Maureen Spencer, RN, M.Ed, CIC

Infection Preventionist Consultant

Boston, MA

Establishing a Culture of Safety:

Working Toward Zero

Orthopedic SSIs

Email: maureen_spncr@yahoo.com

www.workingtowardzero.com

www.creativehandhygiene.com

Example of Working Toward Zero Team Members

2

The teams: Surgical Site Infections: Director Surgical Services, OR Manager, SPD Director, Infection

Control Manager, Two Surgeons, VP Patient Care Services, Director of Nursing, Nursing Manager, Clinical Educator, Microbiology Lab Director

Ventilator Associated Pneumonia: ICU Hospitalist, ICU Nurse Manager, ICU Nurse, Director of

Anesthesia, ICU Clinical Educator, Respiratory Therapy, Infection Control Manager, Micro Lab

Central Line Assoc Bloodstream Infections: Surgeon who inserted most central lines, ICU Manager, Director of Anesthesia, ICU Clinical Educator, ICU Nurse, Infection Control Manager

Catheter Assoc UTI: Clinical Educator, Infection Control Manager, Chief Urology, Lab Director MRSA Elimination: Infection Control Manager, Pre-admission testing, OR Director,

Microbiology Lab Director, Two Surgeons, Director of Nursing, Patient Access Director, Information Technology, ID physician C.difficile: Chiefs of Surgery and Gastroenterology, ICU Nurse Manager, Micro Lab Director,

Infection Control Manager

Pre-op:

Screen for MRSA

and Staph aureus

CHG pre-op

shower or cleanse

with impregnated

cloths

Assure OR meets

AORN standards of

practice

Intraoperative: CHG/alcohol skin prep, antibacterial sutures, incisional adhesive

Irrigation?

Consider using saline or new CHG (0.05%) irrigant and eliminate expensive and toxic bacitracin/polymixin or antibiotic irrigant

Post-op:

Incisional adhesive should be the number one consideration for wound closure – prevents dehiscence and exogenous contamination to wound

If not used consider covering incision for length of hospitalization

Patient education is extremely important since many patients are discharged early in the post-op period and have incisions that are in the exudative state of wound healing

MRSA and Staph aureus

Elimination Program Before Patients Enter

the Hospital for Surgery

4

Prescreening Process

Topical Decolonization Protocol

Vancomycin for MRSA

1. Kim D, Spencer M, Davidson S, et al. J Bone Joint Surg 2010;92:1820-6 2. Spencer M, Kim D, et al: AAOS, 2010

Provided Evidence: February 2006

Anonymous Nares Cultures To Prove to Administration Patients Are Colonized

With Staph aureus and MRSA

5

N = 133 patients anonymously surveyed and

cultured in OR after anesthetized

Purpose: to determine pre-op MRSA and Staph

aureus colonization rates for administration

Results:

38 – Staph aureus (29%)

*5 - MRSA ( 4%)

*all undiagnosed, no precautions used in OR,

PACU, postop nursing unit

*MRSA cases received Cefazolin for surgical

prophylaxis – THE WRONG ANTIBIOTIC!

Implemented Decolonization Protocol

6

• 5-day application of intranasal 2% mupirocin -

applied twice daily - for MRSA and Staph aureus

positive patients

• Prescription called in by Nurse Practitioner in

prescreening unit

• Daily body wash with chlorhexidine (purchased

by patient)

• MRSA Patients – Unique sticker system to notify

Pre-surgery Unit of Vancomycin surgical

prophylaxis

7

Pre-op MRSA and S. aureus Decolonization

8

Results:

