1. Preventing Surgical Site Infections: Back to Basics
Kathleen Kohut, RN, MS, CIC, CNOR

2. Speaker Disclosures 3M
AMN Healthcare
BESmith
The Compass Group

3. Objectives Name the 2 most common mechanisms for wound contamination
Discuss 7 areas of opportunity for improvement
Describe the use of glycemic control and nasal decolonization initiatives for the reduction of SSIs.
List 3 ways to facilitate process improvements in the Operating Room

4. Invaluable Resources National Healthcare Safety Network (NHSN)
1999 HICPAC SSI Guidelines
AORN Guidelines
Surgical Care Improvement Project (SCIP) Measures

5. SCIP Quality Measures Antibiotic Prophylaxis Drug, Timing, Dosing
Hair Removal
Glycemic Control
“Normothermia”
Expanded in June
All surgical patients
Qualitynet.org

6. Back to the Basics Aseptic Technique Traffic Sterilization
ABX Prophylaxis
Hair Removal
Skin Antisepsis
Dressings

7. 1. Aseptic Technique
Principles were developed to reduce the risk of wound contamination.

8. Defining the Risk of SSI
Risk of SSI = Dose of Bacterial
Contamination X Virulence
Resistance of Host (patient)
Berry & Kohn’s, Operating Room Technique, 11th ed., p. 254

9. Causes of Wound Contamination
Exogenous sources
Cleanliness of environment, lack of proper airflow, shedding by the Surgical Team
Endogenous sources
Patient’s own skin/hair
Infection at a remote site

10. The Number One Source People = Shedding
,000 particles per minute
(Berry & Kohn’s, Operating Room Technique, 11th ed., p. 252)
Carried by wind currents to the sterile field which results in wound contamination.
Patient
Surgical Team
Ancillary Personnel
Sales Reps
Students
Passersby

11. Shedding plus Wind Currents
Requires the control of:
Amount of Traffic
Traffic Patterns
Sherertz, et al. “Cloud” HCWs. Emerging Infect Dis. 2001;7(2):
Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6):
Containment is the key

12. 2. Traffic Control Essential personnel only
One foot (min) perimeter around sterile field
Sterile fields should be a destination, not a thoroughfare
Limit students and observers
The right of the student to learn vs. the right of the patient to receive safe patient care
DeKastle, R.  Telesurgery: Providing Remote Surgical Observations for Students.  AORN 2009; 90 (1):
Utilize alternative methods of communication

13. People + Wind + (-) Aseptic Technique
Kohut SSI Equation
People + Wind + (-) Aseptic Technique
> ABX + Skin Prep =
Wound Contamination =
SSI

14. Containment is the key 1. Patient 2. Surgical Team Pre-op Showers
Hat and clean gown/linen for patient
2. Surgical Team
Hand Hygiene
Nocardia farcinica (Wenger, et al. J Infect Dis. Nov 1998)
Proper aseptic technique
Properly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire)

15. Ban Skull Caps
Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov)

16. Lack of Containment
BAD
VERY BAD

17. Standards of Excellence
PETA APPROVED
GOLD STANDARD

18. Environment Room Requirements Room Cleaning
Ventilation System (15/hr – 3 fresh)
Positive pressure
Temperature (68-73° F)
Humidity (30-60%)
Room Cleaning
Between cases
Terminal cleaning
Types of construction materials
Clutter
AORN, Recommended Practices for Perioperative Nursing: Safe Environment of Care. (2008 ed., p 357)

19. Surgical Conscience
Requires strict adherence to the principles of aseptic technique by all team members for every patient on every case.
ORs that value these principles create a patient centered culture.
Girard, NJ. Surgical Conscience: Still Pertinent. AORN (2007):86 (1);

20. 3. Sterilization Proper Management of Sterile Processing Departments
Technology
Workflow
Staff certification
Proper Sterilization Processes
Focus area for The Joint Commission
Cleaning, sterilization, and storage

21. Flash Sterilization Utilized for: Results in contamination due to:
Dropped instruments
Poorly designed work processes
Lack of instrumentation
Surgeon scheduling
Results in contamination due to:
Poor cleaning due to lack of time
Methods of delivery to the sterile field
Closed containers are best practice
TJC will be looking for them
Carlo, A. The New Era of Flash Sterilization. AORN 2007: 86(1); p

22. Flash Data
Calculation: # of flash events = rate x # of cases/month

23. 4. Antibiotic Prophylaxis
SCIP Measures
INF 1,2,3
Goal >90%
Best Practice- Anesthesiologists
Proper dosage for obese population (BMI>30)
Don’t forget redosing q 3 hours

24. 5. Hair Removal
SCIP INF 6: Surgery patients with appropriate hair removal.
Minimize as much as possible
Clippers only
Not in the OR!

