An Initiative of the Florida Hospital AssociationHospital Improvement Innovation Network

Surgical Infection Prevention (SIP) Webinar Series #2:Infection Prevention Strategies in the Intra-operative PeriodMay 22, 2019

• Welcome & FHA Mission to Care HIIN Overview– Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of Quality and

Patient Safety and Improvement Advisor, FHA• Surgical Infection Prevention Series: Taking a Deep Dive into

Intra-operative Recommendations– Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection Prevention,

UR Highland Hospital, Rochester, NY• Q&A• Upcoming HIIN Events and Opportunities• Evaluation Survey & Continuing Nursing Education

Agenda

• Adverse Drug Events (ADE)• Catheter-associated Urinary Tract Infections (CAUTI)• Clostridium Difficile Infection (CDI)• Central line-associated Blood Stream Infections (CLABSI)• Hospital-onset MRSA Bacteremia• Injuries from Falls and Immobility• Pressure Ulcers (PrU)• Sepsis• Surgical Site Infections (SSI)• Venous Thromboembolisms (VTE)• Ventilator-Associated Events (VAE/IVAC/PVAP)• Readmissions (12% reduction)• Worker Safety

HIIN Core Topics – Aim is 20% reduction

SSI Resources, Trainings and Tools

Mission to Care Website HRET HIIN Website

SSI Change Package SSI Top 10 Checklist SSI-Colon Prevention

Resource Guide SOAP UP ResourcesWatch Past Webinars HRET HIIN Resource Library SSI Podcast Series Case Review Templates,

Guidelines and more…

Designed to reduce multiple forms of harm with simple, easy-to-accomplish activities that cut across several topics to decrease harm.

Focused on four components:

• SOAP UP: Hardwire Hand Hygiene• GET UP: Mobilize Patients• WAKE UP: Prevent Over-sedation• SCRIPT UP: Optimize Inpatient

Medications

UP Campaign: Spreading Cross Cutting Strategies

5

FHA Mission to Care Update: SSI Colon Rates

Source: HRET Comprehensive Data System, May 20, 2019

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 10/18 11/18 12/18 1/19 2/19 3/19

FL Rate 4.14 4.40 3.30 4.99 3.93 4.00 3.15 2.64 2.90 2.84 3.66 3.70 3.55 3.31 2.34 4.03 3.21 3.78 4.20 3.17 3.42 3.74 3.03 4.59 4.49 3.85 3.03 3.77 3.61 2.71 2.10

HRET HIIN Rate 4.54 4.31 4.35 4.65 4.35 3.97 4.05 3.89 4.22 4.07 4.03 4.39 4.37 4.06 3.89 4.26 4.10 4.46 4.24 4.15 4.31 4.24 4.29 4.52 4.74 4.11 3.96 3.56 4.15 3.59 2.50

# FL Reporting 83 82 82 81 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 79 80 79 73 73 70

#HRET HIIN Reporting 1,086 1,094 1,093 1,091 1,096 1,091 1,087 1,091 1,092 1,090 1,086 1,086 1,090 1,086 1,086 1,083 1,084 1,082 1,084 1,079 1,075 1,077 1,073 1,070 1,072 1,061 1,050 1,049 947 884 718

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

5.50

Rate

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100

FHA Mission to Care Update: SSI Hysterectomy Rates

Source: HRET Comprehensive Data System, May 20, 2019

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 10/18 11/18 12/18 1/19 2/19 3/19

FL Rate 1.36 1.27 1.92 0.60 0.72 0.91 0.76 0.84 1.18 1.38 1.46 1.03 1.11 1.07 0.94 0.99 0.44 0.68 1.20 1.00 1.26 0.57 1.23 1.85 0.67 1.50 1.15 1.01 1.30 1.29 0.78

HRET HIIN Rate 1.44 1.24 1.42 1.00 1.16 1.31 1.28 1.28 1.38 1.32 1.29 1.26 1.38 1.12 1.28 1.14 1.20 1.02 1.32 1.36 1.26 1.22 1.31 1.39 1.25 1.37 1.13 1.10 1.43 1.08 0.81

