preventing surgical site infections in the or kerri a. thom, md, ms assistant professor, um school...
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Preventing Surgical Site Infections in the OR
Kerri A. Thom, MD, MSAssistant Professor, UM School of Medicine
Key Point
•Up to 60% of surgical site infections may be preventable and there are multiple strategies aims at reducing infection
Key Points – SSI Prevention
•Up to 60% of SSI are preventable •Antibiotic prophylaxis is very important •Be aware of your own bioburden•Be aware of impact of traffic/door openings
Key Points
•Surgical antimicrobial prophylaxis is the most important intervention in the prevention of SSI
•Essential elements include: ▫Selection of appropriate agent▫Timing (within 1 hour of incision) ▫Dose (weight-based, re-dosing) ▫Minimizing adverse events
•Recognize modifiable risk factors for surgical site infection
•Provide safe care by applying key measures to preventing infections in the OR
•Optimize antibiotic prophylaxis by selecting the most appropriate agent and giving the optimal dose at the optimal time
Objectives
•Background ▫Modifiable risks for SSI
•Antibiotic Prophylaxis, What Matters ▫Agent, dose, time
•Other important measures▫Optimizing modifiable risk factors▫Use of the surgical checklist ▫Hand hygiene▫Limiting traffic and door openings
Overview
Surgical Site Infections (SSI)
•Most Common Healthcare infection1
▫21% of all HAIs
HAP14%
CLABSI
14%
20%, SSI
22%, Other
36%, UTI
11%, BSI
11%, PNA
Magill S et al. N Engl J Med, 2014
Surgical Site Infections (SSI)
•Most Common Healthcare infection1
▫21% of all HAIs
HAP14%
CLABSI
14%
20%, SSI
22%, Other
36%, UTI
11%, BSI
11%, PNA
Magill S et al. N Engl J Med, 2014
15 million inpatient surgeries per year
Surgical Site Infections (SSI)
•Most Common Healthcare infection1
▫21% of all HAIs
HAP14%
CLABSI
14%
20%, SSI
22%, Other
36%, UTI
11%, BSI
11%, PNA
Magill S et al. N Engl J Med, 2014
15 million inpatient surgeries per year
2-5% (300-500K) develop SSI
Surgical Site Infections (SSI)
•Most Common Healthcare infection1
▫21% of all HAIs
HAP14%
CLABSI
14%
20%, SSI
22%, Other
36%, UTI
11%, BSI
11%, PNA
Up to 55% of SSIs are
preventable!
Up to 55% of SSIs are
preventable!
1Magill S et al. N Engl J Med, 20142Umscheid et al. Infect Control Hosp Epidemiol, 2011
Surgical Site Infections (SSI)
•Prolong hospital stay (7-10 days)• Increased Mortality
▫Risk of death, 2-11 times greater ▫77% of deaths are attributable to SSI
•More expensive than other complications (e.g., sternal wound infections most expensive complication of CABG)
Kirckland et al, Infect Control Hosp Epi, 1999Managram et al, Infect Control Hosp Epi, 1999
Hollenbeak et al, Chest, 2000Wenzel et al, Clin Infect Dis, 2007
SSI
Microbial Characteristics
Surgical Characteristics
Host Characteristics
e.g. Virulence, Dose
e.g. Host Defense, Immunity
e.g. Duration, Implant
Anderson. Infect Dis Clinics North Am 2011
Pathogenesis
SSI
Microbial Characteristics
Surgical Characteristics
Host Characteristics
e.g. Virulence, Dose
e.g. Host Defense, Immunity
e.g. Duration, Implant
Anderson. Infect Dis Clinics North Am 2011
Pathogenesis
Sources of Microbial Contamination
Endogenous Exogenous
• Most Common• Gram-positive (Skin Flora)
• Air, Instruments, etc…• Post-operative Dressing
Staphylococcus aureus 30.0%Coag-negative Staphylococci 13.7%Enterococcus spp. 11.2%Escherichia coli 9.6%Pseudomonas aeruginosa 5.6%
Rest: Other gram negative bacteria, Candida
Hidron, Infect Control Hosp Epidemiol 2008
Organisms Causing SSI
SSI
Glucose ControlWound Care
Wound ClassProphylactic AntibioticsPre-op CleansingPre-op ScreeningPre-op Hair RemovalSurgical Technique Surgical DurationOR environmentHypothermia
Post-Op
Surgical
Age UndernutritionInfection at Remote SiteProlonged Pre-op StayPrior OperationsImmunesuppressionCancerDiabetesObesitySmoking
Patient
Use for surgeries that require: entering a hollow viscus, insertion of prosthesis,
or if development of SSI would pose catastrophic risk
Prophylactic Antibiotics
One of the most important interventions to prevent
SSI
The Ideal Agent?
The Ideal Agent?
