1. Advances in Surgical Site Infection Prevention
Welcome to this CE seminar, presented at the AORN Surgical Conference and Expo 2019, entitled: Advances in Surgical Site Infection Prevention.

2. To Receive Credit, You Must Register
Expo Mobile App
Online
Expo
Evaluation Center
Deadline for Registration is May 10, 2019
Complete Evaluation and Registration for this course one of three ways:
the AORN Mobile App,
Online, or visit the AORN Connection Center.
Deadline for Registration is May 10, 2019.

3. Continuing Education Provider
Funds Provided by
Continuing education (CE) credit is awarded by the approved provider, Pfiedler Education.
Funds for this learning activity are provided by Ethicon.
(Introduce yourself and disclose your affiliation with Ethicon.)

4. Learner Objectives
Review the impact of SSI on patients and healthcare facilities
Discuss current evidence-based recommendations related to SSI prevention
Describe advanced strategies to prevent SSI in order to deliver high-quality care, reduce costs, and promote positive patient outcomes
Upon completion of this activity, attendees should be able to:

5. Introduction Advanced SSI prevention techniques
Better patient outcomes & satisfaction
Increased value-based
incentives
The incidence of antimicrobial resistance and increased rates of surgical site infection (SSI) continue to be significant challenges for healthcare providers in the perioperative setting. Advanced techniques to prevent SSI can lead to better patient outcomes and satisfaction, which will translate into increased value-based incentives for the healthcare system.
Perioperative nurses and the other surgical team members need to be aware of advances in SSI infection prevention in order to deliver quality care, reduce the overall costs of care, and promote positive patient outcomes.

6. Result of SSIs Patient outcomes are compromised Healthcare costs rise
Reimbursement may be denied
According to the Agency for Healthcare Research and Quality (AHRQ), 14.2 million operative procedures were performed in inpatient settings in United States hospitals in When surgical site infections (SSIs) complicate these procedures, patient outcomes are compromised, healthcare costs rise, and reimbursement for the care of these patients may be denied.
It has been estimated that approximately half of SSIs are preventable by the application of evidence-based strategies. Thus, it is crucial that perioperative personnel be aware of the latest guidelines and tactics for SSI prevention and that they apply these guidelines in their daily practice.

7. Types of SSIs
The NHSN’s Patient Safety Component includes a Procedure-Associated Module on surgical site infection (SSI). The definitions for 3 types of SSI specified in this document are widely used for public reporting, interfacility comparison, and pay-for-performance comparisons. NHSN’s 3 types of SSI are illustrated and are defined as follows:
Superficial incisional SSIs involve only the skin and the subcutaneous tissue of the incision.
Deep incisional SSIs involve deep soft tissues of the incision (eg, the fascial and muscle layers).
Organ/space SSIs involve any part of the body deeper than the fascial/muscle layers that is opened or manipulated during the operative procedure.

8. SSI Incidence Procedure group 90-day SSI prevalence Amputation 17.84%
Biliary, liver, and pancreas
9.38%
Breast
2.57%
Hernia
4.70%
Incidence of surgical site infections
The Centers for Disease Control and Prevention (CDC) HAI prevalence survey estimated that there were 157,500 SSIs associated with inpatient surgeries in 2011 in the United States. According to the NHSN, between 2006 and 2008, there were 16,147 SSIs following 849,659 operative procedures in all groups reported, for an overall SSI rate of 1.9%. That number is likely to be underestimated, because approximately 50% of SSIs do not become evident until after discharge. A 17% decrease in SSIs related to 10 select procedures was reported between 2008 and Worldwide, HAIs are the most frequent adverse event affecting patient safety, and SSIs are the most common type of HAI. In low- and middle-income countries, SSIs are the most frequent type of HAI, affecting up to one-third of patients who have undergone a surgical procedure.
The prevalence of SSI also varies widely among different types of surgical procedures. In one study, 90-day hospital readmission rates for SSI were calculated for amputation procedures; biliary, liver, and pancreas procedures; breast procedures, and hernia procedures, as in the table shown.
The risk of SSI is of particular concern in joint replacement surgery. Infection is the most common reason for revision in total knee arthroplasty and the third most common reason for revision in total hip arthroplasty. By 2030, the infection risks for hip and knee arthroplasty are expected to increase from 2.18% to 6.5% and 6.8%, respectively.

9. Impact on Patients 3% mortality rate
75% of SSI-associated deaths directly attributed to the SSI
Pain
Loss of income
Reduced quality of life
Burden on patient and their families
SSI is associated with a mortality rate of 3%, and 75% of SSI-associated deaths are directly attributable to the SSI. Patients older than age 65 bear an even higher burden in terms of the morbidity and mortality associated with SSI. Little evidence is available, however, on the pain, loss of income, and reduced quality of life associated with SSI, and the economic and non-economic burden on patients’ families is even more difficult to quantify.