# FL Reporting 82 81 80 81 79 79 79 79 79 79 79 79 79 79 79 78 79 79 79 79 79 78 78 79 79 78 79 79 73 73 67

#HRET HIIN Reporting 1,046 1,054 1,053 1,058 1,054 1,052 1,054 1,048 1,051 1,051 1,048 1,044 1,044 1,043 1,041 1,039 1,043 1,036 1,037 1,032 1,028 1,029 1,026 1,026 1,028 1,020 1,008 1,005 897 846 675

0.00

0.25

0.50

0.75

1.00

1.25

1.50

1.75

2.00

2.25

Rate

per

100

FHA Mission to Care Update: SSI Knee Rates

Source: HRET Comprehensive Data System, May 20, 2019

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 10/18 11/18 12/18 1/19 2/19 3/19

FL Rate 0.75 0.87 0.56 0.67 0.50 0.72 0.46 0.60 0.49 0.47 0.76 0.41 0.38 0.59 0.89 0.31 0.45 0.50 0.57 0.69 0.72 0.24 0.55 0.39 0.55 0.78 0.68 0.33 0.68 0.33 0.67

HRET HIIN Rate 0.69 0.59 0.61 0.76 0.48 0.56 0.74 0.63 0.83 0.67 0.83 0.66 0.87 1.16 1.03 0.46 0.58 0.52 0.67 0.78 0.75 0.62 0.63 0.63 0.66 0.75 0.63 0.47 0.51 0.37 0.38

# FL Reporting 68 65 66 65 64 64 64 63 61 60 60 61 62 61 61 61 61 60 58 61 61 61 60 55 55 51 53 53 46 46 38

#HRET HIIN Reporting 806 818 815 818 852 848 852 854 850 848 846 842 847 846 846 847 852 851 851 853 843 847 838 829 828 822 805 812 712 642 531

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Rate

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100

FHA Mission to Care Update: SSI Hip Rates

Source: HRET Comprehensive Data System, May 20, 2019

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18 8/18 9/18 10/18 11/18 12/18 1/19 2/19 3/19

FL Rate 1.42 0.90 1.17 0.80 1.18 0.90 1.16 0.42 1.07 1.16 1.36 0.99 0.89 0.96 1.00 1.03 1.14 0.63 1.02 1.33 1.32 0.81 0.41 0.85 0.80 1.21 0.89 0.74 0.40 0.96 0.51

HRET HIIN Rate 1.23 0.96 1.21 1.04 1.13 1.20 1.16 1.11 1.19 1.03 1.30 1.06 1.39 1.32 0.98 1.18 1.25 1.13 1.13 1.23 1.13 1.36 1.06 0.98 1.15 0.98 0.98 0.98 1.01 0.84 0.61

# FL Reporting 67 64 65 65 64 64 64 63 61 60 60 61 61 61 61 61 61 60 59 61 61 61 61 55 55 52 53 53 46 46 38

#HRET HIIN Reporting 786 800 798 797 834 836 832 834 832 830 827 820 822 827 828 829 839 842 837 841 833 834 828 818 818 816 795 799 697 632 522

0.00

0.25

0.50

0.75

1.00

1.25

1.50

Rate

per

100

Infection Prevention and NHSN Virtual Series

*Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website

Date Topic Register Online

Oct. 23, 2018 NHSN: SSI Surveillance Identification and Analysis

Event archive*

Nov. 20, 2018 SSI-Colon: How to Assess Root Cause and Prevention Strategies

Event archive*

Dec. 18, 2018 NHSN: VAE Surveillance Identification and Analysis

Event archive*

Jan. 22, 2019 VAE: How to Assess Root Cause and Prevention Strategies

Event archive*

Feb. 19, 2019 NHSN: MRSA Bacteremia Surveillance Identification and Analysis

Event archive*

Mar. 26, 2019 MRSA Bacteremia : How to Assess Root Cause and Prevention Strategies

Event archive*

Apr. 26, 2019 SIP Webinar Series #1: Pre-operative Strategies for Prevention of SSI

Event archive*

10

Surgical Infection Prevention;Taking a Deep Dive into Intra-operative

Recommendations

Linda R. Greene, RN, MPS,CIC, FAPICManager, Infection Prevention

UR Highland Hospital Rochester, NY

linda_greene@urmc.rochester.edu

Objectives

Identify specific risks during the intra-operative period

Discuss recent literature linked to risk reduction

Identify strategies to reduce risks

Polling Question1What is your background?