Timeframe: July 17, 2006 through September 2010

Infection rate: 20,065 patient screened

5,988 (23%) positive for Staph aureus

1,027 ( 4%) positive for MRSA

Effectiveness: Repeat nasal screens on MRSA patients

revealed 77% eradication

Pre-op MRSA and S. aureus Decolonization

9

Results: % MRSA and S. aureus SSI

Time Period Inpatient

Surgeries

# of Surgical

Infections %MRSA/MSSA

FY06

10/01/05-07/16/06* 5,293* 24* 0.45%*

FY07

07/17/06-09/30/07 7,019 6 0.08%

FY08

10/01/07-09/30/08 6,323 7 0.11%

FY09

10/01/08-09/30/09 6,364 11 0.17%

FY10

10/01/10-09/30/10 6,437 6 0.09%

*Historical Controls

Pre-op MRSA Decolonization

10

Results: % MRSA SSI in Screened Patients

Time Period

Inpatient

Surgeries

# MRSA

SSIs MRSA%

#Infect/#MRSA

+

FY06

10/01/05-07/16/06 5,293 10 (NA) 0.19% NA

FY07

07/17/06-09/30/07 7,019 3 (3+) 0.04% 3/309 (0.97%)

FY08

10/01/07-09/30/08 6,245 4 (2+) 0.06% 2/242 (0.83%)

FY09

10/01/08-09/30/09 6,336 6* (2+) 0.09% 2/234 (0.85%)

FY10

10/01/10-09/30/10 6,437 1 (1+) 0.01% 1/266 (0.37%)

* isolates have been sent for pulse field gel electrophoresis 5 of the 6 isolates were available for PFGE and were not related genetically

Pre-op Staph aureus Decolonization

11

Results: % S. aureus (MSSA) SSI in Screened Patients

Time Period

Inpatient

Surgeries

# MSSA

SSIs MSSA%

#Infect/#MSSA

+

FY06

10/01/05-07/16/06 5,293 14 (NA) 0.26% NA

FY07

07/17/06-09/30/07 7,019 3 (3+) 0.04% 3/1588 (0.19%)

FY08

10/01/07-09/30/08 6,245 3 (1+) 0.05% 1/ 1422 (0.07%)

FY09

10/01/08-09/30/09 6,336 5 (1+) 0.08% 3/1403 (0.21%)

FY10

10/01/10-09/30/10 6,437 6 (1+) 0.09% 1/1450 (0.06%)

OR Risk Factors:

Contamination from OR Staff

12

• Reviewed orderlies and room turnover procedures

• Improved traffic control – new signage and monitoring system

keep room doors closed and minimize traffic

• Eliminate surgical caps – do not cover hair!

• Cloth cap use – if worn, must be covered in OR room

with disposable cap - hair coverage monitored – Hair harbors organisms – Staff sweat in cloth caps

– How often do they get washed? Hospital laundered

– Where are they stored?

– Would you eat a meal with hair in it? – Why allow hair to potentially fall into

surgical incisions?

OR Risk Factors:

Cleaning/Sterilization of Instruments

13

• Inspection of Orthopedic Instruments – Lumens, grooves, sorting, hand cleaning,

disassembly required – massive kits – Many instruments cannot be disassembled

• Instituted better pre-soaking and rinsing of tissue and blood from the instruments in the operating room before decontamination

• There was a recent outbreak investigated by CDC of shoulder infections - found shavers and cannulas with biofilm and tissue observed inside instruments with small camera

Pathogens survive on surfaces

Organism Survival period

Clostridium difficile 35- >200 days.2,7,8

Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days.1,5,10

Vancomycin-resistant enterococcus (VRE) 58- >200 days.2,3,4

Escherichia coli >150- 480 days.7,9

Acinetobacter 150- >300 days.7,11

Klebsiella >10- 900 days.6,7

Salmonella typhimurium 10 days- 4.2 years.7

Mycobacterium tuberculosis 120 days.7

Candida albicans 120 days.7

Most viruses from the respiratory tract (eg: corona,

coxsackie, influenza, SARS, rhino virus)

Few days.7

Viruses from the gastrointestinal tract (eg: astrovirus, HAV,

polio- or rota virus)

60- 90 days.7

Blood-borne viruses (eg: HBV or HIV) >7 days.5

1. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5.

