Surgical Site Infections

1. Surgical Site Infections Jana Chavous, R.N. Northeastern State University EBP Symposium April 23, 2010 jlchavous@gmail.com

2. PICO Question Among surgical patients, does changing a dressing after 24 hours post-operatively as opposed to before 24 hours make a difference in the reduction of surgical site infections?

3. Statistics Related to Surgical Site Infections Approximately 27 million surgeries are carried out every year here in the U.S. Approximately 290,000 surgical site infections (SSIs) arise each year. An astonishing 8,000 that result in death from these infections. (Centers for Disease Control, 2008).

4. What is a Surgical Site Infection? SSI’s can be defined as an infection that is present up to 30 days after a surgical procedure if no implants are placed and up to one year if an implantable device was placed in the patient (Awad et al. (2009). The majority of SSIs will occur during the first two to three weeks after surgery (Ramos et al. 2008).

5. Types of Surgical Site Infections There are 3 types of SSIs.

6. Cost of Surgical Site Infections $2,734 to $26,019 extra cost per SSI $130 million to $845 million per year estimated national costs in the US for treatment of SSIs SSIs increase length of stay (LOS) in hospital

7. Prevalence of Surgical Site Infections Institute for Healthcare Improvement (IHI) in regards to the CDC’s NNIS (National Nosocomial Infection Surveillance) system state that: 38% of all nosocomial infections in surgical patients are SSIs 2 to 5% of operated patients will develop a SSI 2-5% doesn’t seem like a huge amount but when you are talking about 27 million surgeries per year The LOS is increased by 7.5 days2-5% doesn’t seem like a huge amount but when you are talking about 27 million surgeries per year The LOS is increased by 7.5 days

8. Review of Literature The Centers for Medicare & Medicaid Services (CMS) publicized in July 2008 that they would no longer be making additional payments on surgical site infections following certain elective procedures (CMS, 2008). Hospital Acquired Infections (HAI’s) are a huge problem within healthcare facilities and should be taken very seriously. SSIs cause financial and emotional impact. Such as bariatric surgery for obesity and certain orthopedic surgeries (total joints) According to the CDC HAI’s are accountable for an estimated 17% Through proper education and using performance initiatives the SSIs can be significantly reducedSuch as bariatric surgery for obesity and certain orthopedic surgeries (total joints) According to the CDC HAI’s are accountable for an estimated 17% Through proper education and using performance initiatives the SSIs can be significantly reduced

9. Review of Literature Patient Risk Factors: Smoking Age Poor Nutritional Status Uncontrolled diabetes Obesity Coexistent infection at another remote site Colonization of microorganisms Altered immune system Length of preoperative stay

10. Review of Literature Operation Risk Factors: skin preparation operating room environment A study conducted by Mangram and others reveled risk factors: type of the scrub, the technique of the scrub, the length of the scrub, shaving of operative site Operating Room environment: traffic, ventilation, sterilization of instruments, length of the surgery, technique used by surgeon (removing all dead tissue) RCT by Chundamala & Wright (2007) that povidone-iodine irrigation of surgical wounds before closure of incision significantly reduced the risk for SSIs. There were some risks related to this study. This type of irrigation should not be used in children, patients with iodine sensitivity, burns, thyroid disease or renal disease until additional research is studied. A study conducted by Mangram and others reveled risk factors: type of the scrub, the technique of the scrub, the length of the scrub, shaving of operative site Operating Room environment: traffic, ventilation, sterilization of instruments, length of the surgery, technique used by surgeon (removing all dead tissue) RCT by Chundamala & Wright (2007) that povidone-iodine irrigation of surgical wounds before closure of incision significantly reduced the risk for SSIs. There were some risks related to this study. This type of irrigation should not be used in children, patients with iodine sensitivity, burns, thyroid disease or renal disease until additional research is studied.

