the Slide Set

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Tuesday, April 12

1:00 pm EasternDial In: 888.863.0985

Conference ID: 59378418

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Speakers

David Soper, MD, FACOG

Professor & Director, Obstetric & Gynecologic Specialists,

Medical University of South Carolina

Paloma Toledo, MD, MPH

Assistant Professor, Anesthesiology, Northwestern University

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Disclosures

David Soper, MD, FACOG has no real or perceived conflicts of interest to disclose.

Paloma Toledo, MD, MPH has no real or perceived conflicts of interest to disclose.

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Objectives

Discuss the important role that the multidisciplinary care team plays in helping prevent surgical site infections.

Review the composition and characteristics of successful multidisciplinary care teams.

Identify valuable strategies that can be utilized by care teams, including time outs, huddles, and debriefs.

Provide tips on how your institution can successfully employ a team-based approach to aid in reducing surgical site infections.

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Prevention of InfectionElements of a Checklist

• Control diabetes

• Preop showers

• Clippers – no razors

• S. aureus awareness*

• Normothermia*

• Antibiotic prophylaxis*

• Vaginal preparation

• Skin preparation

• Neg pressure wound Rx

• Postop incision care

*Anesthesiology

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ReadinessPreoperative Standards

• Assigning responsibilities

• Preoperative care and education (nursing)

– Chlorhexidine showers/postop wound care

• Evidence based standards

– Normothermia (Anesthesiology)

– Antibiotic prophylaxis (Surgeon + Anesthesiology)

– Skin preparation (Surgeon)

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Preoperative Showers

• Chlorhexidine showers

• Cruse 1980 = 10,000 patients prospective

• Recent meta-analysis less clear (Cochrane)

• OR 0.2 (0.06-0.7)

– 80% reduction*

* Savage, et al. Surgical site infections and cellulitis after abdominal hysterectomy. AJOG 2013:209:108.e1-10

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RecognitionAmeliorate Risk Factors

• Anticipate and plan

• Risk Factors

– Blood glucose level

– BMI

– Bacterial vaginosis screening

– MRSA awareness

– Nutritional status

– Smoking

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Diabetes Control

• Real issue is postoperative control

• Good preoperative control makes postoperative easier

• Risk increases for postoperative glucose

– Mean 150-250 = 22% increase

– Mean >250 = 44% increase

• Preoperative guideline = A1c < 8%

– Mean glucose 200 mg/dl

King, et al. Glycemic control and infections in patients with diabetes undergoing non-cardiac surgery. Ann Surg 2011;253:158-65

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PPE: OR = 5.8 [3.0-10.9] Cuff cellulitis: RR=3.2 [1.5-6.7]

Watts H, Krohne MS, Hillier SL, Eschenbach DA. Bacterial vaginosis as a risk factor for post cesarean endometritis. Obstet Gynecol 1990;75:52-8

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Hysterectomy SSIBacterial Vaginosis

• Increases risk of SSI

– RR = 3.2 (1.5 to 6.7)

• McElligott cost comparison study

– Screen for BV vs treat all vs neither

– Optimal strategy = treat all patients for BV

• If screen positive – 7 days of therapy

McElligott, et al. Preoperative screening strategies for bacterial vaginosis prior to elective hysterectomy: a cost comparison study. AJOG 2011;205:500.e1-7

Larsson, et al. Clue cells in predicting infections after abdominal hysterectomy. Obstet Gynecol 1991;77:450-2

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MRSA

• Universal, rapid MRSA admission screening did NOT reduce nosocomial infection

• 266 identified as MRSA positive preop

– 115 given preop MRSA prophylaxis

• 0/115 given preop ab prophylaxis active against MRSA developed MRSA infection

Harbarth, et. al. Universal screening for methicillin-resistant staphylococcus areus at hospital admission and nosocomial infection in

surgical patients. JAMA 2008;299(10):1149-1157

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MRSAMUSC Approach

• History of MRSA colonization or infection

• Current culture evidence of MRSA colonization

• Undergoing surgical procedure that warrants antibiotic prophylaxis

• Add vancomycin to antibiotic prophylaxis regimen

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Surgical Care Improvement Project (SCIP) Measures

• SCIP-Inf-1a: Prophylactic antibiotics within 1 hour of surgical incision – overall rate