2. BIOQUELL trials, unpublished data.

3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2

4. Boyce. 2007. J Hosp Infect. 65:50-4.

5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200.

6. French et al. 2004. ICAAC.

7. Kramer et al. 2006. BMC Infect Dis. 6:130.

8. Otter and French. 2009. J Clin Microbiol. 47:205-7.

9. Smith et al. 1996. J Med. 27: 293-302.

10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4.

11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.

Why Better Environmental Cleaning?

Prior room occupancy increases risk

Study Healthcare associated pathogen Likelihood of patient acquiring HAI

based on prior room occupancy

(comparing a previously ‘positive’

room with a previously ‘negative’

room)

Martinez 20031 VRE – cultured within room 2.6x

Huang 20062 VRE – prior room occupant 1.6x

MRSA – prior room occupant 1.3x

Drees 20083

VRE – cultured within room 1.9x

VRE – prior room occupant 2.2x

VRE – prior room occupant in previous two

weeks 2.0x

Shaughnessy 20084 C. difficile – prior room occupant 2.4x

Nseir 20105 A. baumannii – prior room occupant 3.8x

P. aeruginosa – prior room occupant 2.1x

1. Martinez et al. Arch Intern Med 2003; 163: 1905-12.

2. Huang et al. Arch Intern Med 2006; 166: 1945-51.

3. Drees et al. Clin Infect Dis 2008; 46: 678-85.

4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.

5. Nseir et al. Clin Microbiol Infect 2010 (in press).

Floors:

MRSA 55%

C. Difficile 48%

Patient Gowns:

MRSA 51%

Bedsheets:

MRSA 53%

VRE 40%

Windowsill:

C. Difficile 33%

Overbed Table:

MRSA 40%

VRE 20%

Bedrail:

MRSA 29%

VRE 28%

C. Difficile 19%

Blood Pressure Cuff:

VRE 14%

Commode:

C. Difficile 41%

Rates of Surface Contamination (in hospitals) with MSRA, VRE, and C. Difficile

Did you know that every time you get a new roommate, there is an

increase of 3-10% that you will acquire an HAI.

Boyce J.M. et al.: Environmental contamination due to methicillin-resistant Staphylococcus aureus: Possible infection control implications. Infect Control Hosp Epidemiol 18:622-627, Sep. 1997.

Slaughter S., et al.: A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care

unit. Ann Intern Med 125: 448-456, Sep 15, 1996.

Samore M.H., et al.: Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 100:32-40, Jan. 1996.

Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med.

2006 Oct 9;166(18):1945-51

Environmental Disinfection – Joint

Commission and CMS Focus on Surveys

17

Developed cleaning schedules for Patient Care

Services – what equipment, how

cleaned/disinfected, how often, by who, contact

times for disinfectants?

Eliminate dirty buckets of water and string mops

institute micro fiber cloths and mops

Assure staff know proper cleaning technique: left to right, high to low, clean to dirty with

competencies

Daily check sheet for terminal cleaning of OR at

night and for all precaution cases

Decontamination of Portable Equipment

with Contracted Services

18

Ultrasonic scrub

Movable carts

Tables

Poles

Small equipment

1500 pieces cleaned

OR, radiology, nursing

Cost: ~$20,000 / year

M Spencer, at al: The E=MC2 Project: Environment = Maintaining Cleanliness: A Multidisciplinary Approach To

Establish a Routine Cleaning Schedule for Medical Equipment.

