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Eating the Elephant Getting Started in SSI Claude Laflamme Marlies van Dijk June 17, 2008 - PowerPoint PPT Presentation

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Eating the Elephant Getting Started in SSI Claude Laflamme Marlies van Dijk June 17, 2008. This Presentation. Introduction Antibiotic Prophylaxis and Challenges Hair Removal and Challenges Prevention of hypothermia Glucose control SSI rates Team example.

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Eating the elephant getting started in ssi claude laflamme marlies van dijk june 17 2008 l.jpg

Eating the ElephantGetting Started in SSIClaude LaflammeMarlies van DijkJune 17, 2008

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This Presentation

  • Introduction

  • Antibiotic Prophylaxis and Challenges

  • Hair Removal and Challenges

  • Prevention of hypothermia

  • Glucose control

  • SSI rates

  • Team example

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The SSI phenomena: A simply complex problem

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The SHN! SSI Bundle Elements

4 evidence-based interventions to reduce the risk of SSI

Each has an associated performance indicator (process measure)

Performance indicators have set goals intentionally high (≥95%)

Complexity issues with regards to expected outcome measures (visible reduction of SSI rates)

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Impact of SSI

*Pairs matched for procedure, NNIS index, age

Kirkland. Infect Control Hosp Epidemiol. 1999;20:725. Prospective, case-controlled study of 22,742 patients undergoing inpatient surgical procedures between 1991–1995.

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The SSI Bundle Elements:Intervention #1

“Appropriate use of prophylactic antibiotics”

The right drug

At the right time*

For the right duration

Performance measure (target):

% surgical patients given pre-op ABx within 60 min* ( Goal 95% )

% surgical patients having ABx , discontinued within 24 hrs ( Goal ≥95% )

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Perioperative Prophylactic Antibiotics

Classen. NEJM. 1992;328:281.

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Duration Concerns

There is a lack of evidence that antibiotics given after the end of the operation prevent SSIs.

There is evidence that unnecessary or prolonged use of antibiotics promotes antibiotic resistance

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Prophylaxis Dosing

Consider the upper range of doses for large patients

Gastroplasty: SSI rates 16.5% vs 5.6% (Forse, Surgery, 1989)

Repeat doses for long operations (> 4 hours)

Cardiac surgery: SSI rates 16% vs 7% (Zanetti, Emerg Infect Dis 2001)

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Associated risks with antimicrobial agents

Antibiotics disrupt normal flora

Increased or improper use is implicated in:

 Antimicrobial resistance

Clostridium difficile associated diarrhea

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What has worked?and challenges …

Printed order sets

Moving Antibiotics closer to time of incision (holding area or OR)

Premixed dosing

Roles in the Operating Room (anesthesia vs. nursing)

Each site/team is unique

Data collection at the start

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Appropriate hair removal

  • No hair removal or clipping

  • Clipping time as close as possible to incision time

  • Shaving shown to cause microscopic breakage in the epithelial barrier, leading to bacterial contamination of the wound

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Shaving, Clipping and SSI

Cruse. Arch Surg 1973; 107: 206

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Hair Removal Techniques and SSI

For every 1000 patients, $270,000 could be saved by switching from a razor to a clipper

Alexander. Arch Surg 1983; 118: 347

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Appropriate hair removal: How do you do it?

  • Education

  • Evaluation of the new technique (3/12)

  • January 1st 2006 Clippers in each OR Razors in the central core only

  • April 1st 2006: Razors gone

  • Electronic data collection

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Hair Removal

Percentage of selected surgical patients receiving hair removal without use of razors


Not as simple as it sounds


Convincing docs that a smooth surface is not essential

Razor creep 

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Complications of mild hypothermia

  • Increases duration of hospitalization

  • Increases intra-operative blood loss

  • Increases adverse cardiac event

  • Increases patient shivering in PACU

  • Promotes metabolic acidosis

  • Increases SSI rates

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Minimizing hypothermia

  • Anesthetics profoundly inhibits central thermoregulation decreasing the vasoconstriction threshold by 2-4ºC

  • The second major factor is the magnitude of the core-to-peripheral temperature gradient

  • Minimizing the core-to-peripheral temperature gradient and preoperative vasodilatation, is the basis to reduce heat redistribution

  • Degree of adiposity, concurrent medication

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  • Vasoconstriction Decreases the partial pressure of oxygen in tissues which impairs the oxidative killing by neutrophils Reduces the deposition of collagen

  • Impairs immunity Chemotaxis and phagocytosis of granulocytes

    Motility of macrophages Production of antibody

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Blood Glucose Control

Cardiac Surgery Patients

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Wound healing and SSI

  • Decreases phagocytic and chemotactic functions in neutrophils and monocytes

  • Increases apoptosis of neutrophils

  • Decreases monocytes ability to present antigen

  • Stimulates inflammatory cytokines

  • Affects microcirculation

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Surgical Site InfectionCardiac Surgery

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Glucose control

  • SSI

  • Surgical and Medical ICU

  • Intraoperative

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Common Challenges

Discontinuation of prophylaxis:

Is there buy in from the surgeons on this item? What is the root of the challenges with this issue? Who needs to be involved in getting this resolved?

Clinical leadership engagement:

How do you engage the surgeons and anesthetists? (do they believe the evidence?, what are some strategies for engaging them? Who is your clinical champion?

Measurement challenges:

Measurement is manual. ie., You’re using paper and pen and a data collection form to capture bundle components. How might you do this reliably in your area?

Team structure:

Is there only one or two people doing the work, how can you best use your team members without a lot of time commitment. How often should you meet or connect and what is the best forum (huddles, e-mail, meetings) to keep the work moving?

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SSI rates – useful when….

Long term trending

Consistent definitions and case finding

Clinicians very motivated by SSI rates

Measure improvement in process and outcome measures over time…

Difficult to compare between hospitals or facilities

Consider this as you send your date to CMT

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Why calculate SSI rates?

Establish facility/program baseline

Identify abnormal patterns and/or sentinel events

Identify processissues

Evidence that reportingto operators lowersrates

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A cautionary word about rates…

Please take care when interpreting rates!

Don’t expect to see immediate results from new interventions

Rates can be affected by:

Surveillance resources

Numbers of procedures


Surgical approaches/techniques

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Contact information:

Dr. Claude Laflamme

Marlies van Dijk