International Forum on International Forum on

Qulaity and Safety in Health Qulaity and Safety in Health

CareCare

Prevention of Surgical Site

InfectionLiau Kui Hin, FRCS

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Mission Statement

To reduce surgical site infections for gastrointestinal and hernia

operations in Department of Surgery by 50% over the period of 6 months.

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Rationale For Preventing SSI

2nd most common type of adverse events occurring in hospitalized patients

increase :

- mortality

- readmission rate

- length of stay

- cost for patients40 to 60 % of clean and clean-contaminated

wound infections are preventable

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TYPE DEFINITION OF SURGICAL SITE INFECTION

SuperficialIncisional SSI

Infection occurs within 30 days after the operationandInfection involves only skin or subcutaneous tissue of incisionand at least one of the following:1. Purulent drainage, with or without laboratory confirmation, from the superficial incision.2. Organisms isolated from an aseptically obtained culture or fluid or tissue from the superficial incision.3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness,

or heat and superficial incision is deliberately opened by surgeon, unless incision is culture-negative.4. Diagnosis of superficial incisional SSI by the surgeon or attending physician

DeepIncisional SSI

Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation

andInfection involves deep soft tissues (e.g. fascial and muscle layers) of the incisionand at least one of the following:1. Purulent drainage from the deep incision but not from the organ / space component of the surgical site.2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at

least one of the following signs or symptoms: fever (>38oC), localized pain, or tenderness unless site is culture-negative.

3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination.

4. Diagnosis of a deep incisional SSI by a surgeon or attending physician.

Organ / Space SSI

Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation

andInfection involves any part of the anatomy (e.g. organs or spaces), other than the incision, which was

opened or manipulated during an operation and at least one of the following:1. Purulent drainage from a drain that is placed through a stab wound into the organ / space.2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ / space.3. An abscess or other evidence of infection involving the organ / space that is found on direct examination,

during reoperation, or by histopathologic or radiologic examination.4. Diagnosis of an organ / space SSI by a surgeon or attending physician.

Environment Staff Equipment

Patients Procedure

Infection

– OT-traffic/attire/A/C – Post-op: recannulation – HDU – Pre-op: when, where, showers

– Skill mix – nurse – Physiotherapy – Other patients – Aseptic technique – Cross infection – Attire – JMO education

– SCD machine – Drainage systems (closed or open)

– Selection – Expectations – Compliance – Confusion – Pressure ulcer– Nutritional status

– Blood loss – Drainage systems – Storage of equipment – Post-op haematoma – Dressings (time & type) – Epidural insertion– JMO involvement

Sterilization – Surgical technique – Operating time – R/O drains – Urinary catheter – Clipping – Temp Monitoring – Glucose Monitoring – Hair Removal – Prophylactic Antibiotics –

CAUSE & EFFECT DIAGRAM

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Pareto ChartCauses of Surgical Site infections

0%10%20%30%40%50%60%70%80%90%

100%P

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Glu

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Tem

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Ase

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OT

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Bundle of InterventionsPreoperative Hair Removal

• Remove all razors

• Work with the purchasing department

• Use reminders (signs, posters)

• Educate patients not to self-shave

Post Operative Glucose Maintainence

• Implement a glucose control protocol

• Regular blood glucose levels check

• Assign responsibility and accountability

Appropriate Prophylactic Antibiotics

• Use reminders (signs, posters)

• Change drug stocks to only standard drugs and dosage

• Reassign dosing responsibilities

• Involve pharmacy and infection

control staff

Post Operative Normothermia• Use warmed forced-air blankets and IV fluids

• Increase the ambient temperature in the operating room

• Use warming blankets under patients on the operating table

• Use hats and booties on patients perioperatively

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Flow Chart of ProcessPatient selected – labeled “SSI Protocol” in OT Reservation System

Surgical Site Infection Proforma Form - attached (pink)

OT Attendants – Hair Removal

Anesthetists – Antibiotics

PACU – Glucose & Temperature Monitoring

ICU/ HIGH D/ GENERAL WARD – Glucose Monitoring

Day Surgery Ward– Glucose Monitoring

Surgical Site Infection Proforma Form - Collected

HOME

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Run ChartSurgical Site Infection (SSI)

0

1

2

3

4

5

6

7

Nu

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of

SS

I

Start of CPIP

Discussion began

Target

Average

2005 2006

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Outcomes

WARD SUBSIDY PROVIDED COST SAVED

PrivateA 0% $0.00

B1 15% $335.90

SubsidizedB2 35-40% $373.40

C 80% $603.40

* Based on 10 days of hospitalization with surgical site infection

Clean Clean-contaminated

Pre-implementation 0.35% 1.90%

Post-implementation 0.00% 0.40%

Percentage Improvement

100.00% 78.95%

OVERALL = 82% (> target of 50%)

Clinical

Cost

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Lessons Learned

Standardization of workflow enhances the delivery of quality care and patient safety

Each individual’s contribution has significant impact on patient safety.

Quality initiatives are often welcomed when the outcome has significant impact on our patient safety.

Patient safety is not no accident & not by accident.

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SSI TeamSSI Team TAN TOCK SENG HOSPITAL TAN TOCK SENG HOSPITAL