APIC 2005 Poster

SSI risk can be addressed by

controlling risk factors

19

Precautions are already in place to control the risk of bacterial

contamination throughout the peri-operative period

However, additional controllable risk factors remain – wound

closure provides an opportunity to address these risks

Controlled Risks Potentially Uncontrolled Risks

Scrubbing in Gowning Skin antisepsis Controlling OR environment Sterilizing instruments Using minimally invasive techniques

☐ Bacterial colonization of the suture ☐ Contamination of the incisional site

after the wound is closed ☐ Entry of bacteria from the skin during

wound closure ☐ Bacterial infiltration due to dehiscence

Uncontrolled Risk Factor:

Bacterial colonization of the suture

20

Like all foreign bodies, sutures can be colonized by bacteria: Implants provide nidus for attachment of bacteria1

Bacterial colonization can lead to biofilm formation1

Biofilm formation increases the difficulty of treating an infection2

On an implant, such as a suture, it takes only 100 staphylococci per gram of tissue for an SSI to develop3

1. Ward KH et al. J Med Microbiol. 1992;36: 406-413. 2. Kathju S et al Surg infect. 2009;10:457-461 3. Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27:97-134..

Contamination Colonization Biofilm

Formation

Why Plus Suture?

OR Air Current Contamination

In teaching hospitals:

Surgeon leaves room

Resident, Physician Assistant or Nurse

Practitioner work on incision

Circulating Nurse counts sponges and

starts room breakdown

Scrub Technician starts breaking down

tables and preparing instruments for

Central Processing

Anesthesia move in and out of room

Instrument representative might leave

room and Visitors may leave room

Suture with Staphylococcus colonies

Air settling plates in the operating room at the last hour of a total joint case

Potential for Contamination of Sutures at

End of Case

Plus Antibacterial Sutures:

Impact in a Real-World Setting

23

Plus sutures not only kill bacteria on the suture, but also create an

inhospitable environment around the suture

NEBH studied the “zone of inhibition” around the suture

A pure culture—0.5 MacFarland Broth—of S. aureus was

prepared on a culture plate

An antibacterial suture was aseptically cut, planted on the

culture plate, and incubated for 24 hrs

5 day zone of inhibition 10 day zone of inhibition

Traditional suture

Antimicrobial suture

Plus Antibacterial Sutures:

Impact in a Real-World Setting

24

NEBH One Year Prospective Study of 3800 Total Joints

and Antimicrobial Sutures

In July 2005, implemented a full-year evaluation of

antibacterial sutures usage in an orthopedic setting

Changed product over July 4th holiday and did not tell

all surgeons (only those involved with study)

At the end of the year-long trial period:

45% reduction in SSIs caused by Staph aureus and

MRSA

Infection rate dropped from

0.44% to 0.33% with three less infections

Spencer M, et al: Reducing the Risk of Orthopedic Infections: The Role of Innovative Suture Technology

NAON Poster Presentation - 2010

0

0.1

0.2

0.3

0.4

0.5

FY05 FY06

Series1

Articles Related To Antibacterial Sutures

*Justinger, C, et al. Antibiotic coating of abdominal closure sutures and wound infection. Surgery 2009;145:330-4. (*RCT)

Rothenburger S, et al. In vitro antimicrobial evaluation of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect 2002;3 Suppl 1:S79-87

Ford HR, et al. Intraoperative handling and wound healing: controlled clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture). Surgical Infections. 6(3):313-21, 2005.

Edmiston CE, et al. Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination? Journal of the American College of Surgeons. 203(4):481-9, 2006 Oct

Innovative wound closure technologies

can address risk factors for SSIs

26

Topical Skin Adhesive provides a microbial barrier during the

critical wound healing period

SSI Risk Factor Innovative Technology

Bacterial colonization of the suture

Contamination of the incisional site after the

wound is closed

Entry of bacteria from the skin during

wound closure

Bacterial infiltration due to dehiscence

Antibacterial Sutures

Chlorhexidine/alcohol skin prep

Prevention of Dehiscence and

Exogenous Contamination with

Topical Skin Adhesive or

Antimicrobial Dressings

27

Antisepsis with Chlorhexidine

2% CHG/70% alcohol skin preparation (tinted orange) Has a lasting effect on the skin ~ 2 days postop

