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Today’s Webinar will begin at 11:00 PST

Today’s Webinar will begin at 11:00 PST. 12/18/12. Welcome from Barb DeBaun, RN, MSN, CIC. Introduction. Please do not put your phone on hold; use the mute function or *6 Please type questions or comments into text box Interactive question session

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Today’s Webinar will begin at 11:00 PST

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  1. Today’s Webinar will begin at 11:00 PST 12/18/12

  2. Welcome from Barb DeBaun, RN, MSN, CIC

  3. Introduction • Please do not put your phone on hold; use the mute function or *6 • Please type questions or comments into text box • Interactive question session • If time permits, we will open up the phone lines at the conclusion of the presentation

  4. Introducing Sue Barnes, RN, CIC

  5. SSI Prevention - How Are We Doing?Direct OR Observations Sue Barnes, RN, BSN, CIC National IP Leader, Kaiser Permanente

  6. IP Before Holiday Break

  7. Overview and objectives OVERVIEW: This session will describe how inpatient and outpatient surgery centers are doing relative to surgical infection prevention based on a small number of direct case observations. Prevention in all phases of the surgical journey will be addressed: pre-operative, intra-operative and Post-operative. The uncharted arena of surgical technique and infection risk will also be considered. OBJECTIVES Share project overview Review observed compliance with standard infection prevention efforts, share best practices and challenge areas Share my ongoing dialogue with surgeons and periop staff – what do they know that we don’t know about surgical procedures and infection risk?

  8. Project overview Preparation Request permission to observe cases from surgeon colleagues Schedule with OR managers – inform local IP – request time for debrief View UTube video clips of procedures Observations Use checklist to guide observations – take notes: best practices, questions, opportunities for improvement Ask surgeons and periop staff their perspective regarding aspects of surgical procedure, technique and SSI risk – their concerns After the case Debrief post op with OR manager and IP (separately or together at their convenience) Sent thank you to surgeon, team and their supervisors with summary of best practices Sent private list of challenge areas – “your eyes only” to surgeon, IP and OR manager – professional courtesy My next steps 4 cases observed to date (general, OB/GYN, cardiac, plastics). I plan to continue next year with other high risk procedures including: bariatric, ortho, eye, spine

  9. OR Observations “Almost no matter what experimental conditions were imposed, increases in output occurred….The investigators had obviously influenced the subjects’ behavior merely by studying that behavior, and this phenomenon has become known as the Hawthorne effect.” (Kelly Shaver, Principles of Social Psychology, 2nd ed., Winthrop, 1981)

  10. Questions posed • Pre Op: • Hair removal • Skin prep • Hand scrub • Intra Op: • Aseptic technique • Antibiotic weight based dosing and re-dosing • Irrigation • What are you concerned about? • Post Op: • Skin closure • Patient education • Drains, dressings

  11. Observation focus Anesthesia: Foley on floor? Scrub the hub? Mask over nose and mouth? Hair coverage? Aseptic technique movement front to front, hands above waist, sterile field Attire full hair coverage (including chest), long sleeves, mask Environment OR room design and cleaning, clutter, supplies covered/behind closed doors, equipment, instruments Hand degermer outside/inside OR rooms Scrub sinks brushless scrub, no refillable bottles Traffic in OR rooms during case.

  12. Lap hysterectomy + hernia repair

  13. Breast reduction

  14. Laparoscopic colectomy

  15. CABG

  16. My primary take away

  17. Also

  18. A couple of these moments

  19. Pre-operative

  20. Surgical hand scrub With brush: CHG or PVI Brushless: Alcohol +/- CHG Jarral OA, McCormack DJ, Ibrahim S, Shipolini AR. Should surgeons scrub with chlorhexidine or iodine prior to surgery? Interac Cardiovas Thorac Surg. 2011 Jun;12(6):1017-21. Lai KW, Foo TL, Low W Naidu G. Surgical hand antisepsis-a pilot study comparing povidone iodine hand scrub and alcohol-based chlorhexidine gluconate hand rub. Ann Acad Med Singapore 2012 Jan;41(1):12-6.

  21. Pre-operative antibiotics Ho VP, Barie PS,Stein SL, Trencheva K, Milsom JW, Lee SW, Sonoda T Antibiotic regimen and the timing of prophylaxis are important for reducing surgical site infection after elective abdominal colorectal surgery. Surg Infect 2011 Aug;12(4):255-60. Bowater RJ, Stirling SA, Lilford RJ Is antibiotic prophylaxis in surgery a generally effective intervention? Testing a generic hypothesis over a set of meta-analyses. Ann Surg. 2009 Apr;249(4):551-6.

  22. Glucose control Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative glycemic control in general surgery: a report from the surgical care and outcomes assessment program. Ann Surg. 2013 Jan;257(1):8-14.