10. Cost Implications $10-25k+ per infection
$90k+ if prosthetic implant involved
$3-10 Billion annual cost in US
1 million inpatient days per year
No reimbursement for preventable conditions such as SSI
The financial burden SSI places on the US healthcare system is substantial.
The Centers for Disease Control and Prevention (CDC) cite studies that estimate attributable costs of SSI ranging from $10,443 to $25,546 per infection, increasing to more than $90,000 if the SSI involves a prosthetic implant.
Overall, SSIs cost the US healthcare system an estimated $3 to $10 billion annually, and they are associated with nearly 1 million inpatient days every year.
Furthermore, the associated “hard costs” cited above are not the only financial burdens faced by institutions caring for patients with SSIs. The finding that up to 60% of SSIs are preventable has made SSI a primary target of institutions’ quality control measures and a key “Pay-for-Performance” metric. In October 2008, the US Centers for Medicare and Medicaid Services (CMS) stopped providing reimbursement for treatment of 8 largely preventable conditions; of these, 5 were considered “reasonably preventable” conditions, including SSI.

11. SSI Risk Factors Preoperative factors Perioperative team factors
Organizational and management factors
Patient factors
Surgeon factors
Work-environment factors
Care-delivery problems
Spencer identified 7 categories of risk factors that contribute to the SSI events:
Preoperative factors (lack of hand hygiene, patient body colonization, and lack of preoperative shower);
Perioperative team factors (too many people in the operating room, improper surgical hand antisepsis, improper surgical attire, unsterile instruments, use of staples or steri-strips, contaminated environment, inadequate surgical prophylaxis, surgical irrigation, and non-coated sutures);
Organizational and management factors (poor communication among team members; financial constraints, poor leadership, and increased hospitalization days);
Patient factors (nasal colonization with antibiotic-resistant microorganisms; infection at another site; risk factors such as obesity, diabetes, smoking, immunosuppressive agents);
Surgeon factors (use of drains, use of staples, lack of re-dosing of antibiotic, poor surgical technique);
Work-environment factors (inadequate staff levels; deficient design, availability, and maintenance of equipment; workload and shift patterns; environment and physical plant problems [eg, air-handling systems]); and
Care-delivery problems (lack of hand hygiene, failure to remove Foley catheters within 48 hours, inadequate staffing for postoperative care, and postoperative contamination of the incision).

12. SSI Prevention World Health Organization
Centers for Disease Control and Prevention
American College of Surgeons/Surgical Infection Society
Society for Healthcare Epidemiology of America
Association of periOperative Registered Nurses
Because so many factors have been identified as contributing to the risk of SSI, prevention requires the integration of a range of preventive measures before, during, and after surgery.
Numerous government agencies and professional organizations have published guidelines for SSI prevention, including the World Health Organization (WHO), the CDC, the American College of Surgeons and the Surgical Infection Society (ACS/SIS), the Society for Healthcare Epidemiology of America (SHEA), and the Association of periOperative Registered Nurses (AORN).

13. 7 S Bundle Safe operating room practices Showers with chlorhexidine
Screening for MRSA and methicillin-susceptible Staphylococcus aureus (MSSA)
Skin preparation with alcohol-based antiseptics
Sutures containing an antimicrobial
Solution with chlorhexidine for irrigation
Skin adhesive and/or antimicrobial dressings to protect the incision
Spencer developed a systematic 7-step approach to preventing SSIs in the perioperative period. This “7 S Bundle” approach lists a number of practices to be considered when investigating and evaluating SSI prevention programs, including the following:
Safe operating room practices,
Showers with chlorhexidine,
Screening for MRSA and methicillin-susceptible Staphylococcus aureus (MSSA),
Skin preparation with alcohol-based antiseptics,
Sutures containing an antimicrobial,
Solution with chlorhexidine for irrigation, and
Skin adhesive and/or antimicrobial dressings to protect the incision.

14. Safe Operating Room Practices
Traffic control
Limiting the number of staff in the OR during surgery
Compliance with surgical attire recommendations
Proper surgical skin scrub
Proper skin preparation with alcohol-based antiseptics
Effective sterilization of instruments
Monitoring & preventive maintenance of air-handling systems
Adequate surgical antibiotic prophylaxis
Warming of the patient before and during surgery
Hair clipping (no shaving) outside the operating room
Use of wound protectors to prevent tissue contamination
Careful handling of tissues by surgical staff
Disinfection of the environment during room turnovers and terminal cleaning
Safe medication-handling procedures
Safe storage of supplies
According to Spencer, standard safe operating room practices include the following measures:15
traffic control,
limiting the number of staff in the operating room during surgery,
compliance with surgical attire recommendations,
proper surgical skin scrub,
proper skin preparation with alcohol-based antiseptics,
effective sterilization of instruments,
monitoring and preventive maintenance of air-handling systems,
adequate surgical antibiotic prophylaxis,
warming of the patient before and during surgery,
hair clipping (no shaving) outside the operating room,
use of wound protectors to prevent tissue contamination, 
careful handling of tissues by surgical staff,
disinfection of the environment during room turnovers and terminal cleaning,
safe medication-handling procedures, and
safe storage of supplies.
Detailed recommendations related to these and many other well-known standard practices are described in AORN’s Guidelines for Perioperative Practice.14

