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Conquering Surgical Infections in 2014

Stephanie S. Davis, MSHA, RN, CNORVice President of Surgical Services

Julia Moody, MS AM(ASCP)Director of Infection Prevention

Hospital Corporation of American (HCA)Nashville, TN

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Faculty Disclosure

AORN’s policy is that the subject matter experts must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity.  Disclosures for this activity are indicated according to the following numeric categories:

1. Consultant/Speaker’s Bureau 2. Employee 3. Stockholder 4. Product Designer 5. Grant/Research Support 6. Other relationship (specify) 7. No conflict of interest

Stephanie S. Davis, MSHA, RN, CNORJulia A. Moody, MS, SM (ASCP)7. No conflict.

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Objectives

• Review Publicly Reported surgical site infections (SSIs) Data

• Describe common organisms and costs associated with SSI

• Examine the evidence of recent studies and their affect on infection rates for certain surgical procedures.

• Discuss the future trends and changes to our practice that can decrease surgical infection rates and events.

• 2014 Updates to Public Reporting of SSI

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Conquering Surgical Infections• Publicly Reported Post Operative Surgical

Site Infections (SSIs)– Two different sets of metrics:

• Healthcare Associated Conditions (HACs) and• Healthcare Associated Infections (HAIs)

• Common Causes and Costs of SSI infections• Key infection prevention practices

• What’s New in Studies to Reduce SSIs?

• 2014 updates to Publicly Reported SSIs

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Regulatory Rationale to Reduce SSIs• CMS HACs Pay for Performance

– Deficit Reduction Act (DRA) of 2005 required there be an adjustment in Medicare DRG payment for certain hospital-acquired conditions (HACs) with Present on Admission (POA) coding

– Events are sourced from administrative coding based on provider documentation

• CMS / NHSN HAIs Pay for Reporting– 2010 Patient Payment and Affordable Care Act names Healthcare Associated

Infections (HAIs) and HHS target is to reduce SSIs by 25%. – Reporting is via the CDC National Healthcare Safety Network using infection

prevention based surveillance definitions and risk adjustments

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Regulatory Rationale to Reduce SSIs: 2013 Public Reporting

• CMS HACs – Mediastinitis– Bariatric– Orthopedic procedures– Cardiac implantable

electronic device (CIED)

– Readmissions and SSIs

� CMS / NHSN HAIs Colorectal Abdominal

Hysterectomy

� State mandated HAIs Open heart Hip and knee joints Other

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Proportion of Hospital-Acquired Infections (HAIs) in the US

ID Week 2013 Abstract 497 NHSN Reported Data

SSI = Surgical Site Infections

CAUTI = Catheter Associated Urinary Tract Infection

HO-HCFA CDI = Hospital onset Healthcare Facility Associated C difficile Infection

CLABSI = Central Line Associated Bloodstream Infection

VAP = Ventilator Associated Pneumonia

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NHSN Primary Causes of SSI

Source: Hidron et al., ICHE 2008

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Health Care–Associated InfectionsA Meta-analysis of Costs and Financial Impact

on the US Health Care System

JAMA Intern Med 2013: published online September 2

Annual cost $9.8 billion

SSI contributed the most to overall costs-33.7% of total

MRSA SSIs increase cost and LOS

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Conquering Surgical Infections• Public Reporting of Post Operative Surgical Site

Infections (SSIs)

– Two different sets of metrics: Healthcare Associated Conditions (HACs) and Healthcare Associated Infections (HAIs)

• Key infection prevention strategies– Evidence for practices

• What’s New in Studies to Reduce SSIs?

• 2014 updates to Publicly Reported SSIs

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Preventing SSI: Important Modifiable Risk Factors

• Optimize Antimicrobial prophylaxis• Appropriate skin or site preparation

– Hair removal– Skin cleansing and preparation

Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

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SSI: Important Modifiable Risk Factors• Optimize Antimicrobial Prophylaxis

– Right choice (procedure specific)– Right time (pre-incision dose)– Right dose based on body mass index

• Cefazolin increased from 1g to 2g for defined weight decreased SSIs

• ASHP 2013 publication with new dosing– Redosing for procedures >3h– Presence of antibiotic resistant organisms like MRSA

ASHP 2013Medical Letter 2012

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Timing of Antimicrobial Prophylaxis and the Risk of SSIs

Ann Surg 2009; 250:10

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0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Infe

ctio

ns (%

)14/369 15/441

Hours From Incision

Classen. NEJM. 1992;328:281.