1. Infection Prevention

2. Quality or patient safety

3. Management

4. OR nurse

5. Other

Surgical RisksMost Common Complications during surgery:

Surgical site infection

Postoperative sepsis

Thromboembolic complications

Cardiovascular

Respiratory ( pneumonia)

The intra-operative periodProcedural variables that affect risk of SSI:

Antibiotic prophylaxis

Duration of Surgical scrub

Pre-op hair removal

Choice of pre-op skin preparation- need both fast acting and sustained effect

Wound class

VariablesSterilization of instrument and the environment

Foreign material in the surgical site

Surgical technique

Elevated Glucose- high Glucose levels with or without diabetes

Hypothermia – vasoconstriction limits blood flow and oxygen

https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/hospital-infection-control/surgical-site-infections/

Observations All surgical wounds are contaminated by bacteria

but only a few get infected

Different operations have different inoculums of bacteria

Similar operations performed by the same surgeon in different populations have different rates of infection

SSIs have varying degrees of severity

Bacteria get into wounds

Where are the Pathogens ?

Pathogen source for most SSIs is endogenous flora of the patient’s skin, mucous membranes or GI tract.

20% of the skin’s pathogens live beneath the epidermal layer in hair follicles and sebaceous glands.

Any incision can carry some of the bacteria directly to the operative site.

Leading SSI PathogensGram Positive Bacteria

MRSA

MSSA

Coag. Negative Staph

Enterococci

Streptococci Species

Gram Negative Bacteria

Enterobacter

Pseudomonas

Ecoli

Other Bacteria

Anaerobic Bacteria

Fungi

Etiology Exogenous sources:

Hands of care givers

Exposure to non sterile environment

Contamination of fluid, supplies or equipment

Air flow

Etiology Surgical Site Infections can be attributed to the patient’s own endogenous flora or from exogenous sources.

Example:

Patient’s skin

Contamination during surgery

Oropharyngeal contamination

Patient’s natural immunity

Risk Factors for SSIs

Host Factors

Host Factors

Surgical/ Environmental Factors

Microbial Flora

HostObesityAgeASACancer Immunosuppression

Microbial Nasal CarriageVirulence Inoculum

Surgical / EnvironmentalProcedureHair RemovalProphylaxisTechnique ContaminationUrgency

Reviewing what we know Most infections are seeded at the time of surgery

There are several procedural risk factors

Monitoring of Risk factors may help identify opportunities for opportunities

SSIsMajority of SSIs are seeded at the time of surgery while the wound is open examples:

Microorganisms Examples

Patients own skin flora Microorganismscolonizing skin or other body parts, infection present

Surgical Team Colonized member of team

Breaks in aseptic technique

Wound contact with unsterile environment

Sterility failures High bioburden.Contaminated instruments

Door openings Interruption of positive pressure

Other endogenous flora Bowel flora, etc.

Skin Scales

Antibiotics for penicillin allergy ?

Cephalosporin if no immediate hypersensitivity reactions

Bratzler DW et al. Am J Health Syst Pharm 2013Pichichero ME. et al. Ann Allergy Asthma Immunol 2014

Antibiotics for MRSA Patients with a hx or known methicillin-resistant

staphylococcus aureus ( MRSA) Single preoperative dose of vancomycin is

recommended plus Cephalosporin

Bratzler DW et al. Am J Health Syst Pharm 2013Schweizer M.et al. BMJ 2013

Revisit Hair Removal

AORN Edmiston et. al May 2019

AORN Guidelines 2019

GUIDELINE FOR STERILE TECHNIQUE

AORN Continued

Are there gaps between policy and practice?

Direct ObservationOne of out most powerful tools is direct observation:

Examples:

Patients surgical scrub were performed either by a PA or RN that were not sufficient.

Long sleeves on when prepping, but gown was flapping loose and touched prep area. Gowns worn while prepping should be tied to prevent inadvertently grazing the prepped area

Insufficient number of prep sticks used to cover operative area. Found provider prepping patient did not perform in sterile fashion. Prep stick touched non sterile areas and was brought back to “sterile” area.

Observations Continued Clipping of surgical site was done on OR

table. Hairs were pushed on floor and some left on the sheet or on patient’s limb.

Gloves should be changed after patient has been draped, again prior to touching the implant, and every 60 to 90 min. throughout case.