Iodophors are fast kill but no long term effect

CHG dry time is 3 minutes (to prevent fires)

• Evidence that chlorhexidine/alcohol achieves

better skin antisepsis than iodophor Darouiche et al NEJM 2010 Ostrander et al JBJS Am 2005 Saltzman et al JBJS Am 2009

Post-op Skin Issues in Orthopedics

Anterior fusion with tape burns

Posterior fusion with contaminated steri-strips

Contaminated steri-strips

Staples increase infection rate

Associated Wound Infection or Separation After

Cesarean Delivery: Sutures vs Staples

Prospective, randomized study of 435 c-section patients1

197 patients: staples

219 patients: 4-0 MONOCRYL™ (poliglecaprone 25) Suture on PS2 needle

– Wound separation rate: 17% (staples) vs. 5 % (sutures)

– Wound complication rate: 22% (staples) vs. 9% (sutures)

– Staple closure was a significant independent risk factor for wound

separation after adjustment for all other factors (GDM, BMI >30, incision

type, etc)

Meta-analysis of 6 studies with a total of 1487 c-section patients2

803 patients: staples

684 patients: subcuticular suture closure

– Staple closure was associated with a two-fold increase in risk of wound

infection or separation

1. Basha et al. Am J Obstet Gynecol. 2010;203:285.e1. 2. Tuuli et al. Obset Gynecol. 2011;117:682.

The risk for infection after joint surgery is higher with staples vs traditional

stitches, according to the results of a meta-analysis reported in the March

16 2010 issue of the BMJ.

In 6 publications reporting on a total of 683 wounds, 332 patients underwent

wound closure with sutures, and 351 underwent closure with staples.

Compared with suture closure, staple closure was associated with more

than triple the risk for the development of a superficial wound

infection after orthopaedic surgery (RR, 3.83; 95% CI, 1.38 – 10.68; P =

.01).

When hip surgery was analyzed as a separate subgroup, the risk for the

development of a wound infection was 4 times greater with use of

staples vs use of sutures (RR, 4.79, 95% CI, 1.24 – 18.47; P = .02). Suture

closure and staple closure did not differ significantly in development of

inflammation, discharge, dehiscence, necrosis, or allergic reaction.

“The Medical Journal of Australia” has recently updated its guidelines for skin

closure in the treatment of hip fractures, and they state that superficial wound

complication rates are higher for wounds closed with metallic staples than for

wounds closed with subcuticular vicryl.

Obesity and Surgical Incision

31

Incision collects fluid – serum, blood - growth medium for organisms

Spine fusions -incisions close to the buttocks or neck

Heavy perspiration common

Body fluid contamination from bedpans/commodes

Friction and sliding - skin tears and blisters

Itchy skin - due to pain medications - skin breakdown

Topical Skin Adhesive: A Proven Microbial

Barrier

32

Provides a flexible, protective microbial barrier that moves with the patient,

preventing breakage and acting like a temporary “skin”1,2

Adhesive demonstrates inhibition of gram-positive bacteria (MRSA and MRSE) and

gram-negative bacteria (E coli) in vitro2-4

Provides greater than 99% protection for 72 hours against organisms commonly

responsible for SSIs2,3:

S. epidermidis

E. coli

S. aureus

Pseudomonas aeruginosa

Enterococcus faecium

No fractures,

wound failure

or dehiscence

1. Quinn et al. JAMA. 1997;277:1527-1530 2. Bhende et al. Surg Infect (Larchmt). 2002;3:251-257. 3. Narang et al. J Cutan Med Surg. 2003;7:13. 4. World Health Organization. WHO Guidelines for Safe Surgery 2009. 2009.