Perioperative Prophylactic AntibioticsTiming of Administration

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2013 Changes in Antimicrobial Prophylaxis • Cardiac and Orthopedic procedures

– Screen for Staphylococcus aureus, both MRSA and MSSA, and decolonize

– Add Vancomycin to Cefazolin when MRSA positive or unknown status at time of surgery

• Colon procedures– Ceftriaxone (if institution has increased resistance to

first and second generation cephalosporins) plus metronidazole over use of a carbepenem

ASHP 2013

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2013 Changes in Antimicrobial Prophylaxis• Cesarean Section

– Cefazolin given before surgical incision instead of former recommendation after cord clamped

• Does not routinely support topical antimicrobials for irrigations (i.e. CHG)– Parenteral prophylaxis is adequate

• Shortening postoperative prophylaxis – 2013 guideline states most cases can be treated with a single

dose preoperatively. Duration should be <24h*

– There is no data to support continuation of surgical prophylaxis until all drains are removed

*Upcoming CDC guidelines will not recommend postop dosing

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2013 Surgical Antimicrobial Prophylaxis• Weight-based dosing: e.g. Cefazolin dosing from 1gm

to 2gm routine (2gm to 3gm for >120kg)

• Re-dosing for surgeries at 3-4h intraoperative (cefazolin)

• Re-dosing for blood loss over 1500 ml

• Add Gentamicin to some procedures to cover Gram negative bacteria (for beta-lactam allergy or known colonization with MRSA when vancomycin used)

• If antibiotic prophylaxis is continued postoperatively, duration should be <24 hours regardless of the presence of intravascular catheters or indwelling drains

ASHP 2013

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Prophylactic AntibioticsSize of Patient and Size of Dose

Surg 1989; 106:750

• Morbidly obese patients having bariatric operation

• Cefazolin levels lower than in non-obese patients at same dose

• Cefazolin dose changed from 1 g to 2 g– Infection rate at 1 g: 16.5%– Infection rate at 2 g: 5.6%

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Timing of Antimicrobial Prophylaxis and the Risk of SSIs

Ann Surg 2009; 250:10

Intraop Redosing

in Surgeries > 4 h Infection/# Infection Risk

redosing 2/112 1.8%

no redosing 22/400 5.5%*

P=0.06

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Surgical Prophylaxis Dosing Table

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SSI: Important Modifiable Risk Factors

• Skin and site preparation to reduce microbes

– Presurgical shower (regular or antimicrobial soap)• Clean towel and clean clothing

– Avoid hair removal unless hair will interfere • Do not use razors• Instruct patients to not shave prior to the procedure• Use clippers if removal is necessary, clip

immediately prior to the procedure to minimize risk• Disrupting the protective skin surface, allows

microbes to gain tissue access

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SSI: Important Modifiable Risk Factors– Use an approved labeled skin antiseptic agent

• Activity is enhanced with alcohol combination products

• Apply and follow manufacturers instructions• Let dry or dwell thoroughly for maximum

effectiveness– Water based or Waterless Surgical Hand Scrubs

• Apply for the indicated time• Products differ in action and time to achieve activity

– Sterile draping to prevent bacterial contamination

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Antiseptic Surgical Skin Preparations

• Lower SSI rates for iodine containing products– Comparison of 3 products (povidine iodine, iodine plus alcohol, CHG

plus alcohol) in sequential implementation adult general clean and clean contaminated surgery (Swenson ICHE 2009)

• Significantly lower SSI rates for CHG-alcohol compared with iodine paint and scrub for superficial and deep SSI, but not organ/space SSI. – Multicenter study of adults undergoing clean-contaminated surgery

(Darouiche NEJM 2010; 362:18)

• Which is the better prep? CHG+alcohol or Iodine+alcohol? – No recommendation due to absence of direct comparison studies

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Preventing SSI: Important Modifiable Risk Factors

• Glucose control• Blood transfusion• Adequate intraoperative oxygen levels• Operative time and efficiencies

Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

SSI and Glucose ControlGeneral and Vascular Procedures

·Results ·↑SSI Risk(multivariate analysis)

Post-op glucose ASA class Length of operation

•SSI rate increased 30% for every 40

mg/dL glucose > 110

26Ann Surg 2008; 248:203

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� Study Design: Nearly 300,000 operations performed at 173 hospitals from 2005 to 2007, found the 30-day rate of infectious complications rose by almost 2.5% for every 30 minutes between incision and closing.

