Decreasing Surgical Site Infection Using National Recommendations

1. Decreasing Surgical Site Infection Using National Recommendations

3. Avera McKennan�s Size and Scope Approximately 5, 050 employees 550 physicians (300 employed) 115 locations, 54 communities, 3 states 979,000 patient visits each year 60 distinct medical specialties

4. Estimates of Healthcare -Associated Infections* In the United States, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections: 32% are urinary tract infections 22% are surgical site infections 15% are pneumonia 14% are bloodstream infections

5. Cost Analysis of SSI* Direct Costs: Longer hospital stay Readmission Outpatient and emergency visits Further surgery Prolonged antibiotic treatment Radiologic procedures Lab tests Home Health visits Professional fees Estimated costs: Less than $400.00 per case for superficial SSI More than $30,000.00 for serious organ space SSI Not all SSI are alike although by definition all are costly

6. Surgical Care Improvement Project (SCIP) The Surgical Care Improvement Project is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications Modifiable risk factors for reducing the risk for SSI Are not standards, rather process improvement measures The SCIP goal is to reduce the incidence of surgical complications nationally by 25% by the year 2010

7. SCIP Measures SCIP Measures: Prophylactic antibiotic: Received within one hour prior to incision Appropriate preoperative antibiotic used Prophylactic antibiotics discontinued within 24 hours after surgery If needed, appropriate hair removal (clipped, not shaved) Other SCIP Measures: Temperature Oxygenation Glucose control

8. National Recommendations SHEA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals Strategies to Prevent Surgical Site Infections in Acute Care Hospitals Definition of SSI - NHSN Methods for Surveillance Surgical Care Improvement Project (SCIP) CDC 1999 Guideline for Prevention of Surgical Site Infection Preoperative bathing Appropriate prepping antiseptic The period of maximum influence on SSI risk begins and ends in the operating room

9. Resistant Pathogens(MRSA)

11. Abdominal Hysterectomy

12. Risk Index Risk Index: Is subdividing your surveillance population into groups with similar levels of risk before performing any analysis or comparison. Developed to predict a patient�s risk of acquiring a SSI. Risk factors that determine risk index are assigned points: Wound class 3 or greater = 1 point ASA score 3 or greater = 1 point Cut time > 2 hrs = 1 point The number of points determines the risk index. Example: WC=1 or 2, ASA=1 or 2, cut time under 2 hrs�RI = 0

14. Abdominal Hysterectomy Meetings with OR staff and surgeons who performed abdominal hysterectomy procedures Reviewed our current surgical practices: SCIP Prepping of abdomen and vaginal vault: Who did the prep How did they prep What antiseptic was used Were policies followed

15. Abdominal Hysterectomy� Preoperative bathing: Bathing mentioned in preoperative flyer given to patients with admission instructions? Were patients instructed to bathe before coming to the hospital? Instructed how to bathe? Use an antiseptic to bathe with? Instructed not to shave near or on the operative area?

16. Findings Reviewing current surgical practices: SCIP; all were being followed Prepping of abdomen and vaginal vault: Who did the prep: varied between surgeon vs. circulator vs. scrub tech, and, occasionally a scrubbed in person How did they prep: variety of methods What antiseptic was used: if surgeon did not specify, decision was left up to surgical tech Were policies in place and followed: policies were outdated and some did not realize there was a policy

17. Findings� Preoperative bathing: Bathing mentioned in preoperative flyer given to patients with admission instructions? No Were patients instructed to bathe before coming to the hospital? Some were, some were not Instructed on how to bathe? No Use an antiseptic to bathe with? No Instructed not to shave near or on the operative area? Some were, some were not

18. Corrections Prepping of abdomen and vaginal vault: Who did the prep: non-scrubbed personnel - circulator How did they prep: Used consistent, established methods What antiseptic was used: ChloraPrep if not contraindicated for abdomen, Betadine for vaginal vault Were policies followed: Policies were updated and discussed at unit meetings

19. Corrections� Preoperative bathing: Bathing mentioned in preoperative flyer given to patients with admission instructions? Instructions to bathe with soap and water will be included. Were patients instructed to bathe before coming to the hospital? Yes Instructed on how to bathe? Yes Use an antiseptic to bathe with? Not at this time Instructed not to shave near or on the operative site Scripting for Preadmission Nurses was added when calling the patient with admission instructions.

20. Pre-Admission Scripting

21. Bathing Study Patients were given bathing instructions to bathe the evening before and morning of surgery They were given 2-15ml packets of 4% chlorhexidine to bathe the operative site Instructed not to shave Study was repeated with same instructions using soap and water Results were similar, with soap and water slightly better vs. antiseptic

22. Results

24. Can We Prevent SSI in the Operating Room? Factors to consider: SCIP measures Following policies Prepping Draping Maintaining a sterile field Traffic flow/talking/unnecessary personnel Team work

25. Lessons Learned Avoid sacred cows Practices blessed by time, but not necessarily by science Frequently review current processes Surprising what you think current practice is vs. what truly is Educate-educate-educate Implement new practices when current practices no longer effective

26. SSI Prevention All patients All procedures All the time

27. ?? Questions ??