Topical Skin Adhesive: Benefits Beyond Risk

Reduction

33

For Hospital Staff No time spent removing staples or sutures Reduced hospitalization costs Reduces number of suture set ups Simplifies post-op wound checks Reduces number of wound dressings

For Patients

7 days of wound healing strength in less than 95 seconds of application Shower immediately Outstanding cosmesis Reduced follow-up Less pain and anxiety

Incisional Adhesive on Total Knee Incision

Clinical Use of Incisionial Adhesive

Knee: Sealed with incisional

adhesive, covered with Telfa

and a transparent dressing

for incision protection Healed incision

Hip: Sealed with adhesive

covered with gauze and

transparent dressing for

incision protection

Incisional Adhesive and Total

Shoulder Replacements

0

0.5

1

1.5

2

2.5

Total Shoulder Rates

2003 2004 2005 2006 2007 2008 2009 2010

• Propionibacterium acnes related total shoulder infections (TSR)

• Eliminated the use of staples for TSR

• Instituted the use of incisional adhesive

• Covered dressing until day of discharge for protection

Selected Publications: DERMABOND® Topical

Skin Adhesive in Orthopedic Surgery

Procedure Reference No. of Patients Key Findings

Primary hip arthroplasty1 Khurana et al. 2008 93

• Patients followed for >7 months

• No infections

• 1 wound dehiscence

Lumbar and cervical spine

procedures2 Hall and Bailes. 2005 200

Retrospective

• Patients followed for >5 months

• Only 1 documented SSI

• High patient satisfaction

Total hip arthroplasty for

femoral neck fracture3 Kregor et al. 2008 Retrospective

• Surgeon preference to reduce urinary

and fecal contamination of wound

and allow patients to shower

immediately

1. Khurana et al. Acta Orthop Belg. 2008;74:349.

2. Hall and Bailes. Neurosurgery. 2005;56(suppl 1):147.

3. Kregor et al. Techniques Ortho. 2008;23:312.

A protective barrier that adds strength and reduces bacteria

• Has been shown in ex vivo studies to have superior tensile strength versus other octyl

and butyl based products

• Creates a microbial barrier against organisms commonly responsible for SSIs*

DERMABOND ADVANCED™ Topical Skin Adhesive

Data on File. Ethicon, Inc.

*Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, Enterococcus faecium and Pseudomonas aeruginosa

Innovative

Comparison of TSA Components Among Currently

Available Agents

Components

DERMABOND

ADVANCED™

Topical Skin

Adhesive SurgiSeal™

derma+flex® QS™

(octylseal™) INDERMIL®

Histoacryl®

(Repara) LiquiBand® Skinstitch®

Octyl

adhesive

Plasticizers ?

Inert storage

vial,

stabilizer, and

no

refrigeration

Initiator and

heat-

dissipating

agent

High-

viscosity

formulation

The third-party trademarks used herein are trademarks of their respective owners. Data on file: Ethicon Inc.

Evidence-Based Performance

The largest randomized clinical trial database of any TSA

8x the number of patients vs the leading competitor

Product

Total Number

of RCTs

Total Number of

Patients Treated

DERMABOND®

Topical Skin Adhesive 40 4075

Histoacryl® 6 534

INDERMIL® 2 150

LiquiBand® 1 78

SurgiSeal® 0 0

derma+flex® QS™

(octylseal™) 0 0

RCTs only; reasons for exclusion were language of publication other than German or English, nonhuman studies, case series or

case reports, and inappropriate indication.

No RCTs identified for any other competitors.

The third-party trademarks used herein are trademarks of their respective owners.

RCT = randomized controlled trials.