15. Chlorhexidine Gluconate Patient Showers
Supported by:
CDC
ACS
AORN
WHO
SHEA
A number of products containing or coated with chlorhexidine gluconate (CHG) have been identified that can help support the “7 S Bundle” approach to SSI prevention, including antiseptic skin cleansing agents, surgical skin preps, hand sanitizers, vascular catheters, and wound care and oral care products.4 CHG is the most commonly used form of chlorhexidine because it is colorless, odorless, and easily dissolves in water. As an antiseptic agent, CHG is effective against a broad spectrum of gram-positive and gram-negative bacteria, yeasts, and some viruses. Antiseptics like CHG are different from antibiotics, which target only specific classes of bacteria.
This recommendation is supported by:
CDC
ACS
AORN
WHO
SHEA

16. MRSA & MSSA Screening & Decolonization
Two options:
Screen for and treat carriers only
Universally treat everyone
Risk of worsening bacterial resistance and changing the microbiome of both the patient and the facility
Colonization rates of Staphylococcus aureus in the United States are approximately 30%, and colonized patients have a higher risk of developing a MRSA infection. Using 2011 billing data from US hospitals, the Agency for Healthcare Research & Quality found that more 460,000 hospitalizations had a MRSA diagnosis, and 23,000 deaths were associated with those admissions.
Active surveillance for MRSA has been studied in a wide range of surgical patients, including surgical intensive care and non-intensive care units, as well as cardiac, vascular, orthopedic, obstetric, head and neck cancer and gastrostomy patients. Kavanagh et al cited 19 studies that observed a beneficial effect of active surveillance in the prevention of MRSA infections. They pointed out that hospitals have 2 options for the control of MRSA:
to screen for and treat carriers only, or
to universally treat everyone and run the risk of worsening bacterial resistance and changing the microbiome of both the patient and the facility.
They concluded that the vast majority of studies appear to support the effectiveness of surveillance for MRSA colonization followed by targeted intervention prior to surgery in reducing SSI rates. Preoperative MRSA surveillance allows the selection of appropriate prophylactic antibiotics and the use of extended decolonization protocols in positive patients.

17. Alcohol-Based Antiseptics for Surgical Site Prep
CDC, ACS, and WHO – alcohol-based
AORN – most appropriate based on patient needs
WHO – specific to alcohol-based CHG
Surgical site preparation refers to the preoperative treatment of the intact skin of the patient within the OR—both the immediate site of the intended surgical incision and the broader surrounding area of the patient’s skin. The aim of this procedure is to reduce the microbial load on the patient’s skin as much as possible before incision of the skin.
CDC, ACS, and WHO all recommend performing intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated (eg, by fire hazard, surfaces involving the mucosa, cornea, or ear). AORN concludes that no one antiseptic is more effective than another in reducing SSIs, but recommends that the selection of the most appropriate preoperative skin antiseptic should be based on individual patient need. WHO specifically recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation, citing a meta-analysis of available studies showing that alcohol-based CHG is more beneficial in reducing SSI rates compared with alcohol-based povidone-iodine.

18. Intraoperative Surgical Wound Irrigation
Hydrate the wound bed
Assist in allowing better examination of the area immediately before closure
Expedite the healing process, by removing superficial and deep incisional contamination and lowering the bioburden
Intra-operative irrigation during device-related procedures (eg, total joint arthroplasty) has become the standard of care after device insertion as well as for the management of acute peri-prosthetic infection. In other procedures, clinical practice of intraoperative lavage and the solution used are highly variable and dependent upon surgeon preference.
In a literature review published in 2016, Edmiston and Leaper concluded that intraoperative irrigation of the surgical site has 3 benefits:
to hydrate the wound bed;
to assist in allowing better examination of the area immediately before closure; and
to expedite the healing process, by removing superficial and deep incisional contamination and lowering the bioburden.
They conclude that the adoption of appropriate and standardized intraoperative irrigation practices into perioperative care bundles offers an inexpensive and effective method to reduce the risk of postoperative SSIs.

