Surgical Site Infections; Evidence and Engagement

1. Surgical Site Infections; Evidence and Engagement Linda R. Greene, RN, MPS,CIC,FAPIC Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu

2. Objectives • Discuss the impact of surgical site infections (SSIs) • Discuss technical and behavioral issues which may impact SSIs • Identify strategies to reduce SSIs

3. Current Burden Burden (US) • 160,000 - 300,000 SSIs per year • 2-5% of patients undergoing inpatient surgery • Most common and costly HAIs Mortality • 2-11 fold higher risk of death • Length of stay • 7-11 additional post-op days Anderson D et.al Strategies to Prevent Surgical Site Infections in Acute Care hospitals

4. Burden • Cost $3.5 -$10 Billion annually • Estimated cost per infection ranges from $11,000 - $35,000 • Colon and Hysterectomy contribute to HAC reduction and Value Based Purchasing • Contribute to 30 day unplanned readmissions

5. Changes in SSI

6. Surgical Risks Most Common Complications during surgery: • Surgical site infection • Postoperative sepsis • Thromboembolic complications • Cardiovascular • Respiratory ( pneumonia)

7. Patient Risk Factors for Infections

8. Modifiable Risk Factors Pre-operatively • Weight loss • Nutritional status • Diabetes • Tobacco use • Prolonged steroid use • Remote infections

9. Basic Practices

10. Preoperative Measures • Treat remote infections • Manage UTI, URI and skin infection before an elective surgery Treat all infections appropriately in elective surgery • Encourage weight loss and improve nutrition • In planned surgery, recommend weight loss • Immunodeficiency should be corrected if possible • Collaboration with other specialist(s) in patients on prolonged steroids • Improve immune status

11. Evidence Based Guidelines • Optimal hemoglobin A1C targets levels • Advise patients to shower or bathe (full body) with soap (antimicrobial or non-antimicrobial) • or an antiseptic agent on at least the night before the operative day

12. The intra-operative period Procedural variables that affect risk of SSI: Antibiotic prophylaxis Duration of Surgical scrub Pre-op hair removal Choice of pre-op skin preparation- need both fast acting and sustained effect Wound class

13. Variables Sterilization of instrument and the environment Foreign material in the surgical site Surgical technique Elevated Glucose- high Glucose levels with or without diabetes Hypothermia – vasoconstriction limits blood flow and oxygen https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/hospital-infection-control/surgical-site-infections/

14. Observations • All surgical wounds are contaminated by bacteria but only a few get infected • Different operations have different inoculums of bacteria • Similar operations performed by the same surgeon in different populations have different rates of infection • SSIs have varying degrees of severity

15. Bacteria get into wounds

16. Where are the Pathogens ? Pathogen source for most SSIs is endogenous flora of the patient’s skin, mucous membranes or GI tract. 20% of the skin’s pathogens live beneath the epidermal layer in hair follicles and sebaceous glands. Any incision can carry some of the bacteria directly to the operative site.

17. Leading SSI Pathogens Gram Positive Bacteria MRSA MSSA Coag. Negative Staph Enterococci Streptococci Species Gram Negative Bacteria Enterobacter Pseudomonas Ecoli Other Bacteria Anaerobic Bacteria Fungi

18. Etiology Exogenous sources: • Hands of care givers • Exposure to non sterile environment • Contamination of fluid, supplies or equipment • Air flow

19. Etiology Surgical Site Infections can be attributed to the patient’s own endogenous flora or from exogenous sources. Example: • Patient’s skin • Contamination during surgery • Oropharyngeal contamination • Patient’s natural immunity

20. Risk Factors for SSIs Host Obesity Age ASA Cancer Immunosuppression Host Factors Host Factors Surgical/ Environmental Factors Microbial Flora Surgical / Environmental Procedure Hair Removal Prophylaxis Technique Contamination Urgency Microbial Nasal Carriage Virulence Inoculum

21. Reviewing what we know • Most infections are seeded at the time of surgery • There are several procedural risk factors • Monitoring of Risk factors may help identify opportunities for opportunities

22. SSIs Majority of SSIs are seeded at the time of surgery while the wound is open examples:

23. Skin Scales

24. Antibiotics for penicillin allergy ? • Cephalosporin if no immediate hypersensitivity reactions Bratzler DW et al. Am J Health Syst Pharm 2013 Pichichero ME. et al. Ann Allergy Asthma Immunol 2014

