Today s Webinar will begin at 11 00 PST

Today’s Webinar will begin at 11: 00 PST 4/12/12

Welcome from Barb De. Baun, RN, MSN, CIC

Introduction Please do not put your phone on hold; use the mute function or *6 Please type questions or comments into text box Interactive question session If time permits, we will open up the phone lines at the conclusion of the presentation

Introducing Sue Barnes, RN, BSN, CIC 4

Beyond SCIP – SSI Prevention Sue Barnes RN, BSN, CIC National Program Leader Infection Prevention & Control Kaiser Permanente 5

Objectives 1. Discuss strategies to optimize 4 specific SCIP measures, beyond regulatory compliance 2. Discuss 11 products and practices above and beyond SCIP – i. e. “plus” measures 3. Provide resources and references relative to “plus” measures 6

The Bare Minimum 7

SCIP Measures http: //intranet. uchicago. edu/quality/SCIP_files/page 0001. htm ü SCIP INF 1 Prophylactic antibiotic received within one hour prior to surgical incision ü SCIP INF 2 Prophylactic antibiotic selection for surgical patients ü SCIP INF 3 Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) ü SCIP INF 4 Cardiac surgery patients with controlled 6 a. m. post op serum glucose (200 mg/d. L) ü SCIP INF 6 Surgical patients with appropriate hair removal ü SCIP INF 7 Colorectal surgical patients with immediate postoperative normothermia ü SCIP INF 9 Urinary catheter removed on post op day 1 ü SCIP INF 10 Surgery patients with perioperative temperature management 8

Is SCIP compliance good enough? 9

3 grams Ancef for Bariatric Patients 1. Freeman JT, Anderson DJ, Hartwig MG, Sexton DJ. “Surgical site infections following bariatric surgery in community hospitals: a weighty concern? ” Obes Surg. 2011 Jul; 21(7): 836 -40. 2. Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston CE Jr. “Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery”. Obstet Gynecol. 2011 Apr; 117(4): 877 -82. 3. Roe JL, Fuentes JM, Mullins ME. “Under dosing of common antibiotics for obese patients in the ED”. Am J Emerg Med. 2011 Dec 12. [Epub ahead of print] 10

Are you missing anything with 100% compliant hair “clipping”? 11

SAFE Pre-op Hair Removal q Removal outside of OR or clipper with vacuum q Pre op patient teaching no leg shaving q Disposable clipper head or reprocess b/w patients 1. Adisa AO, Lawal OO, Adejuyigbe O. “Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection”. J Infect Dev Ctries. 2011 Oct 13; 5(10): 717 -22. 2. Broekman ML, van Beijnum J, Peul WC, Regli L. “Neurosurgery and shaving: what's the evidence? ” J Neurosurg. 2011 Oct; 115(4): 670 -8. Epub 2011 Jul 1. 3. Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N, Demartines N. “Measures to prevent surgical site infections: what surgeons (should) do”. World J Surg. 2011 Feb; 35(2): 280 -8. 12

Unless your patient looks like this, consider NOT clipping hair Mangram AJ et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250‐ 278; quiz 279‐ 280. 13

Missing Anything? Are only colon patients cold? Is hyperglycemia the only risk? 14

Normothermia 1. Esnaola NF, Cole DJ. “Perioperative normothermia during major surgery: is it important? ” Adv Surg. 2011; 45: 249 -63. 2. Hart SR, Bordes B, Hart J, Corsino D, Harmon D. “Unintended perioperative hypothermia”. Ochsner J. 2011 Fall; 11(3): 259 -70. 3. Moola S, Lockwood C. “Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment”. Int J Evid Based Healthc. 2011 Dec; 9(4): 337 -45. 15

Glucose Control = minimizing extremes 1. Chi A, Lissauer ME, Kirchoffner J, Scalea TM, Johnson SB. “Effect of glycemic state on hospital mortality in critically ill surgical patients”. Am Surg. 2011 Nov; 77(11): 1483 -9. 2. Martinez EA, Chavez-Valdez R, Holt NF, Grogan KL, Khalifeh KW, Slater T, Winner LE, Moyer J, Lehmann CU. “Successful implementation of a perioperative glycemic control protocol in cardiac surgery: barrier analysis and intervention using lean six sigma”. Anesthesiol Res Pract. 2011; 2011: 565069. Epub 2011 Sep 6. 3. Pichardo-Lowden A, Gabbay RA. “Management of Hyperglycemia During the Perioperative Period”. Curr Diab Rep. 2011 Nov 12. [Epub ahead of print] 4. Stawicki S, Schuster D, Liu J, Kamal J, Erdal S, Gerlach A, Whitmill M, Lindsey D, Murphy C, Steinberg S, Cook C. “The glucogram: A new quantitative tool for glycemic analysis in the surgical intensive care unit”. Int J Crit Illn Inj Sci. 2011 Jan; 1(1): 512. 16

“Plus” Measures for SSI Prevention 17

Attire - Surgical q Eliminate or cover cloth skull cap when in surgery q Double gloving q Change sterile gloves before closing q Permit ONLY scrubs laundered by hospital q Red caps for visitors 18

