Junya Jarayopas

Department Manager, Infection Control

Surgical Site Infection Prevention

ทําไม SSI ถึงสําคัญมากในวันน้ี

สถานการณการติดเช้ือที่เปลี่ยนไป

การฟองรองมากข้ึน

ระบบประกันสุขภาพ และ

การรับรองคุณภาพ

โรงพยาบาล

is an infection acquired during hospital care which was not present or incubating at the time of admission, also known as a “Nosocomial” infection

HAIs prevalence may be 25% in ICUsInt Care Med 2004;30:395

BIH HAIs prevalence 36.8 % ( 74/201) in ICUs

• 5% of admissions or• 5/1000 hospital daysIncidence

• Increased LOS, increased antibiotic days, etc.

Morbidity

• ~90,000 deaths annuallyMortality

Cost (Total ) > $ 4.5 billion annually

• 1.7/1000 hospital daysIncidence

• Increased LOS, increased antibiotic days, etc.

Morbidity

• 9 cases / AnnuallyMortality

17,784,201 Bath/Y2011Cost

(ATB only)

MMWR.2000:49(08):140-153

เชื้อกอโรค กบั ผูรับเชือ้

เชื้อกอโรค : ติดหรือไมติด

ตองประเมนิ 3 อยาง

จํานวนเชื้อตองมาก (DOSE)

ความรนุแรงของเชือ้มากพอ

(Virulence of pathogen)

เขาชองทางที่ถูกตอง

(Access to mode of entry)

การติดเช้ือ INFECTION

3.5 billion years: microbes on planet earth

- 0.5 billion years: mammals on planet earth

_____3.0 billion years evolutionary head start

. . . Implications

by Dr Maryanne Demasi

“ I knew I’d be challenged at my next dinner party when someone would ask, “So Maryanne, what story are you

working on at the moment?”.

(Reuters) Scientists fight bugs with poo

"POO IS THE ONLY ANSWER"

Method - NG

- Enema- Colonoscope

Hand Hygiene

ENV Cleaning

Contact Isolation

• “ What I hate about what the hospitals I have come in

contact with are doing.....These are long term pts, They get

a + VRE culture and then isolate them, then get 3

negatives and take them off of isolation, then reculture

them a week or 2 later and we find out that they are again

+ for VRE!! Meanwhile, we have been taking care of the pts

and they haven't been on iso and they have been

transported out of their rooms, all over the hospital for

tests, etc..... Just frustrating.”

Allnurses.com/Isolation VRE

•IPD : Private room with Contact isolation: Personal Protective Equipment (PPE)

- Gown & Glove- Prior to entering the patient environment- Removed before exiting the patient

environment• OPD: Do not segregate in waiting rooms

: Place patients into an examination room without delay

•Strict Hand Hygiene

P4P : Reduced CMS reimbursement

การติดเชื้อทางเดินปสสาวะ (Catheter-associated UTI)

การตดิเชือ้ทางหลอดเลือดดาํ (Central line blood stream infection (CR-BSI)

การติดเชื้อบาดแผลผาตดั (Surgical site infection)

- Mediastinitis after CABG surgery

- Spinal fusion and other surgeries of

the shoulder and elbow

- Bariatric surgery for morbid obesity

- laparoscopic gastric bypass andgastroenterostomy

Guideline to practice According to the CDC, Surgical Site infections

are the most common adverse event for surgical patients.

CDC’s National Nosocomial Infections Surveillance (NNIS) system

BI :Concern issue ( Jan- Jul) Total = 35 cases - Dept : Most from PSM /IMCO = 40% (14) - Topic : HAI = 65%(23)

: SSI = 65% (15) : Other = 35% (8)

:Patients who develop SSI’s are…… Twice as likely to die. 60% more likely to spend time in an ICU, five times more likely to be readmitted to the hospital.

