Classifications of Surgical-Site Infections Superficial Incisional: Involves only skin and subcutaneous tissue Deep Incisional: Involves deep tissues (fascial and muscle layers) Organ/Space: Involves anatomy in organs and spaces other than where incision is Part I: Background Definition

© 2006 HCC, Inc. CD XX 9 © 2010 TMIT Surgical- Site Infections Patient Factors: Immune status and co-morbid conditions Microbial Factors: Degree of contamination, virulence of pathogen, and effect of the microenvironment Surgical Factors: Type of procedure, length of operation, intro of foreign material, and intraoperative contamination Part I: Background Factors Leading to Infection

© 2006 HCC, Inc. CD XX 10 © 2010 TMIT Part I: Background Case for Concern  Surgical-Site Infections (SSI) are the 2nd most frequent healthcare-associated infection arising in hospital setting 1  An estimated 2%-5% of ~30 million patients undergoing a surgical procedure per year experience SSIs (~500,000 each year) 2  SSIs account for ~20% of all healthcare-associated infections

© 2006 HCC, Inc. CD XX 11 © 2010 TMIT Each SSI is associated with 7-10 additional post-op days 1 SSIs are associated with in patient readmission rates (5x increase) Patients with SSIs face a risk of death 2-11x > non-SSI patients 2 Attributable costs of SSIs range from $3,000- $29,000 3 Annual costs of SSIs estimated to be $10 billion 4 Part I: Background Case for Concern

© 2006 HCC, Inc. CD XX 12 © 2010 TMIT Preventability ~ 40%-60% of SSIs are preventable Appropriate use of prophylactic Antibiotics Proper surgical site preparation Supplemental perioperative oxygen Controlled post- op glucose Maintenance of perioperative normothermia Part I: Background Preventability

© 2006 HCC, Inc. CD XX 13 © 2010 TMIT GuidelineNational AverageBenchmark Antibiotics within 1 hour 87.6%98.6% Correct antibiotics93.7%99.5% Antibiotic discontinued within 24 hours 82.9%97.4% Glucose control (cardiac) 85%98.8% No razor93.7%100% Normothermia81.2%99.3% Data Source: Oklahoma Foundation for Medical Quality 2007 National Report Card

14 © 2010 TMIT Challenge: There are proven methods of prevention, but they are not always appropriately implemented to achieve best results WHY? Transferring evidence-based guidelines into practice still requires innovative and diligent implementation strategies!

© 2006 HCC, Inc. CD XX 15 © 2010 TMIT Individual provider obstacles Low priority for Surgeon/Anesthe- siologist/Nurse Inconvenience Systemic process breakdowns Workflow breakdown Lapses in organizational communication Role perception obstacles Different perceptions of shared vs. individual responsibilities and boundaries Part II: Barriers

© 2006 HCC, Inc. CD XX 16 © 2010 TMIT Limited physician involvement and leadership in the implementation and support of changes in SSI prevention practices Absence of teams of surgeons, anesthesiologists, nurses, OR technicians, physician assistants and health professions students with defined roles, and who can be held accountable for implementing SSI prevention guidelines Part II: Barriers

© 2006 HCC, Inc. CD XX 17 © 2010 TMIT An Invaluable Role of Health Professions Students in SSI Prevention: Implementation Approaches to Put Proven Prevention Practices to Work

© 2006 HCC, Inc. CD XX 18 © 2010 TMIT Provide pre-op instructions and information for reducing SSI risk Educate patients and families about SSI prevention Risk factors: Diabetes, smoking, obesity, poor nutrition, advanced age, alcoholism, medication, systemic steroid use, coincident infections Note patient characteristics that increase SSI risk and alert team during pre- and post-op follow-up care Collect data on number of non-SSI cases achieved between SSI cases over 12 months. Goal to double non-SSI cases in between Collect data to capture # of non-SSI surgical cases Initiate QI project. See NQF QuickStart package on how to start a student project to establish roles, goals, measures of performance and evaluation for SSI prevention Volunteer to assemble the team to facilitate workflow and define responsibilities Part III: Strategies in the Preoperative Period

© 2006 HCC, Inc. CD XX 19 © 2010 TMIT Patient Pre-Op Prep If hair removal necessary, remove immediately prior to operation with electric clippers Wash and clean at and around incision site to remove gross contamination before skin prep Use appropriate antiseptic agent for skin prep Apply pre-op antiseptic skin prep in concentric circles, moving toward periphery Surgical Team Antisepsis Keep nails short and do not wear artificial nails Surgical scrub at 2-5 min (up to elbow) using appropriate antiseptic Do not touch scrubbed arms on objects Dry hands with sterile towel and don sterile gown and gloves BE PREPARED TO ALERT THE TEAM if you observe accidental contamination of the sterile field Part III: Strategies in the Preoperative Period

© 2006 HCC, Inc. CD XX 20 © 2010 TMIT Adhere to Proper Intraoperative Attire and Behavior Wear surgical mask that fully covers mouth and nose Wear cap/head- cover to entirely cover head and facial hair, if necessary Avoid wearing shoe covers, if possible, for prevention of SSI If scrubbing in as a surgical team member, wear sterile gloves Wear surgical gowns that are effective barriers when wet Change scrub suits if noted to be visibly soiled Part III: Strategies in the Intraoperative Period

© 2006 HCC, Inc. CD XX 21 © 2010 TMIT A link to the checklist, guidelines, and examples for modifications are included below. The checklist outlines key safety steps that should be implemented during the perioperative care of every single operation. Its application has been associated with significant reductions in complications and mortality from surgery. Implement the WHO safe surgery checklist through the “Safe Surgery Student Mentor Project” Part III: Strategies in the Intraoperative Period

© 2006 HCC, Inc. CD XX 22 © 2010 TMIT Wash hands properly prior to dressing change and contact with surgical site, and after contact Use sterile technique to change incision dressing Do not use topical antimicrobial agents for surgical wounds healing by primary intention For incision with primary closure: Protect with sterile dressing for hours in post-op period Educate patient and caretakers on necessary incision care, potential symptoms of an SSI, and the need to report symptoms Part III: Strategies in the Postoperative Period Practice diligent postoperative incision care

© 2006 HCC, Inc. CD XX 23 © 2010 TMIT Refer to the IHI Open School for Health Professions (Link Below) Find tools, support, and suggestions to help develop your ideas Find a simple list of variety of ways to get involved Introduce an innovative project to improve patient safety at your institution How to Get Involved!

© 2006 HCC, Inc. CD XX 24 © 2010 TMIT Summary  Surgical-site infections are the 2nd most frequent healthcare-associated infection arising in a hospital setting.  SSIs have been shown to increase mortality, readmission rate, length of stay, and cost for patients who incur them.  Evidence-based recommendations to prevent 40% - 60% of SSI infections are available.  Despite availability reports show low compliance with SSI prevention measures.  There are a number of individual, systematic and perception barriers that impede compliance and implementation.  Health Professions Students can play an instrumental role in overcoming barriers and improving SSI prevention efforts.

© 2006 HCC, Inc. CD XX 25 © 2010 TMIT Learning Objectives Review Participants will be able to:  Explain criteria for defining a Surgical-Site Infection (SSI) and describe guidelines and recommendations for prevention.  Describe barriers to implementing SSI prevention practices.  Identify a strategy in the pre-, intra- and post- operative period to improve adoption of prevention practices and to decrease SSIs.

© 2006 HCC, Inc. CD XX 26 © 2010 TMIT Thank You for Your Interest and Attention Questions?