Attire - Surgical q Double Gloving: Phillips S. “The comparison of double gloving q q q to single gloving in theatre environment. ” J Perioper Pract. 2011 Jan; 21(1): 10 -5. Changing gloves: Epstein NE. “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections. ” Surg Neurol Int. 2011 Feb 21; 2: 17. Hair coverage : Frey K, Ross T. eds. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 3 rd ed. Clifton Park, NY: Delmar Cengage; 2008. Scrubs: Belkin NL. Home laundering of soiled surgical scrubs. American Journal of Infection Control. 2001; 29: 58 -64. 19

Blood – Minimizing Transfusions 20

Blood - Minimizing Transfusions Young H. Et al. “Statewide collaboration to evaluate the effects of blood loss and transfusion on surgical site infection after hysterectomy”. ICHE Jan 2012, Vol. 33, No 1 pp 90 -93. 2. Schwarzkopf R et al. “Effects of Perioperative Blood Product Use on Surgical Site Infection Following Thoracic and Lumbar Spinal Surgery”. Spine. 2010; 35(3): 340 -346. 3. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008; 466(7): 1710 -1715. 4. Talbot TR et al. “Perioperative Blood Transfusion Is Predictive of Poststernotomy Surgical Site Infection: Marker for Morbidity or True Immunosuppressant? ” Clinical Infectious Diseases 2004; 38: 1378– 82 1. 21

Drains, Drapes, Dressings 22

Drains, Drapes and Dressings 1. 2. 3. 4. DRESSING - Epstein NE. “Preoperative, intraoperative, and postoperative measures to further reduce spinal infections. ” Surg Neurol Int. 2011 Feb 21; 2: 17. DRESSING - Krieger BR, Davis DM, Sanchez JE, Mateka JJ, Nfonsam VN, Frattini JC, Marcet JE. “The use of silver nylon dressing in preventing surgical site infections following colon and rectal surgery”. Dis Colon Rectum. 2011 Aug; 54(8): 1014 -9. DRAINS - Rao SB, Vasquez G, Harrop J, Maltenfort M, Stein N, Kaliyadan G, Klibert F, Epstein R, Sharan A, Vaccaro A, Flomenberg P. “Risk factors for surgical site infections following spinal fusion procedures: a case-control study”. Clin Infect Dis. 2011 Oct; 53(7): 68692. DRAPE - Kramer A, Assadian O, Lademann J. “Prevention of postoperative wound infections by covering the surgical field with iodine-impregnated incision drape (Ioban 2)”. GMS Krankenhhyg Interdiszip. 2010 Sep 21; 5(2). 23

Hand Scrub – Brushless & Dual Agent 24

Hand Scrub - Brushless & Dual Agent q Olson LK et al. “Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis”. American Journal of Infection Control Volume 40, Issue 2, March 2012, Pages 155– 159. q Usavadee Asdornwised “An Evaluation of Brush, Brushless, and Waterless Surgical Hand Scrubs among Health Care Workers in Operating Rooms at a University Hospital in Thailand “. J Nurs Sci Vol. 29 No. 3 July. September 2011. 25

Irrigation: Intra-operative 26

Irrigation: Intra-operative 1. COPIOUS IRRIGATION - Watanabe M, Sakai D, Matsuyama D, Yamamoto Y, Sato M, Mochida J. “Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation”. J Neurosurg Spine. 2010 May; 12(5): 540 -6. 2. CHG - Han Y, Giannitsios D, Duke K, Steffen T, Burman M. “Biomechanical analysis of chlorhexidine power irrigation to disinfect contaminated anterior cruciate ligament grafts”. Am J Sports Med. 2011 Jul; 39(7): 1528 -33. 3. PULSATILE - Nikfarjam M, Kimchi ET, Gusani NJ, Avella DM, Shereef S, Staveley-O'Carroll KF. “Reduction of surgical site infections by use of pulsatile lavage irrigation after prolonged intra-abdominal surgical procedures”. Am J Surg. 2009 Sep; 198(3): 381 -6. 4. OPHTHALMOLOGY - Fernandes M, Pathengay A. “Reduction of anterior chamber contamination rate after cataract surgery by intraoperative surface irrigation with 0. 25% povidone-iodine”. Am J Ophthalmol. 2011 Aug; 152(2): 320; author reply 320 -1. 27

OR Observations “Almost no matter what experimental conditions were imposed, increases in output occurred…. The investigators had obviously influenced the subjects’ behavior merely by studying that behavior, and this phenomenon has become known as the Hawthorne effect. ” (Kelly Shaver, Principles of Social Psychology, 2 nd ed. , Winthrop, 1981) 28

Oxygen - Supplemental 29

O 2 - Supplemental q Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr. “Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials. ” Arch Surg. 2009 Apr; 144(4): 359 -66; discussion 366 -7. q James T. Lee, MD, Ph. D “Supplemental Oxygen and Risk of Surgical Site Infection”JAMA 2004; 291(16): 1957 -1958. q Hopf H, Hunt T, Rosen N. “Supplemental Oxygen and Risk of Surgical Site Infection”. JAMA. 2004; 291(16): 1956. 30

