1. Surgical Site Infections: Preparing Our Patients For Surgery

2. Our Last Call Together Three problems that sit at the core of surgical site infections –Doing reliably what we know needs to be done –Teamwork and communication –Always being vigilant about keeping the patient safe The South Carolina Surgical Safety Checklist as a drug

3. Preventing SSI’s Pre-IncisionIncision/SurgeryPost Op Patient Basics of Skin Prep Showers Skin Wipes Hair Removal Weight Based Dosing MRSA Screening Glucose Control Hyperoxia Wound care Dressings Operation Antibiotic Bowel Prep Re-dosing Operating Time Use of Tourniquet Surgical Technique Wound protectors Environment Basics of Sterility Instrument Sterility Hand Hygiene Temperature Control Teamwork Culture Basics of Sterility Instrument Sterility Hand Hygiene OR Traffic Temperature Control Teamwork Culture Discontinue antibiotics Teamwork Culture

4. Todays Topics Chlorhexidine Wipes Preoperative Bacterial Screening Keeping Your Patient Warm Alcohol-Based Skin Preps

5. Chlorhexidine Wipes: Common Sense Science Bacteria on the skin is bad. Wiping the skin with chlorehexidine could be good Started in the ICU when patients who bathed with chlorexidine impregnated cloths on a daily basis developed fewer bloodstream infections Patients are less likely to develop a SSI if they use wipes the night and morning before their procedure 1 50% overall reduction in SSI in orthopaedic surgery 1 Studies show that even if patients are not fully compliant wipes still can have an impact 2 1. Eiselt. Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical Patients. Orthopaedic Nursing. 2009; 28: 141-145. 2. Zywiel et al. Advance pre-operative chlorhexidine reduces the incidence of surgical infections in knee arthroplasty. International Orthopaedics. 2011; 35; 1001-1006.

6. Useful Resources The Institute for Healthcare Improvement has examples of patient materials for preparing skin before surgery http://www.ihi.org/knowledge/Pages/Tools/PreparingYourSkinBeforeSurgeryPatientInstructionsSSI.aspx

7. Preoperative Bacterial Screening: Common Sense Science Patients who carry Staphylococcus aureus (SA) are more likely to develop a surgical site infection Patients should be screened prior to surgery Schedule the screening so there is enough time to kill the bacteria How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty. Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org)

8. S. Aureus Nasal Carriage Kluytmans. Clin Microbiol Rev 1997; 10:505 Persistent carriers Always carry one strain of S. aureus 20% Intermittent carriers Carry different strains of S. aureus intermittently 60% Noncarriers 20%

9. S. Aureus Nasal Carriage Usual Prevalence Population Percentage General population 20% Health care workers27% Patients on admission36% Patients on insulin56% Hemodialysis patients52% Chronic renal failure21% I.V. drug users55% Kluytmans. Clin Microbiol Rev 1997; 10:505

10. Useful Resources The Institute for Healthcare Improvement has sample tools for educating patients http://www.ihi.org/knowledge/Pages/Tools.aspx

11. Keeping Your Patient Warm: Common Sense Science Human beings are warm-blooded The body fights infection better when it is warm The operating room is a cold place Keeping patients warm can be a challenge The best thing to do is to never let your patient get cold

12. Redistribution Hypothermia Core 37°C Vasoconstricted Periphery 31-35°C Anesthesia Periphery 33-35°C Core 36°C Vasodilated Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012.

13. Perioperative Warming, Intraoperative Temperature and Complications Wong. Br J Surgery 2007; 94: 423-6 Periop N=47 Standard N=56 P Value Blood loss200 ml400 ml0.011 Any complication32%54%0.027 SSI13%33%0.09

14. Temperature and SSI Following Colectomy Kurz. NEJM 1996;334:1209 Normo (104) Hypo (96) P Value SSI618.009

15. Keep your patient warm before they go to surgery It is like “money in the bank” Use warming blankets before they go into the OR Think about putting a hat on your patient Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012 How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012..

16. Keeping Your Patient Warm in the O.R. Pre-warming and active warming in the OR is much more important than the OR room temperature Put warming blankets under and over your patient on the operating table (if possible) Use warmed fluids for IVs Use warm irrigation on the field (if possible) Dellinger. Preventing SSI – Some Things Old and Some Things New. HRET Hospital Engagement Network Meeting. May 2012 How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012..

17. Alcohol-Based Skin Preps: Common Sense Science The combination of alcohol together with another agent is probably better because there are two things killing the bacteria An antibacterial prep that lasts on the skin is better than one that doesn’t 1 If you don’t let the prep dry or wipe it off it can’t work because it is not on the skin anymore 1. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18-26. 2. Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infection rates: A prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol.

18. No skin prep will be effective if you don’t use it the way that you are supposed to Let the prep completely dry prior to draping Avoid pooling of the skin prep How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012

19. Take Home Messages Pre-IncisionIncision/SurgeryPost Op Patient Basics of Skin Prep Showers Skin Wipes Hair Removal Weight Based Dosing MRSA Screening Glucose Control Hyperoxia Wound care Dressings Operation Antibiotic Bowel Prep Re-dosing Operating Time Use of Tourniquet Surgical Technique Wound protectors Environment Basics of Sterility Instrument Sterility Hand Hygiene Temperature Control Teamwork Culture Basics of Sterility Instrument Sterility Hand Hygiene OR Traffic Temperature Control Teamwork Culture Discontinue antibiotics Teamwork Culture

20. ? ? Questions

21. Upcoming Calls Thursday, June 13 th 2:00-2:45 Preventing VTE’s in Surgical Patients Thursday, June 27 th 2:00-2:45 Other Ways of Preventing Venous Thromboembolism

22. Office Hours: Wednesday 2:00-3:00

23. Resources Website: www.safesurgery2015.org Email: safesurgery2015@hsph.harvard.edu