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Presented by: Kathleen Kohut , RN, MS, CIC, CNOR System Director of Infection Prevention Cone Health, Greensboro, NC. "SSI Prevention:  Preparing for the future by going back to the basics". Speaker Disclosures. 3M AMN Healthcare The Compass Group BE Smith Consulting

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Presented by:

Kathleen Kohut, RN, MS, CIC, CNOR

System Director of Infection Prevention

Cone Health, Greensboro, NC

"SSI Prevention:  Preparing for the future by going back to the basics"

Speaker disclosures

  • 3M

  • AMN Healthcare

  • The Compass Group

  • BE Smith Consulting

  • Johns Hopkins Hospital

  • NCH Healthcare System

  • APIC

Learning objectives
Learning Objectives

  • Discuss the five basics of SSI prevention

  • Describe the use of glycemic control, nasal decolonization, and normothermiainitiatives for the reduction of SSIs.

  • Name the 2 most common mechanisms for wound contamination

  • Name 3 SCIP Measures

  • Discuss two opportunities for practice improvement

Preparing for the future

Current National SSI Initiatives include:

The Joint Commission National Patient Safety Goal NPSG.07.05.01 included in 2009

CMS Public reporting requirements for SSIs

  • 2012 - Colon Resections and Abd Hysterectomies

    • Nationally

Scip quality measures
SCIP Quality Measures

  • Antibiotic Prophylaxis ( Inf- 1,2,3)

    • Drug, Timing, Dosing, Discontinuation

  • Hair Removal (Inf- 6)

  • Glycemic Control (Inf – 4)

  • Foley Catheter removal POD1 or POD2 (Inf- 9)

  • “Normothermia” (Inf 10)

    • Expanded in June 2011

    • All surgical patients

Barriers to progress in ssi prevention
Barriers to Progress in SSI Prevention

SSI is an unfortunate possibility (it says so right on the consent form)

Challenge-change the culture of tolerance to one of intolerance to SSI

The Business Case- maximization of OR volume to increase revenue

Challenge- improve efficiencies without compromising infection prevention


Challenge- re-examine practices from a fresh perspective to find new opportunities

Lack of research

Challenge- conduct research and publish to create a solid body of evidence

Going back to the basics
Going Back to the Basics

Five Focus Areas:

  • Patient Preparation

  • Aseptic Technique

  • ABX Prophylaxis

  • Hair Removal

  • Skin Antisepsis

1 optimal patient p reparation includes
1. Optimal Patient Preparation Includes:

  • Losing weight, quitting smoking

  • Glucose Management

  • Nasal Decolonization

  • Normothermia – pre-warming


  • The stress response induced by surgical procedures increases blood glucose levels

  • Non-diabetics may also experience hyperglycemia during this critical perioperative period

    CDC(2011).; accessed on May 10, 2013.

Glycemic control
Glycemic Control

  • >25 million Americans diagnosed with diabetes

  • > 7 million are undiagnosed

  • 79 million considered pre-diabetic

  • 30-35% of cardiac patients are diabetics

Glycemic control1
Glycemic Control

  • SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.

  • All Patients should be managed with a target of <200

  • The first 24 hours is critical

  • The OR cannot be a black hole

S aureus nasal carriage
S. aureus Nasal Carriage

  • Between 25-30% of all patients are colonized at any given time and another 60% carry it intermittently.

  • Carriers are at higher risk

  • S. aureus causes 25-35% of all HAIs

  • 20% of all surgical pts acquire some type of HAI during their postoperative course

    Perl, TM, et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infections. N Engl J Med 2002; 346(24): 1871-7.

Nasal decolonization
Nasal Decolonization

  • 85% of S. aureusinfections were endogenous in SSI study populations

    Van Rijen, et al. Intranasal Mupirocin for reduction of S. aureusin surgical patients with nasal carriage. J Anti Chemotherapy 2008; 61:254-261.

  • MRSA SSI rates decreased from .23% to .09% (5,094 pts) with MRSA eradication program

    Pofahl, WE, et al. Active Surveillance Screening of MRSA and Eradication of the Carrier State Decreases Surgical-Site Infections Caused by MRSA. J Am CollSurg 2009;208:981-988.


  • SCIP Measure Inf-10

    • Includes all SCIP surgical patients (June 2011)

      • Total Knee, Hip, Vascular, Cardiac, ABD Hyst, Colon Resect

    • Requires one temperature > 96.8º F(36º C) 30 min. before or 15 min after anesthesia end time.

    • Start with pre-warming

2 aseptic technique
2. Aseptic Technique

Principles were developed to reduce the risk of wound contamination.

Defining the risk of ssi
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

Causes of wound contamination
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

The number one source
The Number One Source

People = Shedding

4000-10,000 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

Traffic control
Traffic Control

  • Requires the control of the amount of traffic and the traffic patterns themselves

    • 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

    • Utilize alternative methods of communication

      Sherertz, et al. “Cloud” HCWs. Emerging Infect Dis. 2001;7(2): 241-44.

      Edmiston, et al. Airborne Particulates in the OR Environment. AORN 1999; 69(6): 1169-1183.

Kohut ssi equation
Kohut SSI Equation

People + Wind + (-) Aseptic Technique

> ABX + Skin Prep =

Wound Contamination = SSI

Containment is the key
Containment is the key

Patient Opportunities

  • Pre-op showering program

    -At least 2 showers with CHG

  • Hat and clean gown/linen for patient transport

  • Hair removal only when necessary

    • Clippers, not in the OR

      Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.