– An estimated 40 - 60% of SSIs are preventable

Institute for Healthcare Improvement (IHI)

Endogenous flora of the patient

Operating theater environment

Hospital personnel (MDs/RNs/staff)

Seeding of the operative site from distant focus of infection (prosthetic device, implants)

Source of SSI Pathogens

Host Risk Factors

* Age,Obesity,Nutritional status

* Underlying disease e.g. diabetes

* Nasal carriage of S.aureus* Infection at another site

* Pre-op hospitalization > 5 days

* Steroids

Surgical Site Infection (SSI)

Risk Factors

Pathogenesis

Prevention

Surveillance

Microbe-related Risk Factors

* Number of bacteria

Implant > 103

No implant > 105

* Virulence of organism

* Ability to attach to wound

surfaces / prosthetic device

Prevention

* Pre-operative

*Intra-operative

*Post-operative

*Surveillance

Pre - operative

* Treat remote infections (IA)

* Shorten pre-op hospitalization (II)

* Eliminate nasal S.aureus

colonization (U)

* Avoid antimicrobials pre-op

ATB

Nasal decontamination eliminate S. aureus : reduce surgical site infection?

Guideline to practice : Obstacle

Nostril, main reservoir for S. aureus

S. aureus is the most common cause of SSI

2 RCTs (n = 4478)

Do not use nasal decontamination with topical antimicrobial agents

aimed at eliminating Staphylococcus aureus routinely to reduce the risk of surgical site infection.

Nasal decontamination eliminate S. aureus

BI :Physician order only

Pre ñOperation : Surgical site Prep

* Donít remove hair (IA)

* If hair remove :

- Just before surgery (1A)

- Use electric clipper (1A)

* Shower or bathe with antiseptic thenight before surgery (1B)

* ? Bathe x 2 with CHG

Hair Remove Before Surgery

Rate of SSI by Method and Timing of Hair Removal

13

8

20

0

5

10

15

20

25

No hairremove

Shave justbeforesurgery

Shave<24hbeforesurgery

Shave>24hbeforesurgery

# S

SI p

er 1

000 pr

oced

ures

Guideline to practice : Obstacle Pre operative hair removal : reduce surgical site infection?

SSIShaved 2.8% (46/1627)Clipped 1.3% (21/1566)Sig. (RR 2.02, 95% CI 1.21 to 3.36)

3 RCTs (n=3193)

SSI

Depilatory cream also better than shaved(7 trials, n= 1231)

Hair Removal

The CDC Recommends:

“ Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation”.

Category IA

“If hair is removed, remove immediately before the operation, preferably with clippers”. Category IA

Guideline to practice : Obstacle

Pre operative showering : reduce surgical site infection?

Guideline to practice : Obstacle

Systematic review ( 6 RCTs, n = 10,007) 2007

5 RCTs (n =8445)

Advise patients to shower or have a bath using soap, either the day before, or on the day of, surgery.

Pre operative showering

BI :Shower bath with soap or CHG solution : Focus only designate areaPhysician order

* Remove contamination before

antiseptic skin prep (1B)

* Use antiseptic (1B) (see table)

* Apply prep in concentric circles

extend to periphery (II)

Pre ñOperation : Surgical site Prep

Characteristics of Antiseptic Agents

Agent Gm+ Gm- Speed ResidualAlcohol E E Most None

rapid

CHG E G Inter- E

mediate

lodophor E G Inter- Minimal

mediate

Alcohol/ E G Rapid Varies

lodophor

E = excellent G = good

Skin Preparation: reduce surgical site infection?

Guideline to practice :Obstacle

Most Common Antiseptic Agents

Alcohol

Chlorhexidine Gluconate (CHG)

Povidone Iodine (PI)

Recommendations AORN & CDC Guidelines

You cannot render the skin sterile

You can reduce the risk of postoperative SSI– By removing transient micro-organisms.– By significantly reducing the resident microbial count quickly and

slowing rapid re growth of micro-organisms on the skin.

Skin Preparation

BI :Concern : Skin flora PathogenBetadine solution

Hibitene in water 1 : 100

Hibitene in alc 1: 100

Future : Chlora prep

* Nails sort ; no artificial nails (1B)

* 2-5 minute scrub with antiseptic (1B)

* >20 sec scrub alcohol hand rub

* Clean underneath fingernails before first scrub (II)

* No jewelry (II)*No scrub with brush (IA)

Surgical Hand Hygiene

Surgical Hand Hygiene

* No scrub with brush (1A)

* Shorter scrub duration

* Waterless hand antiseptic acceptable

alternative to antiseptic detergent (1A)

* Hand moisturizers (1A)

Surgical Hand Preparation: reduce surgical site infection?