� Findings: After adjusting for patient variables, type and complexity of surgery, wound class, and need for transfusion, operative time remained a significant predictor of postoperative infection.

� Conclusions:• Surgeries lasting 2.1 to 2.5 hours had nearly double the risk of

infectious complications compared to those patients whose procedure no more than an hour.

• Across all procedures, hospital stays increased geometrically along with operative times, at a rate of about 6% for every 30 minutes.

General Surgical Operative Duration is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of StayJ Am Coll Surg 2010;210:60-65

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Mean Number of Complications in Intervention Hospitals and Control Hospitals before and after Implementation of the Surgical Safety Checklist

de Vries EN et al. N Engl J Med 2010;363:1928-1937

SSI 3.8%→2.7% P 0.006

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Surgical Safety ChecklistBriefing Time Out Debriefing

Before Induction of Anesthesia(Circulator Initiates)

Before Skin Incision(Circulator Initiates)

Before Surgeon and Patient Leave the Room (Circulator Initiates)

*Team Members should stop activity and respond to each question of the briefing, time out, and debriefing.STEP 1 STEP 2 STEP 3

1. Has the patient been identified using two unique identifiers?

1. Confirm that all team members have introduced themselves by name and role.

1. Circulator announces the results of the counts (instrument, sponge, needle as applicable)

2. Who are providers and what is the procedure site and side? 2. Is this the correct patient, correct procedure

and correct side?· Images displayed and labeled· Consent correct· Reports confirm site and side· Position correct

2. Circulator confirms exact procedure and diagnosis with surgeon.

3. Does this patient have any drug or latex allergies?

3. Circulator confirms all specimens are accurately labeled.

4. Has the anesthesia safety check been completed?

(Machine and medication check)3. What are the safety concerns for this

patient?· Appropriate pre-op antibiotic selected and

started· DVT risk· Normothermia assured· Anticipated blood loss· Patient history or medication - use

precautions· Implants and equipment needed present· Fire risk· Expected length of procedure· Any other concerns?

4. Were there any delays for this case? (Assign delay codes)

5. Does the patient have a difficult airway or aspiration risk?

5. Are there any permanent changes to the preference card?

· Equipment or instrument malfunctions or issues

6. Is there a need for any anesthesia procedures before the incision (central line, block)?

6. What are the key concerns for recovery and management of the patient?

7. Are medications secured?

HCA Template for a Surgical Safety Checklist

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2011 Updated Recommendations for Control of Surgical Site Infections

Alexander 2011 Annals of Surgery

• Reduce environmental contamination in OR

• Preoperative antiseptic showering and cleansing

• Clipping to remove hair

• Prep skin with an alcoholic CHG or alcohol iodophor

• Double gloving and incise drape use

• Minimize tissue damage and dead spaces

• Drains and placement

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2011 Updated Recommendations for Control of Surgical Site Infections

• Optimize prophylactic antibiotics

– Selection, Timing, Weight Based dose and Redosing• Normothermia 36oC or higher

• Oxygenation

• Glucose Control <180 mg/dL

• Smoking cessation

• Limit blood transfusions and fluids

Alexander 2011 Annals of Surgery

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Conquering Surgical Infections• Public Reporting of Post Operative Surgical Site

Infections (SSIs)

– Two different sets of metrics: Healthcare Associated Conditions (HACs) and Healthcare Associated Infections (HAIs)

– Historical Background• Key infection prevention strategies

• What’s New in Studies to Reduce SSIs?• 2014 updates to Public Reporting of SSIs

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BMJ 2013: Effectiveness of a bundled interventionof decolonization and prophylaxis to decrease