Skin Antisepsis Estimates of costs/mortality associated with infections 31

Skin Antisepsis 1. SKIN - Lee I, Agarwal RK, Lee BY, Fishman NO, Umscheid CA. 2. 3. 4. “Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection”. Infect Control Hosp Epidemiol. 2010 Dec; 31(12): 1219 -29. SKIN- Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM, Connor DL, Lee I, Muder RR, Lee BY Economic value of dispensing homebased preoperative chlorhexidine bathing cloths to prevent surgical site infection. Infect Control Hosp Epidemiol. 2011 May; 32(5): 465 -71. NASAL - Pofahl WE, Ramsey KM, Nobles DL, Cochran MK, Goettler C. “Importance of methicillin-resistant Staphylococcus aureus eradication in carriers to prevent postoperative methicillin-resistant Staphylococcus aureus surgical site infection”. Am Surg. 2011 Jan; 77(1): 27 -31. ORAL - Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. “Prevention of nosocomial infections after cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine; a prospective, randomised study”. Ned Tijdschr Geneeskd. 2008 Mar 29; 152(13): 760 -7. 32

Skin Antisepsis: Pre-op bathing with CHG cloths Also used as pre-op skin prep for emergency C-sections 33

Skin Closure 34

Skin Closure 1. Fraeman KH, Reynolds MW, Vaughn BB, Hart JC. “Patient outcomes associated with 2 -octyl cyanoacrylate topical skin adhesive in coronary artery bypass graft surgery”. Surg Infect (Larchmt). 2011 Aug; 12(4): 307 -16. 2. Singer AJ, Chale S, Giardano P, Hocker M, Cairns C, Hamilton R, Nadkarni M, Mills AM, Hollander JE. “Evaluation of a novel wound closure device: a multicenter randomized controlled trial”. Acad Emerg Med. 2011 Oct; 18(10): 1060 -4. 3. Iyer A, Gilfillan I, Thakur S, Sharma S. “Reduction of surgical site infection using a microbial sealant: a randomized trial”. J Thorac Cardiovasc Surg. 2011 Aug; 142(2): 438 -42. . 4. Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ. “Randomized trial of antimicrobial-coated sutures to prevent surgical site infection after breast cancer surgery”. Surg Infect (Larchmt). 2011 Dec; 12(6): 469 -74. 35

Reducing Traffic in the OR 36

Reducing OR Traffic 1. 2. 3. Dunbar MJ, Richardson G. “Minimizing infection risk: fortune favors the prepared mind. ”Orthopedics. 2011 Sep 9; 34(9): e 467 -9. Lynch RJ, Englesbe MJ, Sturm L, Bitar A, Budhiraj K, Kolla S, Polyachenko Y, Duck MG, Campbell DA Jr. “Measurement of foot traffic in the operating room: implications for infection control”. Am J Med Qual. 2009 Jan -Feb; 24(1): 45 -52. Young RS, O'Regan DJ. “Cardiac surgical theatre traffic: time for traffic calming measures? ” Interact Cardiovasc Thorac Surg. 2010 Apr; 10(4): 526 -9. 37

Wound edge protector 38

Wound Edge Protector 1. 2. 3. Green C, Molony D, Cashman J, Burke T, Masterson E. “Another string. . but no bow”. Acta Orthop Belg. 2011 Apr; 77(2): 258 -9. Kadowaki Y, Kurokawa T, Tamura R, Okamoto T, Ishido N, Mori T. “Lap-Protector and Circular Stapler Are Useful in Cystogastrostomy for Large Pancreatic Pseudocyst with Severe Infection”. Case Rep Gastroenterol. 2010 Jul 21; 4(2): 215 -219. Nakamura Y, Matsumoto S, Tajiri T, Uchida E. “A safe technique for laparoscopic distal pancreatectomy involving a large cystic tumor”. J Nihon Med Sch. 2011; 78(6): 374 -8. 39

RESOURCES: 1. AORN/APIC ASC Toolkit/library contents http: //www. aboutinfectioncontrol. com/Sub. Webs/APIC/MAIN_Tool kits. htm 2. APIC Cost Calculator http: //www. apic. org/Content/Navigation. Menu/Practice. Guidance/G uidelines. Standards/TMIT_V 1_Cost. Calculator 02082011. xls 3. APIC/SHEA Compendium http: //www. sheaonline. org/Guidelines. Resources/Compendiumof. Strategiesto. Prev ent. HAIs. aspx 4. KP Patient Story Video Clip http: //nursingpathways. kp. org/national/quality/infectioncontrol/tool kit/index. html 5. KP Infection Prevention “Plus Measures” Toolkit http: //nursingpathways. kp. org/national/quality/infectioncontrol/toolkit/inde x. html 40

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Thanks for your time! Any Questions? 42

bdebaun@cynosurehealth. org

Next Beyond SCIP Webinar May 17 th: 12: 30 -1: 30 PST Pascal Fuchshuber, MD, Ph. D, FACS The Power of NSQIP data to drive change and improvement 45

Cynosure Quality Swap Meet May 21, 2012 www. cynosurehealth. org

Thanks for joining us today