Turnover started when patient was still in the room.

Anesthesia was noted to have removed his mask and peering over the operative drape.

Polling Question 2Do you routinely perform audits and direct observation of cases periodically?

1. Yes

2. No

Challenges

- Time - Turnover

-Surgeon preference-Adherence factors

TopicsCore :

Antibiotic Prophylaxis

Glycemic control

Normothermia

Tissue oxygenation

Skin Preparation

Arthroplasty

Transfusion

Immunosuppresive therapy

Anticoagulation

Orthopedic space suit

Antimicrobial prophylaxis withdrains

Biofilm

Recommendations

Evidence Based Practices Compendium of Strategies -2014WHO -2016

Compendium of Strategies 2014

2 levels of recommendations

Basic – Recommended for all hospitals

Special – Consider if there is still a problem based on surveillance data or risk assessment

Basic Practices Maintain intra-operative temp > 35.5

Use an alcohol containing skin prep unless contraindicated

Use a surgical safety checklist Maintain post-operative blood glucose ≤ 180 mg/dL.

Cardiothoracic surgical procedures (High ) Non-cardiac procedures ( Moderate)

Use impervious wound protectors in GI and biliary procedures

Dronge Arch Surg 2006; Golden Diabetes care 1999; Olsen MA J BoneJoint Surg Am 2008

Surgical Technique

May have to look beyond the bundle

Sterile fluids

Soaking

Wound closure technique

Intra-operative management

Complex Practice Setting

Quality Initiative: Traffic

46

Quality Initiative: Traffic

Ritter, et al., 1975 # of CFUs cultured from a clean operating room Empty – 13

Doors Open – 25

5 or more people in the room at any given time – 447

47

46 Consecutive cardiac surgeries, electronic door monitors Mean frequency of Door opening was 92.9 per case Doors were open for a mean frequency of 10.7% of

each hour Average time of door closure was 20 seconds Trend toward increased rates of door opening among

patients who developed SSIs

48

49

50

30 consecutive orthopedic procedures Interval sampling of airborne micro-organisms in the

operating room Samples collected from the area around the wound in

sterile fashion Measured traffic flow and reasons for entry

throughout cases Strong positive correlation between Rate of traffic flow and CFU/m3 (r = 0.74, p < 0.001) Number of people in the operating room (r = 0.24, p =

0.04)

51

- Doors open average of 9.5 minutes per case

- Loss of positive pressure

- 77 of 191 cases had doors open long enough to defeat positive pressure

• Enhancing air quality by reducing airborne contamination has been shown to be of great importance, especially in relation to implant surgery.,

• Suggested levels be maintained at <10 CFU/m during implant surgery, and that clinical benefits can be expected by reducing it to 1 CFU/m

• Very low levels of clinically relevant coagulase-negative staphylococci can initiate a device-related infection

Quality Initiative: Traffic Audit Sheet Developed and Observer Identified

First Traffic Audit Has Been Performed Total Duration (Wheels in to Wheels out) 6:21

Total Number of Door openings (i.e. closed behind) 155!!

Mean # people in room at any given time 10.5

Event Total Count Door # # of times opened Reason

Room Entry 8 A 51 Wash, pass through

Induction 8 B 65 Equipment

Skin Prep 11 C 18 Pass through

Incision 10 D 16 Anes- (blood sample)

Start of Closure 8 Total count

155

d l d l f

Traffic ControlTracers in OR

Primary Hip observed- 27 different entries into OR room

Hysterectomy Davinci - 31 entries

Strategies

OR Environmenthttps://www.arthroplastyjournal.org/prosthetic-joint-infection

Temperature in OR

Joint replacement Consensus:

Based on the available evidence, it appears that OR temperature is an important environmental factor that needs to be optimally controlled during surgical procedures.

There is an indirect link between the OR temperatures and the potential for subsequent SSIs/ periprosthetic joint infections

OR HVACDo Departmental staff understand what the air handling and ventilation Requirements are for their area?

Is there a recent report that verifies that the pressure gradients are correctand is the report annotated if corrections were needed?

When surveyors ask OR management about air exchanges, temp and humiditthey will not be impressed with the answer “engineering handles that”

Polling Question 3Do you have policies that guide actions for HVAC disturbances during a case?