      Chlebicki MP, et al. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: A meta-analysis. Am J Infect Control 2013;41:167-73. Accessed 4/3/13.

Containment is the key1
Containment is the key

Surgical Team

  • Hand Hygiene

    • Nocardiafarcinica (Wenger, et al. J Infect Dis. Nov 1998)

  • Proper aseptic technique

  • Properly worn hats, masks, clean OR scrubs, jackets, minimal jewelry (AORN scrub attire)

  • Ban skull caps
    Ban Skull Caps

    If it takes 17 years to adopt new technology, our time is up!

    Dineen, P, Drusin, L. Epidemics of Postoperative Wound Infections Associated with Hair Carriers. Lancet 1973; (Nov) 1157-59.

    Institute of Medicine (IOM). (2001). Crossing the quality chasm. Crossing the quality chasm: A newhealth system for the 21st century. Washington: National Academy Press.

    Other industries
    Other Industries

    The Jackson Laboratory

    Biotechnology Company



    Room Requirements

    • Ventilation System

      • (min 15- recommended- 20-25/hr, 3 fresh)

      • Positive pressure

    • Temperature (68-73° F)

    • Humidity (20-60%)

      Room Cleaning

    • Between cases

    • Terminal cleaning

    • Types of construction materials

    • Clutter

      AORN, Recommended Practices for Perioperative Nursing: Patient & Worker Safety. (2011 ed., p 219-221)

    3 antibiotic prophylaxis
    3. Antibiotic Prophylaxis

    SCIP Measures - INF 1,2,3 and NPSG.07.05.01 (#7)

    • Goal >95%

      • Challenge the organization to 100%

    • Proper dosage for obese population (BMI>30)

      (Surg 1989;106:750)

    • Redosingq 3 hours (Ann Surg2009; 250:10)

    • RCA or Med Error if missed

      Bratzler, DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst. Pharm. 2013;70:195-283.

    4 hair removal
    4. Hair Removal

    • SCIP measure (Inf-10)

    • NPSG.07.05.01 (#8)


      • Minimize as much as possible

      • Clippers only

  • Not addressed: Location of hair removal

  • 5 skin antisepsis
    5. Skin Antisepsis

    The attributes of an appropriate surgical skin antiseptic require:

    • The ability to significantly reduce microorganisms

      (2 log-dry sites, 3 log-wet sites)

    • Provide broad spectrum activity

    • Be fast acting

    • Have a persistent effect

      All products with FDA approval meet this criteria

      Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.

    Other skin antisepsis considerations
    Other Skin Antisepsis Considerations

    • Procedure (location and type of incision site)

      • May challenge the prep area with the presence of blood, saline, friction from retractors, etc.

    • Patient Safety

      • Consider not using alcohol based preps for head and neck surgeries due to the highest risk of fire.

    There are no specific recommendations
    There are no specific 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

    • NQF 2011 recommendation: “use solutions that contain isopropyl alcohol as skin antiseptic preparation until other alternatives have been proven as safe and effective, and allow appropriate drying time per product guidelines.”

National Quality Forum:

    Surgical skin antisepsis research
    Surgical Skin Antisepsis Research

    • Limited research is available that compares commonly used skin antiseptic agents with SSI outcomes

    • The majority of the literature compares microbial counts

    • Much more work must be done to create a body of evidence to guide practice

    Current research
    Current Research

    Saltzman, MD, et al. Efficacy of Surgical Preparation Solutions in Shoulder Surgery. J Bone Joint Surg AM 2009;91:1949053

    • Microbial culture study of 150 patients comparing 3 methods (IodophorScrub/Paint vs. ChloraPrep® vs. Duraprep™)

      Swenson, et al. Preoperative skin preparation on postoperative wound infection: a prospective study of three skin preparation protocols. Infect Control Hosp Epidemiol2009; 30:964-971

      • SSI Outcome study of 3209 pts comparing 3 methods (Iodophor Scrub/ETOH/Paint vs. ChloraPrep® vs. DuraPrep™

        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 comparing 2 methods (Iodophor Scrub/Paint vs. Chlorhexidine-alcohol)

      Savage, JW et al. Efficacy of Surgical Preparation Solutions in Lumbar Spine Surgery. J Bone Joint Surg Am. 2012;94:490-4

      • Efficacy study comparing ChloraPrep® to DuraPrep™ preop, post prep, and post-op

    Isopropyl alcohol
    Isopropyl Alcohol

    Mechanism of actions:

    • Denatures (kills) proteins

      • Bactericidal

      • Fungicidal

      • Virucidal

      • Does not kill spores

    • Has no persistent effect

      Association of periOperative Registered Nurses (AORN). Recommended Practices for Perioperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices 2013 ed., pp75-89.

    Product application methodology
    Product Application Methodology

    • Follow manufacturer’s directions

      • Read the labels!

    • Utilize proper aseptic technique during application & gloves to contain shedding

    Facilitating process improvements
    Facilitating Process Improvements

    Create relationships between IP, OR, SPD, Pre-op, Surgeons (and their offices):

    • Learn how they do their work

    • Learn how you can help each other

    • Choose process measures together

    • Its about partnering not policing

    Process improvements
    Process Improvements

    • Provide process data on an ongoing basis

      • Maintains focus

        • IUS rates

        • Compliance with surgical attire

    • Review outcome data regularly

      • SSI Rates


    • SSIsare preventable and there is much work to be done

    • The tools for success include SCIP measures, NPSG.07.05.01, process and outcome data and the operating room basics to:

      • Educate

      • Measure

      • Communicate