Gram positive surgical site infections after cardiac or orthopedic surgery

• What’s already known on this topic: Surgical site infections (SSIs) are potentially preventable adverse events of

cardiac and orthopedic operations

SSIs significantly increase hospital length of stay, readmission rates, healthcare costs, and mortality rates

Clinicians and researchers have debated whether nasal decolonization or glycopeptide antibiotic prophylaxis reduce SSIs caused by Gram positive bacteria

• Study type: Systemic review and meta-analysis

BMJ 2013;346:f2743 doi: 10.1136/bmj.f2743

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BMJ2013: Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease

Gram positive surgical site infections after cardiac or orthopedic surgery

• What this study adds among patients undergoing cardiac or orthopedic surgery:

Nasal decolonization with mupirocin ointment was protective against Gram positive SSIs

Preoperative prophylaxis with anti-methicillin resistant Staphylococcus aureus (MRSA) antibiotics when given to all patients was not protective against Gram positive SSIs

A bundle that included nasal decolonization and anti-MRSA prophylaxis for MRSA carriers was significantly protective against Gram positive SSIs

BMJ 2013;346:f2743 doi: 10.1136/bmj.f2743

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HCA’s MRSA Solution: The A,B,Cs…

• Active Surveillance of high risk patients

• Barrier Precautions • Compulsive Hand

Hygiene • Disinfection /

Environmental Cleaning

• Executive Championship

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HCA MRSA ABCs• Program initiated in 2008 across system

• Presurgical nares screening of MRSA in open heart, open spine, hip joint and knee joint replacements

• Decolonization by surgeon preference

• Initiate contact precautions for MRSA positive patients by screening or history

• Promoted vancomycin for perioperative prophylaxis

• Reduced SSIs due to MRSA by 15% [SHEA 2010 Abstract,, 2013 J Healthcare Quality]

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Study Design 2012-2013 • Quasi Experimental in Adult patients (18 y/o and older)

– Based on 2013 BMJ review and meta analysis

– 20 HCA hospitals

• Cardiac operations – Primarily CABG and valve replacements performed by sternotomy approach

• Orthopedic operations– Hip (total and partial) arthroplasty

– Knee (total and partial) arthroplasty

• Algorithm: Screening for MRSA and MSSA, CHG plus mupirocin decolonization and surgical prophylaxis

http://www.ahrq.gov/research/action10.htm

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STOP SSI Study Outcomes• Implementation of the algorithm will be associated with:

– Lower rates of SSIs (MRSA, MSSA, & other Gram-positives)

– Shorter lengths of stay– Lower readmission rates– Improved patient outcomes

• Study period June 2012 to March 2014

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Surgical CUSP to Reduce SSIs Wick Am Coll Surg 2012

• Study Design: Pilot CUSP (Comprehensive Unit-based Safety Program) in Colorectal Surgical Patients

• Interventions and Checklist:– Preoperative CHG showers

– Selective elimination of mechanical bowel prep

– Standardized skin prep to CHG

– Optimal antibiotic prophylaxis

– Preanesthesia warming

– Enhanced sterile techniques for skin and fascial closure

• Outcomes:– Decreased SSIs 33%, p value < 0.05

– Implementing safety science improves patient outcomes

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2012 Surgical Site Infections ProjectJoint Commission Center for Transforming HealthCare

• Background: 7 leading hospital and health systems collaborated with the American College of Surgeons to reduce colorectal SSIs

• Design: Identification of 34 unique correlating variables for risk of colorectal SSIs: patient characteristics, surgical procedure, antibiotic administration, preoperative/intraoperative/postoperative processes and measurement

• Outcomes: – Reduced superficial incisional SSIs by 45% and all types of colorectal SSIs by 32

percent.

– Estimated cost savings of more than $3.7M for 135 estimated SSI cases avoided.