11. Review of Literature Incisional Care Postoperative issues would include incision care and discharge planning (Mangram et al., 1999 p. 254-263). The suggested instructions for incisional wound care advise that surgical wounds be covered for 24 to 48 hours postoperatively. The rationale for this includes that by this time hemostasis is achieved and a fibrin scab has formed to seal the wound (Wynne et al, 2004). Discharge Teaching Discharge teaching is another focus to help reduce post-operative complications, such as specific discharge instructions regarding recognizing signs and symptoms of SSIs and when to seek treatment (Kable, Gibberd, & Spigelman, 2004). JCAHO also states that surgical incision should be covered for a minimum of 24 hours Specific discharge instructions should be available for nurses to use as a guideline for consistency of nursing care. It is also important for patients to know what signs and symptoms to watch for and who to report it to. The patients role is becoming more important due to the dynamic changes that are being made in healthcare.JCAHO also states that surgical incision should be covered for a minimum of 24 hours Specific discharge instructions should be available for nurses to use as a guideline for consistency of nursing care. It is also important for patients to know what signs and symptoms to watch for and who to report it to. The patients role is becoming more important due to the dynamic changes that are being made in healthcare.

12. Review of Literature After the 24 hour period there are no known specific recommendations regarding incisional care. The dressing changes are up to the physician’s discretion after the 24 to 48 hour period (Odom-Forren, 2006). According to Mangram et al. approximately 12-84% of SSIs are identified after patients are discharged from the hospital (1999).

13. Review of Literature SCIP (Surgical Care Improvement Program) began in April 2003 after many representatives met to align efforts in reducing SSIs. SCIP is a national quality partnership of organizations that are committed to improving surgical complications (Bratzler, 2006). Hospitals participating in SCIP encountered a 27% decrease in their SSI rate during their first year. According to CMS it is required that hospitals that are participating in SCIP begin publicly reporting these measures by January 2010 in order to receive full Medicare Annual Payment Update. SCIP consists of surgical infection prevention, adverse cardiac events, prevention of DVT and post-op pneumonia pre-op abx and stopping 24 hours after surgery unless other reasons identified When facilities are monitoring for SSIs it is important that they don’t just rely on the inpatient findings. According to a study by Mangram et al. 12-84% of SSIs are identified after discharge.SCIP consists of surgical infection prevention, adverse cardiac events, prevention of DVT and post-op pneumonia pre-op abx and stopping 24 hours after surgery unless other reasons identified When facilities are monitoring for SSIs it is important that they don’t just rely on the inpatient findings. According to a study by Mangram et al. 12-84% of SSIs are identified after discharge.

14. Review of Literature In 2004 JCAHO identified reducing the risk of health care-acquired infections as a National Patient Safety Goal (NPSG). This includes complying with the CDC hand hygiene guidelines or the World Health Organization (WHO). Managing sentinel events in identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection is also included within this NPSG. It is important for all entities within the healthcare system are educated and understand the importance of HAIs as nurses are not the only ones touching the patients.It is important for all entities within the healthcare system are educated and understand the importance of HAIs as nurses are not the only ones touching the patients.

15. Review of Literature Nurses and physicians are not the only personnel having contact with patients, this involves many other entities such as lab, x-ray, physical, occupational and speech therapy, food service personnel and housekeeping. Hand hygiene is an area that should be mentioned at all monthly meetings with all entities. A hand hygiene study conducted by Peden, A & Vaughan, J saw a 6-13% increase in hand hygiene compliance after placing colorful signs that read “Foam In, Foam Out” and as a positive reinforcement for ones that were in compliance they presented coupons for a free lunch.

16. Review of Literature Discharge teaching is an extremely important issue since SSIs have been defined as an infection that occurs within 30 days after the operation (Mangram et al., 1999, p. 251-252). Structured and detailed discharge instruction sheets are available at my current facility for almost any type of surgical procedure. Education to the patient and any family members available on what signs and symptoms to report to healthcare professionals should be made a top priority upon discharge from the healthcare facility.

17. Recommended Interventions A wound care policy regarding the different surgical specialty areas is available at my facility, but upon assessment I did notice that it needs to be updated and should be revised to include: that dressings should stay in place for 24 hours following surgery since this is policy. The wound care policy would be followed unless there were specific dressing change orders. This is another area that needs to be communicated with nurses especially so that they know where this information can be found.This is another area that needs to be communicated with nurses especially so that they know where this information can be found.