Effective
Safe
No impact on Microbiome
•Activity against expected pathogens•Favorable safety profile (toxicities, allergies) •Favorable cost profile
Antibiotic Selection
•Weight-based•Cefazolin 2 gm for all
•RCT of 1 versus 2 gm▫1 gm decreased serum/tissue concentrations,
below necessary MICs
Dose
Forse, Surg, 1989
Successful prophylaxis relies on drug availabilityat the operative site during time of contamination
Begin administration within 1 hour of cut time• 2 hr for Vanc/FQ
Complete administration by incisionRe-dose at 3 hour intervals (and/or blood loss)Stop antibiotics after procedure
Timing
SSI rates corresponding to the temporal association between
administration of antibiotics and the start of surgery
Timing
Classen NEJM, 1992
Timing
Steinberg JP, Ann Surg, 2009
Association between the timing of prophylaxis and incidence of SSI following Cardiac Surgery, THA/TKA, Hysterectomy
Successful prophylaxis relies on drug availabilityat the operative site during time of contamination
Begin administration within 1 hour of cut time• 2 hr for Vanc/FQ
Complete administration by incisionRe-dose at 3 hour intervals (and/or blood loss)Stop antibiotics after procedure
Timing
•SCIP (Surgical Care Improvement Project)▫Appropriate selection ▫Within 1 hour ▫Stopped within 24 hours
•CMS Reporting▫SSI after CABG, THA, TKA▫Soon…SSI after Colorectal and Hysterectomy
National QI Initiatives
Other Infection Prevention Measures
Use an OR Checklist (based on WHO Surgical Checklist)
Surgical Checklist
Results of Starting Checklist
Variable % Decrease p value•Total disruptions/case 47 <0.01•Miscommunications/case 53 0.03•Time circulator gone 56 0.01
Henrickson. J Amer Coll Surgeons 2009; 208: 1115-23
Does the Checklist Impact Mortality?
•22 item checklist modeled on WHO•25,513 patients followed•Record of checklist completion:
• Not done• Partial - at least 1 of 22 done• Completed - all done
van Klei. Ann Surg 2012; 255: 44-9
Checklist Completion and Mortality
Adjusted Odds RatioMortality
All patients 0.85 (0.73-0.98)
van Klei. Ann Surg 2012; 255: 44-9
Checklist Completion and Mortality
Adjusted Odds RatioMortality
All patients 0.85 (0.73-0.98)
Completed 0.44 (0.28-0.70)
Partial 1.09 (0.78-1.52)
Not done 1.16 (0.86-1.56
van Klei. Ann Surg 2012; 255: 44-9
Reducing our own bioburden
•Hand hygiene (and/or surgical scrub) •Appropriate attire
▫Including covering hair •Monitor for skin lesions
Hand Hygiene
• In/Out of Room
•Multiple opportunities during case
Managing Air Flow
Microbial Air Counts and OR Traffic
•68% of the variance in total CFU/m3 (p = 0.001) explained by▫Traffic flow (door openings)▫Number of persons (clutter) in the OR▫Procedure duration
AE Andersson et al. AJIC 2012, Jan 28 epublished
Door Openings
•284 operations•22 pts had SSI:
▫Mastectomy (n = 5; 2.8%)▫Colon resection (n = 16; 21.6%)▫Aorta reconstruction (n = 1; 2.8%)
•Risk factors for SSI:▫Wound class: p < 0.001▫Emergency procedure: p = 0.001▫Door openings/hour 0-6 vs > 6: p = 0.02
FJ Prakken, et al. NED TIJDSCHR GENEESKD. 2011;155:A3269
Reasons for Door Openings•177 (33.5%) = necessary
▫40 = expert consultations▫137 = supplies & equipment
•184 (35.7%) = semi-necessary ▫76 = surgical team members entering or leaving▫134 = breaks
•168 (31.8%) = unnecessary▫30 = logistics, like planning other operations▫45 = social▫93 = no detectable reason
AE Andersson et al. AJIC 2012, Jan 28 epublished
Door Openings
•Number of door openings varied by specialty▫ 19-50 door openings/hour
•OR doors open: ▫~20 seconds/opening▫15-20 min/hour
•Requests for information > breaks (~25%) > supplies (~20%)
RJ Lynch, et al. Am J Med Qual 2009;24;45-52
Strategies to Reduce Door Opening
Key Point
•Up to 60% of surgical site infections may be preventable and there are multiple strategies aims at reducing infection
Key Points – SSI Prevention
•Up to 60% of SSI are preventable •Antibiotic prophylaxis is very important •Be aware of your own bioburden•Be aware of impact of traffic/door openings
Key Points
•Surgical antimicrobial prophylaxis is the most important intervention in the prevention of SSI
•Essential elements include: ▫Selection of appropriate agent▫Timing (within 1 hour of incision) ▫Dose (weight-based, re-dosing) ▫Minimizing adverse events
ANY QUESTIONS?
WASH YOUR HANDS!