19. Antimicrobial-Impregnated Sutures
Suture selection provides an important opportunity to address a key risk factor for infection: bacterial colonization of the suture. Sutures coated with triclosan have been shown to inhibit bacteria commonly associated with SSIs (including S. aureus, S. epidermidis, MRSA, methicillin-resistant S. epidermidis (MRSE), E. coli, and K. pneumoniae) from colonizing the suture. They have been shown in vitro to inhibit bacterial colonization of the suture for 7 days or more, as well as bacterial growth in a zone around the suture.
The 2017 CDC guidelines include a recommendation for the use triclosan-coated sutures for the prevention of SSI. The ACS recommends that, when available, triclosan antibacterial sutures be used for wound closure in clean and clean-contaminated abdominal cases. Similarly, WHO suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery.

20. Skin Adhesives & Antimicrobial Dressings
Octyl cyanoacrylate
Polyhexamethylene biguanide (PHMB) gauze dressings
Silver dressings
Combination product consisting of:
Sterile liquid topical skin adhesive containing a monomeric 2-octyl cyanoacrylate
Self-adhering mesh
There are many types of surgical incision closure, including stitches, steri-strips, staples, and topical incisional adhesives. Some surgeons also protect the incision with antimicrobial dressings. Studies have suggested that the use of staples and stitches are associated with an increased risk of wound dehiscence and infection, due to the potential for exogenous contamination from the environment.
As an alternative, special skin closure systems are available that provide greater skin-holding strength than skin staples or subcuticular suture, while also providing effective microbial barrier protection. For example:
Octyl cyanoacrylate provides a strong flexible bond that lasts approximately 7-10 days. It eliminates staple removal, can reduce the potential for suturing injuries to staff, and provides flexible bonding strength and microbial barrier properties.15
Added protection to a newly healing incision can be provided with the use of antimicrobial dressings, such as polyhexamethylene biguanide (PHMB) gauze dressings and silver dressings.
One combination product consists of:
a sterile liquid topical skin adhesive containing a monomeric 2-octyl cyanoacrylate formulation that acts as a barrier to microbial penetration as long as the adhesive film remains intact, and
a self-adhering mesh that is applied to achieve closure of the approximated skin edges to provide temporary skin edge alignment until the liquid adhesive is applied.

21. Skin Adhesives & Antimicrobial Dressing Results in Knee Arthroplasty
12% reduction in length of hospital stay,
31% reduction in probability of discharge to skilled nursing facility or other non-home setting
Reduced 30-day readmission rates (1.8%) when compared with skin staples (4.4%)
Potential cost savings of $12,839 per patient, by avoiding readmission within 30 days
Patient may be able to shower immediately
Patient may experience less pain
When compared with skin staples in total knee arthroplasty, this system was associated with:21
a 12% reduction in length of hospital stay,
a 31% reduction in probability of discharge to skilled nursing facility or other non-home setting,
reduced 30-day readmission rates (1.8%) when compared with skin staples (4.4%), and
a potential cost savings of $12,839 per patient, by avoiding readmission within 30 days.
In addition, the patient may be able to shower immediately after the procedure and may experience less pain than with other wound closure devices

22. Implementation Strategies
Engagement phase
Clear and effective communication of the reasons why SSI implementation strategies are important for patient care
Education phase
Senior leadership, physicians, nurses, and patients and families are taught about practices to prevent SSI
Execution phase
Focuses on implementation strategies to reduce barriers and improve adherence to evidence-based practices
Evaluation phase
Focuses on the use of measurement and evaluation tools to determine the effectiveness of implementation strategies
Effective implementation of an SSI prevention strategy requires accountability and commitment across the organization. SHEA identifies a 4-part implementation strategy that uses the concepts of engagement, education, execution, and evaluation:13
The engagement phase involves clear and effective communication of the reasons why SSI implementation strategies are important for patient care.
In the education phase, senior leadership, physicians, nurses, and patients and families are taught about practices to prevent SSI.
The execution phase focuses on implementation strategies to reduce barriers and improve adherence to evidence-based practices.
The evaluation phase focuses on the use of measurement and evaluation tools to determine the effectiveness of implementation strategies.

23. Summary
Surgical site infections are persistent and preventable. Although the goal of preventing 100% of SSIs may not be attainable, even with use of evidence-based prevention strategies, it is clear that comprehensive implementation of such strategies has the potential to prevent tens of thousands of infections, save thousands of lives, and save hundreds of millions of dollars annually.

24. To Receive Credit, You Must Register
Expo Mobile App
Online
Expo
Evaluation Center
Deadline for Registration is May 10, 2019
Complete Evaluation and Registration for this course one of three ways:
the AORN Mobile App,
Online, or visit the AORN Connection Center.
Deadline for Registration is May 10, 2019.