18. Recommended Intervention Process The first intervention of updating the wound care policy will be to discuss with the surgeons their preferred type of dressing, if antiseptic should be used and type of technique to be used. The second intervention would be to have all managers of each surgical specialty review them. The third intervention would be to get the information to the Quality Assurance nurse to change the policy according to the changes that were made. The fourth intervention would be to have unit meetings on each surgical specialty units informing them of the changes.

19. Leadership Support Nursing management and surgeons will be the main personnel involved with updating the wound care policy. To implement the changes involved with the wound care policy, no additional personnel would be needed, but additional working hours may be necessary while making changes to the wound care policy.

20. Leadership Support Collaboration with administration is essential when dealing with a problem that is significant as SSIs. Teamwork is more imperative now than ever before in dealing with SSIs. This is an issue that needs to be communicated with all entities since we all know patients go to other departments for different procedures. It is just so important that everyone work together so that patient outcomes are better.This is an issue that needs to be communicated with all entities since we all know patients go to other departments for different procedures. It is just so important that everyone work together so that patient outcomes are better.

21. Evaluation The consequences of SSIs greatly impact patients and the healthcare systems. It is imperative that facilities have open-minded management teams, regulatory agencies and medical associations that want to provide the foundation required to generate a culture of patient safety in our health care systems.

22. Evaluation Many recommendations based off of the research regarding SSIs are already in use at my facility. The first recommendation that should be taken into consideration is the updating of the wound care policy to provide consistency with wound care. The second recommendation is to continue the monthly audits on hand washing and encouraging compliance of hand washing and its importance to all healthcare members.

23. References Awad, S., Palacio, C., Subramanian, A., Byers, P., Abraham, P., Lewis, D., & Young, E. (2009). Implementation of a methicillin-resistant staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. The American Journal of Surgery, 198(5), 607-610. doi:10.1016/j.amjsurg.2009.07.010 Bratzler, D. (2006). The surgical infection prevention and surgical care improvement project: Promises and pitfalls. The American Surgeon. 72(11). 1010-1016. Retrieved from http://www.highbeam.com/The+American+Surgeon/publications.aspx Centers for Disease Control and Prevention. (2008). Surgical site infections, frequently asked questions. Retrieved from: http://www.cdc.gov/ncidod/dhqp/FAQ_SSI.html Centers for Medicare & Medicaid Services. (2008). Medicare and Medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events. Retrieved from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

24. References Chundamala, J., & Wright, J. (2007). The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: An evidence-based review. Canadian Journal of Surgery. 50, 473-481. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/journals/505 Institute for Healthcare Improvement. (IHI). Surgical Site Infections. Retrieved from http://www.ihi.org/ihi/Topics/PatientSafety/SurgicalSiteInfections/SurgicalSiteInfectionsCaseForImprovement Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 2004. Hospital National Patient Safety Goals. Retrieved from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/04_npsgs.htm Kable, A., Gibberd, R., & Spigelman, A. (2004). Complications after discharge for surgical patients. ANZ Journal of Surgery, 74, 92-97. doi:10.1046/j.1445-2197.2003.02922.x. Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., Jarvis, W. R., & The Hospital Infection Control Practices Advisory Committee. (1999). Guideline for prevention of surgical site infection. Infection Control and Hospital Epidemiology, 20, 247-278. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf

25. References Peden, A. & Vaughan, J. (2006). American Journal of Infection Control. Hand Hygiene, 34(5), E60. Retrieved from http://www.ajicjournal.org/handhygiene Odom-Forren, J. (2006). Preventing surgical site infections. Nursing Management, 36, 58-64. Retrieved from http://journals.lww.com/nursingmanagement/Pages/issuelist.aspx Ramos, A., Asenslo, A., Munez, E., Torre-Cisneros, J., Montejo, M., Aguado, J.,… Cisneros, J. (2008). Incisional surgical site infection in kidney transplantation. Reconstructive Urology, 72, 119-123. doi:10.1016/j.urology.2007.11.030 Wynne, R., Botti, M., Stedman, H., Holsworth, L., Harinos, M., Flavell, O., & Manterfield, C. (2004, January). Effect of three wound dressings on infection, healing comfort, and cost in patients with sternotomy wounds. Chest Journal, 125, 43-49. Retrieved from http://intl.chestjournal.org

26. Questions?