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PREVENTION OF SURGICAL SITE INFECTION Refueling Your Quality Engine Winnipeg March 3 & 4, 2011 Slide 2 Risk Factors for SSI Age Nutritional status Diabetes Smoking Obesity Steroid use Prolonged pre-op LOS PatientOperationPost-op care Antimicrobial prophylaxis Blood Glucose Normothermia Hair Removal Antiseptic technique Surgical technique Wound classification Length of surgery Blood transfusion OR Ventilation Traffic Control Wound care Discharge Slide 3 Prophylactic Antibiotics Slide 4 Appropriate Use Of Antibiotics Appropriate Use Of Antibiotics The right drug The right dose 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% ) Slide 5 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 1 1. Bratzler & Houck. Clinical infectious Diseases 2004; 38: 1706-15 Slide 6 SHN! Recommendation 1 Based on the evidence, the Safer Healthcare Now! faculty recommend that prophylactic antibiotics be completely absorbed within 60 minutes of first incision, and should be repeated for surgeries lasting longer than the half-life of the antibiotic (4 hours for cephalosporins). Antibiotics administered for cardiac, thoracic, orthopaedic and vascular patients should be discontinued within 24 hours of the end of surgery, whereas non- complex and uncomplicated surgeries require no further administration of antibiotics following surgery. 1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010 Slide 7 Prophylaxis Dosing Consider the upper range of doses for large patients - Gastroplasty: SSI rates 16.5% vs 5.6% 1 Repeat doses for long operations (> 4 hours) - Cardiac surgery: SSI rates 16% vs 7% 2 1 Forse, R; Karam, B; Maclean, D; Cristou, N. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery, 1989, 106: 750-7 2 Zanetti et al., Emerg Infect Dis, 2001 Slide 8 Weight Based Dosing in Canada: Evidence into Practice Healthcare FacilityCefazolinVancomycin Fraser Health Authority, Vancouver, British Columbia 1g IV if 80kg 2g IV if >80kg Not Available Edmonton and Area Acute Care Facilities, Alberta Health Services, Alberta 1g IV if 100kg 2g IV >100kg Vancomycin 1g for everyone Grace Hospital, Winnipeg Regional Health Authority, Winnipeg, Manitoba 1g IV if 80kg Not Available Horizon Health Network, Moncton, NB 1g IV if 100kg 2g IV >100kg Not Available Slide 9 SHN! Recommendation Based on the evidence, SHN Faculty recommends that prophylactic antibiotic administration be started and completed within 60 min. of first incision for c-sections instead of after cord-clamping. Faculty recommend that prophylactic antibiotic infusion be started and completed within 60 min. (120 min. for Vancomycin) prior to application of tourniquet to maximize antibiotic efficacy. Slide 10 Change Ideas Use pre-printed or computerized standing orders specifying choice of antibiotic, dose, timing, and discontinuation. Change operating room drug stocks to include only standard doses and standard drugs, reflecting locally agreed upon guidelines. Incoporate pre-mixed antibiotics for use by OR staff. Reassign antibiotic administration responsibilities to anesthesia or holding area nurse to improve timeliness. Incorporate the use of the surgical safety checklist so that Antibiotic absorbed is addressed in the time out. Slide 11 Hair Removal Slide 12 SHN! Recommendation 1 Based on the evidence, the Safer Healthcare Now! SSI faculty recommend that patients be educated not to shave in the vicinity of the incision for one week preoperatively. No hair removal prior to surgery is optimal. If hair removal is necessary, clippers should be used outside of the OR and within 2 hours of surgery. Do not use razors in the vicinity of the surgical area. Patients should shower after clipping due to increased risk of bacterial contamination of the surgical site. 1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010 Slide 13 Change Ideas Develop a letter for surgeons offices to provide to their patients that includes a reminder about not shaving for one week prior to surgery Indicate that the clipping of any hair will be done in the hospital on the day of surgery Slide 14 Perioperative Normothermia Slide 15 Consequences 