Preventing Surgical Site Infections (SSIs): What the Direct Caregiver Should Know

Prepared by Ann Bailey, RNC, BSN, CIC Joanne Dixon, RN, MN, CIC December 16, 2009

Objectives Upon completion of this module, the learner will be able to:

• Define Surgical Site Infection • Name 4 factors that may influence the development of surgical site infections • List 3 bundle components SFoH practices which decrease the risk of surgical site infections From CDC’s NNIS

What Is a Surgical Site Infection?

• Infection at the site of surgery that occurs within 30 days of surgery if there is no implant (hardware, artificial graft, mesh, etc) OR occurs within 1 year of the surgery with an implant in place • Types of SSIs: • Superficial incisional • • Deep incisional Organ or body space From CDC’s NNIS

Why Prevent SSIs?

• Approximately 500,000 surgical site infections (SSI) occur annually in the United States • Patients that develop SSI have twice the mortality and are: • 60% more likely to spend time in ICU • 5 times more likely to be readmitted From CDC’s NNIS

Why Prevent SSIs?

• SSI increases length of stay in hospital by an average of 7.5 days • $2,734 to $26,019 extra cost per SSI (1985, US dollars) • $130 million to $845 million per year estimated national costs in the USA From CDC’s NNIS

Factors That may Influence SSI Development

Patient Age Nutritional status Diabetes Smoking Obesity Coexistent infections at a remote body site Colonization with microorganisms Altered immune response Length of preoperative stay CDC Guideline for Prevention of Surgical Site Infections, 1999

Factors That may Influence SSI Development

Operation Duration of surgical scrub Skin antisepsis Preoperative shaving Duration of operation Antimicrobial prophylaxis Operating room ventilation Inadequate sterilization of instruments Foreign material in the surgical site Surgical drains Surgical technique CDC Guideline for Prevention of Surgical Site Infections, 1999

What Are We Doing at SFOH to Prevent SSIs?

• Utilizing good surgical hand antisepsis & hand hygiene

What Are We Doing at SFOH to Prevent SSIs?

• Using a best practice “bundle” on all surgical patients • Adapted from the Surgical Care Improvement Project (SCIP) Infection prevention components

Remember a Bundle is:

• A grouping of best practices that individually improve care, but when applied together result in substantially greater improvement.

• Science behind the bundle elements is well established – the standard of care.

• Bundle element compliance can be measured as “ yes/no.” • “All or none” approach.

Surgical Site Infection Prevention Bundle Components

1.Prophylactic antibiotic given within one hour prior to surgical incision 2.Prophylactic antibiotic selection for surgical patients 3.Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery) 4.Cardiac surgery patients with controlled 6 A.M. postoperative serum blood glucose

Surgical Site Infection Prevention Bundle Components

5.Surgery patients with appropriate hair removal 6.

Surgery Patients with Perioperative Temperature Management - maintaining normothermia 7. Urinary Catheter Removal on Postoperative Day 1 or 2 with day of surgery being day zero.

Surgical Site Infection Prevention Bundle Components

1. Prophylactic antibiotic given within one hour prior to surgical incision -The goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of incision.

Rationale: “…reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses.*” *CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle Components

2. Prophylactic antibiotic selection for surgical patients Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure) have fewer surgical site infections Rationale: “Use an AMP (surgical antimicrobial prophylaxis) for all operations or classes of operations in which its use trials…*” has been shown to reduce SSI rates based on evidence from clinical *CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle Components

3.Prophylactic antibiotics discontinued within 24 hours after surgery end time Rationale: Short duration antibiotics are as effective in preventing infection as long duration antibiotics Long duration antibiotics are more likely to cause development of drug resistant bacteria

Surgical Site Infection Prevention Bundle Components

4. Cardiac surgery patients with controlled postoperative blood glucose Rationale: Hyperglycemia has been associated with increased in-hospital morbidity and mortality for multiple medical and surgical conditions. -Risk of infection is significantly higher for patients undergoing CABG if blood glucoses are elevated.

-Deep wound infections in diabetic patients undergoing cardiac surgery is reduced by controlling blood glucose levels < 200 mg/dL in the immediate postoperative period.

Surgical Site Infection Prevention Bundle Components

5. Surgery patients with appropriate hair removal Hair removal, if indicated should be accomplished with clippers rather than razors or depilatories.

Rationale: Razor shaving has been associated with increased SSIs attributed to microscopic cuts in the skin that serve as foci for bacterial multiplication* *CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle Components

6. Surgery Patients with Perioperative Temperature Management - Maintaining normothermia Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature ≥ 96.8

o anesthesia end time.

F/36 o C recorded within the 30 minutes prior to or the 15 minutes immediately after Rationale: Hypothermia (<36 o C) increases the risk for surgical site infection *CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle Components

7. Urinary Catheter Removal on Postoperative Day 1 or 2 with day of surgery being day zero. Rationale: Removing the indwelling urinary catheter decreases risk of urinary tract infection and associated complication of bacteremia that could lead to increased length of stay, more frequent readmissions and increased morbidity and mortality *CDC Guideline for Prevention of Surgical Site Infections, 1999

Other SSI Prevention Measures*

• Encourage patient tobacco cessation prior to surgery • Ask patients to shower or bathe with antiseptic agent on at least the night before the operative day *CDC Guideline for Prevention of Surgical Site Infections, 1999

Other SSI Prevention Measures*

• Ill surgical staff refrain from working • Surgical team keeps nails short and does not wear artificial nails • Surgical team performs appropriate hand/forearm antisepsis prior to surgery *CDC Guideline for Prevention of Surgical Site Infections, 1999

Other SSI Prevention Measures*

• Surgical team wears appropriate surgical attire • Uses proper aseptic and surgical technique during procedures • Use appropriate antiseptic agent for skin prep *CDC Guideline for Prevention of Surgical Site Infections, 1999

Other SSI Prevention Measures*

• Protect closed incision with sterile dressing for 24-48 hours postoperatively • Maintain adequate/recommended ventilation processes in the operating rooms *CDC Guideline for Prevention of Surgical Site Infections, 1999

Other SSI Prevention Measures*

• Perform adequate cleaning and disinfection of environmental surfaces in the surgery areas • Sterilize all surgical instruments according to published guidelines *CDC Guideline for Prevention of Surgical Site Infections, 1999

Your Role

• • • • • Follow the bundle components specific to your role in the patient’s care Provide appropriate/indicated patient teaching regarding these bundle component and other recommended practices Document patient education related to the goal of SSI prevention Patient education materials related to SSI prevention can be found on the Intranet: • http://intranet.seton.org/polandproc/infectcontrol/docs/ssi.pdf

• • • http://intranet.seton.org/polandproc/infectcontrol/docs/ssi_largertext.pdf

http://intranet.seton.org/polandproc/infectcontrol/docs/ssi_spanish.pdf

http://intranet.seton.org/polandproc/infectcontrol/docs/ssi_span_lg_txt.pdf

Remind peers of the importance of following the recommended practices if they are observed to be non compliant

Questions?

• Contact the Infection Preventionist at your site

References

• • • http://www.jointcommission.org/Performance Measurement/PerformanceMeasurement/SCIP +Core+Measure+Set.htm

http://www.cdc.gov/ncidod/dhqp/gl_surgicalsi te.html

http://www.ihi.org/IHI/Topics/PatientSafety/S urgicalSiteInfections/