Data on file: Ethicon Inc, Literature Search 2/2011 PubMed

41

A unique combination of

2 components

• A 2-octyl cyanoacrylate topical skin

adhesive for proven strength and

microbial protection1,2

– Sets in approximately 60 seconds

when applied to mesh

– 2-hour working time3

• A flexible, self-adhesive polyester mesh

for superior approximation and healing1,3

– Contains initiator that accelerates

polymerization of liquid adhesive

– Each dispenser contains 60 cm of tape

New, innovative, minimally invasive DERMABOND™ PRINEO™ Skin Closure System

1. DERMABOND™ PRINEO™ IFU. PM72449C. STATUS 6/2010.

2. Shapiro AJ et al. Am Surg. 2001;67(11): 1113‐1115. 3. Data on file. Ethicon, Inc.

42

Gently and evenly disperses tension across the entire area

of the incision, without penetrating the skin

Minimally invasive closure that distributes tension away from the wound

Traditional closure DERMABOND™ PRINEO™ Skin Closure

System

DERMABOND™ PRINEO™ removal

Patient is shown 2 weeks after circumferential body lift and immediately

after removal of

DERMABOND™ PRINEO™ Skin Closure System.

Areas for Cost Savings

45

Surgical Incise Drapes

Iodophor- impregnated incise

barrier drape

No data to support these

drapes reduce SSI – although

do reduce bacteria on skin

Surgeon preference based on

adhesion to skin and drapes

Consider using non-

impregnated drapes and using

cost savings for other innovative

technologies

Use of plastic adhesive drapes during surgery for preventing surgical site infection

Objective:

Compared the effect of adhesive drapes used during surgery on surgical site infection, cost, mortality and morbidity

Five studies involving 3,082 participants comparing adhesive drapes with no drape

Two studies involving 1,113 participants comparing iodine-impregnated adhesive drapes with no drape

Conclusion:

A significantly higher proportion of patients in adhesive drape group developed a surgical site infection when compared with no drape

Iodine-impregnated adhesive drapes had no effect on the surgical site infection rate

Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006353

47

Bacitracin/Polymixin Irrigation

Feb 2007 - stopped routine use of Bacitracin/Polymixin Irrigation

Cost: > $110,000/year reduced to $10,000

Limited use for revisions, allografts and infected cases (irrigation and

debridements)

New irrigant available – FDA approved for mucous membranes with

0.05% CHG - Irrisept

Fletcher N, et al: Prevention of perioperative infections. J Bone

Joint Surg Am. 2007;89:1605-1618

48

Finally, an alternative to saline and antimicrobial irrigation The first and only FDA-cleared cleansing and debridement system, containing

0.05% Chlorhexidine Gluconate (CHG) in Water for Irrigation

IrriSept O.R. (sterile packaging)

Irrigation Applicators: Custom designed

applicators facilitate

cleansing for a variety of

applications

SplatterGuard® LT SplatterGuard® IrriProbe®

IRRISEPT

Review: Bundled Approach to Eliminating SSIs

1. Pre-screen inpatient surgeries for MRSA and Staph aureus (MSSA) using PCR rapid molecular technology

2. Decolonization protocol for MRSA/MSSA positive patients (eg mupirocin 2% ointment 2 x day, daily CHG wash x 5 days)

3. Preoperative shower with CHG (eg Hibiclens) or CHG washcloths (eg Sage) night before/morning of surgery

4. Assure OR standards are being met (traffic control, surgical attire, surgical hand scrub, sterilized instruments, room turnover and terminal cleaning, precautions in OR)

5. Assure surgical prophylaxis is delivered for maximum tissue concentrations

6. Surgical skin prep with CHG/alcohol prep

7. Irrigation with CHG if necessary (eg Irrisept)

8. Antibacterial sutures (eg Ethicon)

9. Incisional Adhesive (octyl cyanoacrylate) (eg Dermabond and Prineo)

10. Post-op incision care instructions

11. Data driven, analysis and calculation of rates, communication/feedback

Reducing Risk Factors for SSIs:

Tools for success

50

Institutional support

Senior leadership and “C Suite” involvement

“lead the effort” from top down

Clear goals

Structured program with clearly defined goal of

zero tolerance for HAIs

Theoretical foundation to IP Program: Social

Learning Theory (Role Modeling, Self Efficacy,

Positive Deviance)

Communication – effective and consistent

Ongoing and creative education

Financial support to Infection Prevention program

Thank You