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 1 1. Melling et al. 2001 Lancet, 358: 876-80 Slide 16 SHN! Recommendation 1 Based on the evidence, the Safer Healthcare Now! SSI faculty recommend that measures are taken to ensure that surgical patient core temperature remain between 36.0C and 38C preoperatively, intraoperatively, and in PACU. 1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010 Slide 17 Change Ideas Pre operative warming utilizing forced warm air blankets for 30+ min pre-op Continue active warming in the OR (include warmed IV fluid and lavage for abd. cases) Increase the ambient temperature in the operating room to 20C Hats and booties on patients during surgery PACU warming to discharge as needed Do this routinely on all procedures slated 60 min. + Slide 18 Blood Glucose Control Slide 19 Recent Research Strict vs. conventional blood glucose control 2009 consensus statement on glycemic control from American Association of Clinical Endocrinologists and American Diabetes Association report BG should be maintained between 7.8 and 10 mmol/L for most critically ill patients Slide 20 SHN! Recommendation 1 Based on the evidence, The Safer Healthcare Now! SSI faculty recommend that preoperative blood glucose levels be checked on all surgical patients. Teams are encouraged to apply glucose control to surgical populations as directed by your local organization. 1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010 Slide 21 Change Ideas Pre-op blood sugar analysis to pick up on undiagnosed diabetics Referral to endocrinology or initiate treatment prior to slated date Slide 22 Skin Prep Prevention Strategies and Skin Antisepsis Slide 23 The Ideal Skin Antimicrobial The ideal antimicrobial agent for skin should have the following properties: - Broad spectrum - Rapid bactericidal activity - Persistence or residual properties on the skin - Effective in the presence of organic matter - Non-irritating or have low allergic and/or toxic responses - None or minimal systemic absorption Slide 24 Current Approaches: Prevention of SSIs Multiple studies have shown that CHG and CHG/alcohol solutions display these important properties: CHG plus 70% isopropyl alcohol (IPA) has demonstrated efficacy against a wide range of bacteria, including P. aeruginosa, S. aureus, and antibiotic-resistant bacteria. CHG/IPA exhibits a rapid onset of action, persists for up to 24 hours, and has increased efficacy with repeated applications. Chlorhexidine is not inactivated in the presence of blood, which neutralizes the effects of iodine and PCMX and dilutes the effects of alcohol. Florman et al. Current Approaches for the Prevention of SSIs. Am J Infect Dis. 3(1):51-61, 2007. Slide 25 Safety CHG 2%/70% IPA solution is flammable CHG-alcohol skin prep solution should not be used around eyes, ears, and mouth, or come in direct contact with neural tissue Slide 26 SHN! Recommendation 1 Based on the evidence, the Safer Healthcare Now! SSI faculty recommends that the skin should be cleansed before surgery with a chorhexidinebased solution, preferably with no rinse disposable chlorhexidine gluconate impregnated wash cloths. The antiseptic of choice for skin prep should be alcohol based chlorhexidine antiseptic solutions instead of povidone-iodine. Following application of chlorhexidine-alcohol skin prep solution, surgical teams should complete the time out of the surgical checklist to allow time for the skin prep to dry. 1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010 Slide 27 SHN! Recommendation 1 To maximize its efficacy, CHG-alcohol skin prep should not be washed off for at least 6 hours following surgery. In order to prevent a fire hazard, It is imperative that CHG- alcohol skin prep be allowed to air dry for at least 3 minutes, or longer if there is excessive hair insitu. Povidone-iodine should be used as a skin preparation in emergent cases where there is not enough time to allow CHG- alcohol solution to completely dry before incision. Chlorhexidine-based solutions must not be used for procedures involving the ear, eye, mouth or neural tissue. 1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010 Slide 28 http://www.youtube.com/watch?v=4IG8ItaTTzY