  23. Normothermia Moola S, Lockwood C. Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment. Int J Evid Based Healthc 2011 Dec;9(4):337-45 Lista F, Doherty CD, Backstein RM, Ahmad J. The impact of perioperative warming in an outpatient aesthetic surgery setting. Aesthet Surg J. 2012 Jul;32(5):613-20.

  24. Skin Antisepsis Yeung LL, Grewal S, Bullock A, Lai HH, Brandes SB. A comparison of chlorhexidine-alcohol versus povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: a randomized controlled trial. J Urol. 2013 Jan;189(1):136-40.

  25. MRSA Decolonization high risk cases Vonberg RP, Gastmeier P. Prevention of surgical site infections in bone and joint procedures. Curr Infect Dis Rep 2012 Oct;14(5):576-84. Craft RO, Damjanovic B, Colwell AS. Evidence-based protocol for infection control in immediate implant-based breast reconstruction. Ann Plast Surg. 2012 Oct;69(4):446-50.

  26. Hair Removal Grober ED, Domes T, Fanipour M, Copp JE. Preoperative Hair Removal on the Male Genitalia: Clippers vs. Razors J. Sex Med 2012 Aug 21. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011 Nov 9;(11):CD004122.

  27. CHG cloths for pre-op antiseptic bathing Webster J, Osborne S. “Home-based preoperative chlorhexidine bathing cloths to prevent surgical site infection” ICHE 2011 Oct;32(10):1047.

  28. Intra-operative

  29. Aseptic technique Blanchard, Byron Burlingame, Bonnie Denholm, Sharon Giarrizzo-Wilson, Mary Ogg, and Sharon A. Van Wicklin. Perioperative Standards and Recommended Practices. Vol. 1, 2012.

  30. Traffic control intra-operatively Al-Benna S. Infection control in operating theatres. J Periop Pract 2012 Oct;22(10):318-22.

  31. Staff hair coverage Alicia J. Mangram GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY Vol. 20 No. 4 247. “Wear a cap or hood to fully cover hair on the head and face when entering the operating room.” (CDC category IB).

  32. Foley on floor - Anesthesia Gould C et al. CDC HICPAC GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 “Do not rest the bag on the floor.” (Category IB) .

  33. Scrub the hub - Anesthesia Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a post insertion care bundle. AJIC.2010 Aug;38(6):430-3.

  34. Hand hygiene - Anesthesia Henderson DM, et al. “A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-line-associated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections.” J Healthc Qual . 2012 Sep-Oct;34(5):39-47.

  35. Red cap: Version1: visitors Version 2: patient pre-op checklist pending

  36. Change gloves before closing Partecke LI, Goerdt AM, Langner I, Jaeger B, Assadian O, Heidecke CD, Kramer A, Huebner NO. Incidence of microperforation for surgical gloves depends on duration of wear. ICHE 2009 May;30(5):409-14.

  37. Use of disposables – hard to clean items Brown DQ. Disposable vs. reusable electrocardiography leads in development of and cross-contamination by resistant bacteria. Crit Care Nurse. 2011 Jun;31(3):62-8.

  38. Post-operative

  39. Patient teaching – S & S Infection Hari M, Rosenzweig M. Incidence of preventable postoperative readmissions following pancreaticoduodenectomy: implications for patient education. Oncol Nurs Forum. 2012 Jul;39(4):408-12.

  40. High dusting, de-cluttering, cleaning OR Munoz-Price LS, Birnbach DJ, Lubarsky DA, Arheart KL, Fajardo-Aquino Y, Rosalsky M, Cleary T, Depascale D, Coro G, Namias N, Carling P. “Decreasing operating room environmental pathogen contamination through improved cleaning practice.” ICHE 2012 Sep;33(9):897-904.

  41. UV light as adjunct to manual cleaning Boyce JM, Havill NL, Moore BA. “Terminal decontamination of patient rooms using an automated mobile UV light unit”. ICHE. 2011 Aug;32(8):737-42. Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis. 2010 Jul 8;10:197.

  42. Antimicrobial post-op dressing Epstein NE. “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections.” Surg Neurol Int. 2011 Feb 21;2:17. Krieger BR et al. “The use of silver nylon in preventing surgical site infections following colon and rectal surgery”. Dis Colon Rectum. 2011 Aug;54(8):1014-9.

  43. Antimicrobial dressing for pins and drains Egol KA et al. “Treatment of external fixation pins about the wrist: a prospective, randomized trial.” J Bone Joint Surg Am. 2006 Feb;88(2):349-54.

  44. D/C instructions with surgeon cell #

  45. Surgical technique and SSI risk: Questions posed to and by surgeons

  46. Electronic devices that discharge air, or are designed to blow air in OR – a risk?

  47. Intra-operative Irrigation Pour? Bulb syringe? Jet?

  48. Intra-operative Irrigation NS, RL, CHG, antibiotics?

  49. What about the operative wound – size of incision, dead space, exposed adipose tissue?

  50. What’s the benefit of the wound edge protector – when to apply?

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