– Decreased Average Length of Stay for hospital patients with any type of colorectal SSI from 15 to 13 days

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2012 Surgical Site Infections ProjectJoint Commission Center for Transforming HealthCare

Contributing Factors for Targeted Solutions• Preop testing and health screening to identify risk factors

• Management of medical conditions that increase the risk of SSIs

• Preop skin cleansing and disinfection

• Protocol/orderset variation

• Weight based dosing and redosing

• Normothermia

• Closure processes

• Intra and post-operative wound management

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New Evidence to Reduce SSIs2013 Publications

• High perioperative Oxygen supplementation has benefit in open abdominal procedures especially colorectal surgeries. Munoz-Price et al 2013 CID

• Blood transfusion was associated with a risk of major infection post cardiac surgery. Recommendations include limiting RBC use. Horvath et al 2013 J Thorac Surg

• Choice of IV antibiotic prophylaxis for colorectal surgery does matter. Deierhoi et al 2013 J Am Coll Surg

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New Evidence to Reduce SSIs2013 Publications

• Decolonization to reduce SSIs due to S. aureus– Mupirocin and CHG bathing reduced SSIs in

orthopedic, vascular, cardiac or neurosurgical proedures Thompson and Houston AJIC 2013

– S. aureus screening and decolonization in Orthopedic surgery is cost effective to reduce Chen et al SSIs 2013 Clin Orthop Relat Res

– Pre-admission CHG bathing reduces SSIs in total hip arthroplasty Kapadia et al 2013 J Arthroplasty

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CDC 2014 SSI Update• Glycemic Control

– Further research is needed to understand the association between hemoglobin A1C levels and the risk of SSI in diabetic and non‐diabetic patients. (No recommendation / unresolved issue).

– In diabetic and non‐diabetic surgical patients perioperative glycemic control using blood glucose target levels <180mg/dL (standard practice) is recommended. (Category IB)

– Further research to define optimal blood glucose target levels in diabetic, non‐diabetic, and critically‐ill surgical patients should evaluate the benefits and harms associated with glycemic control in different surgical populations, and postoperative settings which may impact choice of optimal target levels, delivery methods, timing of instituting, and duration of the protocol. (No recommendation / unresolved issue)

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CDC 2014 SSI Update• Normothermia

– Maintenance of perioperative normothermia is recommended. (Category 1A)

• Oxygenation – In patients undergoing general anesthesia with mechanical ventilation,

increased fraction of inspired oxygen (intraoperatively and post‐extubation in the immediate postoperative period) is recommended and should be administered in combination with strategies to optimize tissue oxygen delivery through maintenance of perioperative normothermia and adequate volume replacement. (Category 1A)

– Further research addressing the optimal fraction of inspired oxygen, timing, duration, and delivery method in SSI prevention should also evaluate potential benefits and harms. (No recommendation/ unresolved issue)

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CDC 2014 SSI Update

• Exhaust Suit – Further research addressing the use of orthopaedic

exhaust suits in arthroplasty procedures should evaluate their impact on surgical site infections, potential benefits and harms, the surgical personnel that should wear them, and the impact on their safety. (No recommendation/unresolved issue)

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Conquering Surgical Infections• Publicly Reported Post Operative Surgical Site Infections

(SSIs)– Two different sets of metrics:

• Healthcare Associated Conditions (HACs) and• Healthcare Associated Infections (HAIs)

• Common Causes and Costs of SSI infections

• Key infection prevention practices

• What’s New in Studies to Reduce SSIs?

• 2014 updates to Publicly Reported SSIs

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2014 NHSN Surgical Procedure Reporting Required Data Elements

– Patient ID– Gender– Date of Birth– Procedure Code– Procedure Date– Outpatient Y/N– Cut time/close time to

calculate duration in Hours and Minutes

– Wound Class (*NEW no unknowns accepted)

– ASA score– Scope Y/N– Emergent Y/N– *NEW Closure Primary

or Other– General Anesthesia Y/N– Trauma Y/N

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2014 NHSN Surgical Procedure Reporting Required Data Elements

‾ *NEW required Spinal Level Approach

‾ *NEW height feet and inches

‾ *NEW weight

‾ *NEW diabetes

‾ *NEW Type of HPRO or KPRO

• *NEW Specific type of Total joint replacement

• *NEW Specific type of Hemi joint replacement

• *NEW Type of Resurfacing joint replacement (HPRO)

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Surveillance Changes SSI• Primary incisional closure: definition changed to

include all incisions with some closure to the level of the skin, regardless of extruding wicks, wires, etc.