25. Antibiotics for MRSA • Patients with a hx or known methicillin-resistant staphylococcus aureus ( MRSA) • Single preoperative dose of vancomycin is recommended plus Cephalosporin • Bratzler DW et al. Am J Health Syst Pharm 2013 • Schweizer M.et al. BMJ 2013

26. Revisit Hair Removal AORN Edmiston et. al May 2019

27. AORN Guidelines 2019 GUIDELINE FOR STERILE TECHNIQUE

28. AORN Continued

29. Are there gaps between policy and practice?

30. Direct Observation One of out most powerful tools is direct observation: Examples: • Patients surgical scrub were performed either by a PA or RN that were not sufficient. • Long sleeves on when prepping, but gown was flapping loose and touched prep area. Gowns worn while prepping should be tired to prevent inadvertently grazing the prepped area • Insufficient number of prep sticks used to cover operative area.  Found provider prepping patient did not perform in sterile fashion.  Prep stick touched non sterile areas and was brought back to “sterile” area.

31. Observations Continued • Clipping of surgical site was done on OR table. Hairs were pushed on floor and some left on the sheet or on patient’s limb. •  Gloves should be changed after patient has been draped, again prior to touching the implant, and every 60 to 90 min. throughout case. • Turnover started when patient was still in the room.   •  Anesthesia was noted to have removed his mask and peering over the operative drape.

32. Etiology Surgical Site Infections can be attributed to the patient’s own endogenous flora or from exogenous sources. Example: • Patient’s skin • Contamination during surgery • Oropharyngeal contamination • Patient’s natural immunity

33. Etiology Exogenous sources: • Hands of care givers • Exposure to non sterile environment • Contamination of fluid, supplies or equipment • Air flow

34. Challenges • Time • Turnover -Surgeon preference -Adherence factors

35. Leading SSI Pathogens Gram Positive Bacteria MRSA MSSA Coag. Negative Staph Enterococci Streptococci Species Gram Negative Bacteria Enterobacter Pseudomonas Ecoli Other Bacteria Anaerobic Bacteria Fungi

36. SSIs Majority of SSIs are seeded at the time of surgery while the wound is open examples:

37. Evidence Based Practices • HICPAC Guidelines for Prevention of SSI-? • Compendium of Strategies -2014 • WHO -2016

38. http://www.who.int/gpsc/ssi-guidelines/en/

40. Compendium of Strategies 2014 2 levels of recommendations Basic – Recommended for all hospitals Special – Consider if there is still a problem based on surveillance data or risk assessment

41. Basic Practices • Maintain intra-operative temp > 35.5 • Use an alcohol containing skin prep unless contraindicated • Use a surgical safety checklist • Maintain post-operative blood glucose ≤ 180 mg/dL. Cardiothoracic surgical procedures (High ) Non-cardiac procedures ( Moderate) • Use impervious wound protectors in GI and biliary procedures DrongeArch Surg 2006; Golden Diabetes care 1999; Olsen MA J BoneJointSurg Am 2008

42. http://apic.org/Resource_/TinyMceFileManager/Implementation_Guides/APIC_ImplementationPreventionGuide_Web_FIN03.pdfhttp://apic.org/Resource_/TinyMceFileManager/Implementation_Guides/APIC_ImplementationPreventionGuide_Web_FIN03.pdf

43. Complex Practice Setting

44. Selected Elements of Surgical Care Bundle from Literature https://www.dhs.wisconsin.gov/hai/ssi-prevention.htm

45. Colorectal Bundle

46. Strategies to Prevent SSIs You must consider whether any given risk is : Modifiable: i.e. glucose, antimicrobial administration, hair removal Non Modifiable: i.e. age, co-morbidities, severity of illness, wound class

47. General Cleaning Recommendations Beginning of the day Wipe down: • Horizontal features • Furniture • Equipment After each procedure Frequently touched areas

49. Traffic Control Tracers in OR Primary Hip observed- 27 different entries into OR room Hysterectomy Davinci - 31 entries What does the evidence tell us?

50. - Doors open average of 9.5 minutes per case • - Loss of positive pressure • 77 of 191 cases had doors open long enough to defeat positive pressure