Guideline to practice :Obstacle

Surgical hand rubbing with 75% aqueous alcohol solution

Surgical hand scrubbing with 4% povido-iodine or 4% chlorhexidine

ลางอยางไร

ลางดวยอะไร

New 2009 AORN Recommended Practices for Hand Hygiene in the Perioperative Setting

surgical hand scrub using

– water-aided brushless surgical antiseptics;

– waterless, brushless surgical antiseptics; or

– traditional surgical hand scrub using a sponge.4,5

AORN is strongly recommending elimination of scrub brushes in the OR.

AORN does not recommend a pre-scrub.

AORN do recommend a prewash if hands are visibly soiled with plain soap and water or antimicrobial soap agent.

Use agents that have been found to have greatest residual activity : FDA approve

For first scrub of the day - clean under nailsit is not clear that such cleaning is necessary for subsequent scrubs

CDC GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

BI :Brush & Brushless surgical hand scrub CHG + Pevidine , Alcohol waterless hand rub

* Give AP Only when indicated by publishedrecommendations (1A)

* Antibiotic timing :

* Optimal tissue level time of incision (1A)

* Give within 1 hr before incision

* administer during induction

* For C-section-immediately after umbilical cord clamped

Survey : 30-70% improper timing in USA

Pre- op :Antibiotic Prophylaxis

Timing of Prophylactic Antibiotics and Rate of SSI

3.8

0.6

1.5

3.3

0

0.5

1

1.5

2

2.5

3

3.5

4

Early Preop Periop Postop

# S

SI p

er 1

000 pr

oced

ures

Intra- operative

* Operative technique

- Homeostasis,Dead space,Tissue trauma

* Wound classification

- Clean,Clean contam.,Contaminated,Dirty

* Duration of procedure

* Hair removal technique

* Antibiotic prophylaxis

Intra- operativeElements of SSI Risk

Increase risk

Bacterial concentration in wound

* Virulence * Resistance

Tissue injury

Foreign material

Decrease risk

Host immunity

* general * localPerioperative antibiotics

ïSterile gloves (1B) - Double gloving & routine outer glove changes

- Lengthy cases or excessive manipulation

* Sterile gown - Resist liquid (1B)

* Cap or hood to fully cover hair (1B)

* Masks if sterile supplies open (1B)

* Eye protection

Intra- operative

* No proven benefit to cover gowns

* Scrubs suits do not prevent infections in patients

* Scrub suits are comfortable and easy to change

* May be important for professional

recognition,but not to prevent infection

Cover Gowns and Scrub Suits

* Protect staff from blood exposure

* Filters infectious aerosols from

staff to patient

- Not proven,No talking has same effect

Mask

* No proven benefit to patient

* Do not lower SSI rate

* Only rationale is to protect staff

* If soiled,remove in room

Shoe Covers

Drapes* Use drapes that are a barrier to

organisms and fluids (1B)- Lifting of drape increases infection rate

- Alcohol followed by antimicrobial

impregnated films may be more

effective than longer skin preps

Intra- operative

Guideline to practice :Obstacle

Incise drapesDisposable Gown

BI :Concern : Skin flora Pathogen

Incise drapes : only orthopedic

Disposable Gown : only HIV+

VentilationMinimize airborne contamination :* Ventilation - > 15 air exchanges per

hour,filtered,positive pressure (1B)

* Door closed (1B)

* Limit traffic (II)

* Proper attire

Intra- operative

What News ? SSI Bundle

* ทาํไดยาก : Post discharge

* ไมทํา : ไมรูขนาดของปญหา

: ไมสามารถใชขอมลูในการสรางความตระหนัก(แพทย)

หรือทําใหเห็นความสําคัญ (ผูบริหาร)

Surveillance

“If You Can’t Measure It , You Can't Manage It”

SSI Data Analysis

BI :Give Antibiotic prophylaxis in 30 min and not more than 2 hrs. before surgery

Focus group

Process ? Physician order , Drug delivery system.

Procedure ? Meningitis po Craniotomy.

Persons ? By Team or Person

Benchmarking

Organization

National

International

SSI กับ Change 3

Change knowledge

Change Attitude

Change practice