25. 6. Skin Antisepsis
The attributes of an appropriate surgical skin antiseptic require:
The ability to significantly reduce microorganisms (2 log, 3 log)
Provide broad spectrum activity
Be fast acting
Have a persistent effect
All products with FDA approval meet this criteria
AORN, Recommended Practices for Perioperative Nursing: Skin Antisepsis. (2008 ed., pp )

26. Other Skin Antisepsis Considerations
Procedure
Prep area
Application Methodology
Scrubbing vs. Painting
Length of the procedure
Challenges to the prep area
-blood, saline, friction
Patient Safety

27. Critical Thinking is Required
Ultimately, the OR nurse decides at the point of care by assessing the patient to insure that the skin antisepsis planned for will be appropriate for that patient based on allergy status, body site, and skin integrity.

28. Current Recommendations
CDC SSI guideline states to “use an appropriate antiseptic”
SHEA Compendium - “Optimal preparation and disinfection of the operative site”
AORN compares products but does not provide specific product recommendations

29. Current Research
Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes
The majority of the literature compares microbial counts
The correlation between microbial counts and SSI outcomes is unclear

30. Current Research
Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91:
Microbial culture study of 150 patients
Compared 3 methods
Iodophor Scrub/Paint vs. ChloraPrep® vs. Duraprep™
Result
Microbial counts were less using ChloraPrep®
SSI Outcome was no SSIs in any of the groups

31. Current Research
Swenson, et al. Preoperative skin preparation on postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol 2009; 30:
SSI Outcome study of 3209
general surgery patients
Compared 3 methods
Iodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™
Result
SSI Outcomes- A statistical difference with lower SSI rates using iodine based products.

32. Current Research
Darouiche, RO, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362(1):18-26.
Microbial culture study of 849 patients
Compared 2 methods
Iodophor Scrub/Paint vs. Chlorhexidine-alcohol
Result
Significantly lower SSI rates with Chlorhexidine-alcohol prep for surperficial and deep incisional wounds

33. Clear as Mud……..

34. Product Application Prewash prior to application
Follow manufacturer’s directions
Utilize proper aseptic technique during application & gloves to contain shedding

35. 7. Dressings Optimal dressings are: Permeable to gas exchange
Impermeable to microbes/contamination
Create a moist healing environment (37°C)

36. Dressings Stay in place
Good adherence properties
Change on day 2-3 unless drainage, dirty, or damaged
Use proper aseptic technique when applying the dressings before the drapes are removed
Partner with Wound Care Specialists
Sussman, C, Bates-Jensen, B. Wound Care: A Collaborative Practice Manual for Health Professionals 2006; (Chap11)

37. The “New Basics”
Glycemic Control
Nasal Decolonization

38. Glycemic Control 30-35% of cardiac patients are diabetics
SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.
The OR cannot be a black hole

39. S. aureus Nasal Carriage
Between 25-30% of all patients are colonized
Another 60% carry it intermittently
85% of S. aureus infections were endogenous in SSI study populations
Nasal decolonization should be considered due to the risk of S. aureus SSIs
Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureus in surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61:
Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24):

40. Speciality Specific Opportunities
Cardiac
Spinal Fusions
Labor and Delivery
Cath Lab

41. Cardiac Surgery 2 concurrent surgeries Skin antisepsis Bone wax
Traffic and # of people
Hypothermia

42. Spinal Surgery Equipment Antibiotics Time Dressings
Amount, position, cleanliness
Weiner, BK, Kilgore, WB. Bacterial shedding in common spine procedures: headlamp/loupes and the operative microscope. Spine 2007;32(8):
Biswas, D, et al. Sterility of C-arm fluroscopy during spinal surgery. Spine 2008; 33(17):
Antibiotics
Redosing
Time
Longer surgeries, waiting for X-ray
Dressings
Posterior incisions (higher risk)

43. L&D and Cath Lab
Aseptic technique
Skin antisepsis

44. Facilitating Process Improvements
Provide the data
Trend and report ABX and flash data monthly
SSI Outcome data Quarterly
Utilize data to implement change
NPSGs
Multidisciplinary- IP, Quality, nurses, techs, surgeons, anesthesia, schedulers, housekeeping

45. Process Improvements Make regular observations of aseptic technique
Standardize
Use forms to quantify when possible
Simplify- pick one thing to get started

46. Process Improvements Implement Changes
Seek out champions
Communication is essential
Get feedback from staff and re-evaluate prn
Insure that new outcome data is communicated to staff
Celebrate Success!

47. Results After Process Improvements

48. Questions?