• Implant variable: no longer used to determine length of follow-up and removed from data collection requirements

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2013 NHSN Post Operative Surveillance• Rationale for reduced surveillance follow-up:

– Majority of infections occur within 90 days after the primary surgical procedure

– Many patients were lost to follow-up after 90 days – Surgeon’s signed off patient follow-up– Co-morbidities and new medical conditions unrelated

to the primary surgical procedure complicate associating the infection to the primary procedure

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2013 Surveillance Changes SSI• 90 days: deep incisional

and organ / space SSI BRST– CARD, CBGB, CBGC– CRAN, VSHN– FUSN, RFUSN, FX,

HPRO, KPRO– HER– PACE, PVBY

• 30 days:– Superficial SSIs of

any procedure type– Secondary incisional

SSIs of any procedure type

– Deep Incisional and Organ / Space SSI for all procedure types not listed in the 90 day group

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Top Take-Aways• Antibiotic timing needs to be as close to incision time as

possible.

• Dosages have gone up and redosing is required for long procedures.

• Preop bathing to be implemented. Tell patients to use a clean towel and place on freshly laundered clothing.

• Normothermia is here to stay.

• Double gloving, decreased OR traffic, proper temp/humidity, air exchanges.

• Clipping for hair removal.

• Limit blood transfusions.

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To-Do’s for Best Practice

• Expand nares screening for MRSA and MSSA in cardiac and orthopedic procedures

• Review perioperative antimicrobial prophylaxis ordersets and include new guidelines

• Hardwire antimicrobial administration processes

• Hardwire perioperative documentation

• Adjust and align SSI surveillance for 2013 nd 2014 cases

• Communicate rationale for changes

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• Prevention is a bundle of practices when performed in a highly reliable manner result in safe, positive patient outcomes.

Preventing SSIs

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References • CDC, NHSN Semiannual Report. December 2009.

• Hidron et al., Antimicrobial Resistant Pathogens associated with HAIs. Annual NHSN Report ICHE 2008 (29):996-1011

• NHSN SSI Surveillance definitions accessed at NHSN website http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

• Culver, et al. Surgical wound infection rates by wound class, operative procedure and paitnet risk index. Amer J Med. 1991;91(suppl 3B):152S.

• Mangram AJ, et al. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999; 20:250

• Anderson et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals Infect Control Hosp Epidemiol 2008; 29:S51–S61

• Steinberg et al Timing of Antimicrobial Prophylaxis and the Risk of Surgical Site Infections Ann Surg 2009; 250:10

• Classen et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection N Engl J Med.. 1992;328:281.

• Forse et al. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989; 106:750

• Campbell et al, Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results of the First American College of Surgeons–National Surgical Quality Improvement Program Best Practices Initiative J Am Coll Surg 2008;207:810–820

• Swenson et al. Effects of Preoperative Skin Preparation on Postoperative Wound Infection Rates: A Prospective Study of 3 Skin Preparation Protocols Infect Control Hosp Epidemiol 2009; 30:964-971

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References• General Surgical Operative Duration is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of S

Darouche et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis N Engl J Med 2010;362:18-26.

• STOP SSI Collaborative: http://www.ahrq.gov/research/action10.htm

• Roa et al. A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections. Clin Orthop Relat Res 2008; 466:1343

• Bode et al. Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus N Engl J Med 2010;362:9-17.

• Haynes et al A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491

• de Vries et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes N Engl J Med 2010;363:1928-1937

• Diekema et al. Current Practice in Staphylococcus aureus Screening and Decolonization Infect Control Hosp Epidemiol 2011;32(10):1042

• 2012 Treatment Guidelines from The Medical Letter: Antimicrobial Prophylaxis for Surgical Procedures, Volume 10 (Issue 122) October 2012

• Alexander et al, Updated Recommendations for Control of Surgical Site Infections Ann Surg 2011;253:1082–1093

• Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections Am Coll Surg 2012; 212:193-199

• 2012 Surgical Site Infections Project Joint Commission Center for Transforming HealthCare , accessed December 2012 http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_SSI_Fact_Sheet.pdf

• Bratzler et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis during Surgery. Am J Health-Syst Pharm. 2013; 70:195-283