• SCIP-Inf-2a: Proportion of patients who received prophylactic antibiotics consistent with current guidelines – overall rate

• SCIP-Inf-3a: Prophylactic antibiotics were discontinued within 24 hours of surgery end time –overall rate

• SCIP-Inf-6: Proportion of patients with appropriate hair removal

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Team-Approach to Antibiotic Administration

• Pharmacy-generated antibiotic order sets

• Pharmacy to prepare antibiotics

• Nursing or anesthesia staff verifying antibiotic, patient allergies, correct dose

• Administration of antibiotics within one hour of incision

• Use of the team time out to verify antibiotic administration prior to incision

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Antibiotic Selection

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Standardized Order Sets

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Standardized Order Sets

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Obesity and Weight Based DosingAntimicrobial Prophylaxis

• Obesity – >220# (100 kg) or BMI > 35

– Increase dose of cefazolin

Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989;106:750-7

Time Serum level Adipose tissue (minutes) (g/ml) level (g/gm)

Group Incision Closure Incision Closure Incision Closure

A (control) 13.5 + 6.3 98.1 + 25.2 110.5 + 18.9 44.5 + 7.4 6.0 + 1.3 4.1 + 0.8

C (1 gm IV) 12.7 + 7.8 123.9 + 20.8 65.2 + 15.0* 23.5 + 5.1* 4.0 + 2.3 † 2.4 + 1.0 †

D (2 gm IV) 15.7 + 8.2 116.5 + 22.8 127.8 + 16.3 46.2 + 9.9 7.3 + 3.1 4.1 + 1.1

*Significantly (p < 0.001) different from control group A by ANOVAR†Significantly (p <0.01) different from control group A by ANOVAR

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Antibiotic Administration

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Timing of Antibiotic Administration

Classen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New England Journal of Medicine 1992;326:281-6

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Huddles/Team Time Out

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Sign In/Time Outs

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Impact of Checklist Use

Before ChecklistN=3733

After checklistN=3955

P

Rate of Death 1.5% 0.8% 0.003

Inpatient Complications

11% 7% P<0.001

Haynes, A, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine. 2009; 360: 491-9.

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Time Out

• Elements include:

– Patient identification

– Procedure(s)

– Risks including anticipated EBL

– Use of antibiotic prophylaxis

– Anticipated difficulties

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Changes in Intraoperative Conditions

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Northwestern Postpartum Hemorrhage Protocol

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Northwestern Postpartum Hemorrhage Protocol

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Re-dosing of antibiotics

• Add intraoperative doses for long cases

– 1 - 1.5 times the half-life of the antibiotic

– Cefazolin half life = 1.8 hours

• Administer second dose ~ 4 hours

• Second dose for increased blood loss

– > 1500 cc

Swoboda SM, et al. Does intraoperative blood loss affect antibiotic serum and tissue concentrations? Arch Surg 1996;131:1165-72

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Maintenance of Intraoperative Normothermia

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Intraoperative Normothermia

• Randomized controlled trial, n=200

• Routine intraoperative care (hypothermia) vs. active warming

Kurz, Andrea et al. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. New England Journal of Medicine 1996; 334: 1209-15

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Intraoperative Normothermia

NormothermiaN=104

HypothermiaN=96

P

Vasoconstriction 22% 78% <0.001

Surgical site infection

6% 19% 0.009

Kurz, Andrea et al. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. The New England Journal of Medicine.

1996; 334: 1209-15

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Recommendations for Maintaining Normothermia

• Room temperature 68-72°F

• Use of active warming devices, if indicated

– Use of warming blankets

– Use of fluid warmers

• Team communication if issues with intraoperative temperature

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Prevention of SSI

• Clippers = less SSI vs razor

– Cochrane review

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Chorhexidine-alcohol Skin Preparation at Time of Surgery

Darouiche RO et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. The New England Journal of Medicine 2010;362:18-26

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Hysterectomy Wound InfectionDepth of Subcutaneous Tissue

Soper, DE, et al. Wound infection after abdominal hysterectomy: Effect of the depth of subcutaneous tissue. AJOG 1995;173:465-71

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Closure of Subcutaneous Fat

• Meta-analysis

• Cesarean delivery – n = 875

• Wound disruption – RR = 0.56[0.36-0.86]

– Decrease in wound seromas

– For thickness > 3

Chelmow, et al. Suture Closure of Subcutaneous Fat and Wound Disruption After Cesarean Delivery: A Meta-Analysis. Obstet Gynecol 2004;103:974-980

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Subcuticular Skin Closure

• No staples!