1. Yes

2. No

Airborne MicroorganismsIs there a relationship between levels of airborne microorganisms in the operating room and the risk of peri- prosthetic joint infections (PJIs)?

Recommendation:

Yes. High-quality evidence indicates that there is a proportional relationship between intra-operative levels of airborne microorganisms (colony-forming units or CFUs) and the incidence of PJIs.

https://www.arthroplastyjournal.org/prosthetic-joint-infection

Airborne Contamination

Four of these 5 level of evidence I studies demonstrate statistically significant correlations between levels of airborne CFUs (measured either by active air sampling at or near the incision site or by wound washout) and the incidences of PJIs

https://www.arthroplastyjournal.org/prosthetic-joint-infection

Neurosurgery Reduction Project

Identified implants and instrumentation as risk factors

Looked at door openings,

especially at implant

Reviewed instrumentation and

kerrison cleaning

Purchased new kerrisons

Vendor policies

.Measure: Observed infections/predicted infections (Standardized Infection Ratio). Data

Source:CDC/NHSN.

Analysis

FY18 SIR : 4.103 8 infections Statistically High (p value 0.0011)

FY19 YTD SIR: 1.287 3 infections 63% infection reduction

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

FY18 FY19

SIR

Internal Goal

Linear (SIR)

Fusion Standard Infection Ratio (SIR)FYTD Deep/Organ Space Comparisons Fusion SSI

Project Updates New cleanable Kerrisons

– intra-op

Antibiotic prophylaxis update-

Ongoing Projects:

Glucose control and Hemoglobin A 1C protocol

Instrumentation Dancer S J, Stewart M, Coulombe C, Gregori A, and Virdi M.: Surgical site infections linked to contaminated surgical instruments. J Hosp Infect. 2012; 81(4): 231–238

• Sudden increase in surgical site infection rate following 'clean' surgery. • 15 orthopedic patients following metal insertion • 5 ophthalmology patients who developed endophthalmitis

Findings:• Lapses in sterilization• Lack of pre - cleaning by OR staff

Conclusions:• Collaboration• Cooperation• Standardization

Instrumentation

Preparation for decontamination of instruments should begin at the point of use

During the procedure, the scrub person should remove gross soil from instruments by wiping the surfaces with a sterile surgical sponge moistened with sterile water

Every case, Every patient, Every time?

Selected Elements of Surgical Care Bundle from Literature

https://www.dhs.wisconsin.gov/hai/ssi-prevention.htm

Example – Action Plan

Conclusion

The intra-operative period can be complex with several opportunities for improvement

Standardizing practice, audits and implementation of evidence based practices are important foundational elements.

Questions ?

Upcoming Virtual Events

Check the weekly MTC HIIN Upcoming Events for details and registration

In-Person Meeting:May 30-31 | Orlando, FL – Infection Prevention Boot CampJun. 5 | Orlando, FL – Preventing Post-Surgical HarmVirtual Events:FHA HIIN Surgical Infection Prevention (SIP) Webinar Series:• Apr. 26, 2019 - #1: Pre-operative Strategies for Prevention of SSI (Recordings | Slides

• May 22, 2019 - #2: Intra-operative Strategies for Prevention of SSI (Event archive will be available)

• Jun. 25, 2019 - #3: Post-operative Strategies for Prevention of SSI

FHA Monthly Quality Hot Topics• Jun. 4, 2019 [NEW DATE] - Hot Topics Virtual Meeting #8: Post-Legislative Session Review of

Bills Impacting Clinical Care and Quality Reporting

• Eligibility for Nursing CEU requires submission of an evaluation survey for each participant requesting continuing education:https://www.surveymonkey.com/r/SIP-05-22-19

• Share this link with all of your participants if viewing today’s webinar as a group (Survey closes after June 2, 2019)

• Be sure to include your contact information and Florida nursing license number

• FHA will report 1.0 credit hour to CE Broker and a certificate will be sent via e-mail (Please allow at least 2 weeks after the survey closes)

Evaluation Survey & Continuing Nursing Education

Cheryl D. Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRMDirector, Quality and Patient SafetyFlorida Hospital Associationcheryll@fha.org | 407-841-6230

Linda R. Greene, RN, MPS, CIC, FAPICManager, Infection PreventionUR Highland Hospital, Rochester, NYlinda_greene@urmc.rochester.edu

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