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Negative Pressure Wound Therapy

• Cesarean at risk for infection

– Including BMI > 30

• Note association of seroma with SSI

– Savage 2013 AJOG – OR 6.7 (3.5-12.8)

• NPWT until discharge (average 3 days)

• NPWT lower rate of wound infection

– 2.7% vs 11.5%

Swift, et al. Effect of single-use negative pressure wound therapy on post-cesarean infections and wound complications for high-risk patients. J Reprod Med. 2013;60:211-8

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Prevention of InfectionHysterectomy Checklist

• Control diabetes

• Preop showers

• Clippers – no razors

• S. aureus awareness

• Normothermia

• Antibiotic prophylaxis

• Vaginal preparation

• Skin preparation

• Subcutaneous closure

• Subcuticular

• Neg pressure wound Rx?

• Postop incision care?

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MUSC Opportunities

• Attention to postoperative glucose control

• Preop showers with chlorhexidine

• MRSA awareness

– Review culture record

– History consider positive

• Increase dose of cefazolin

– 2 grams for all with 3 grams for > 120 kg

• Negative pressure wound therapy? - investigation

• Postop incisional care?

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It Takes a Village

• 120 lives had to be touched to hardwire our SSI prevention program

• Standardization and SYSTEMS development = ABOG MOC credit

– Can’t be the Lone Ranger

• Real time review of each SSI

– Make sure definitions are met

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Data Collection, Measurement, and Reporting

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Data Collection

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Process Measures

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Provider and Surgical Process Measures

Potential Measures

Provider • Adherence with hand washing• Adherence with use of proper surgical attire

Surgical • Proper preoperative skin antisepsis• Proper preoperative hair removal• Proper operating room temperature• Appropriate re-dosing of antibiotics (e.g. due to prolonged

duration of surgery, excessive blood loss)

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Outcome Measures

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Sources to identify infection data

• ICD-9/ICD-10 codes

• Readmission for treatment of surgical site infections

• Surveys

• Microbiology reports

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Risk Adjustment

Risk Factors

Patient-level risk factors • Obesity• Diabetes mellitus• Smoking status• Steroid use• Nutritional status• American Society of Anesthesiologists

Physical Status (ASA PS)

Surgical-level risk factors

• Type of surgery• Duration of surgery• Insertion of foreign material

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National Healthcare Safety Network (NHSN) index

• Three variables contribute one point each:

– American Society of Anesthesiologists Physical status score >3

– Contaminated or dirty wound classification

– Procedure duration > 175th percentile

• Scores range from zero to three

– Zero represents the lowest risk

– Three represents the greatest risk

Culver DH, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med

1991; 91: 152S-157S

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Standardized Infection Ratio (SIR)

• Accounts for patient- and procedure-related risk factors within each type of surgery (e.g. patient age, wound class, duration of surgery)

• Compares the number of infections that were observed at the hospital-, state-, or national-level, with the number of predicted infections. – Ratio <1: Fewer infections were observed than

expected

– Ratio>1: More infections were observed that were expected

Centers for Disease Control and Prevention (CDC). Healthcare-associated Infections http://www.cdc.gov/hai/surveillance/progress-report/faq.html. Accessed on: 3/24/16

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Reporting

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Dashboards or Scorecards

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National Reporting

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Multidisciplinary review

• Physicians

– Surgeons

– Anesthesiologists

• Nursing

• Pharmacy

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Q&A Session Press *1 to ask a question

You will enter the question queue

Your line will be unmuted by the operator for your turn

A recording of this presentation will be made available on our website:

www.safehealthcareforeverywoman.org

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Next Safety Action SeriesAssessing Risk for Antenatal Venous

ThromboembolismWednesday, April 20th | 11:30 a.m. Eastern

Michael Paidas, MD, FACOG

Professor & Vice Chair, Obstetrics, Yale

School of Medicine

Liyana Winchell, RN, BSN

Yale-New Haven Hospital

Click Here to Register