the application of evidence based bundle approach to
TRANSCRIPT
The Application of Evidence Based Bundle Approach to Reduce Surgical Site Infection in Geriatric Hip Fracture Patients – A Single Centre Experience Chan PHA1, Chu WSV 1, Hung KYR 2, Chow CYV 3, Yuen FYF 4, Kwok KBC 1, Hung YW 1, Fan CHJ 1 , Ho PC 1 1 Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital 2 Infection Control Nurse, Alice Ho Miu Ling Nethersole Hospital 3 Department of Microbiology, Prince of Wales Hospital 4 Department of Anaesthesiology and Operating Services, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
Geriatric Hip Fracture Hemiarthroplasty
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
• Common Orthopaedic Procedure
• At least 1 Surgeon + At least 1 Assistant
• Done by Trainee or Specialist
Background • The Surgical Site Improvement Program and Audit
for Orthopedic surgeries has been developed in 2009 in AHNH
• 10.3% Surgical Site Infection (SSI) in Geriatric Hip Hemiarthroplasties in 2010
• 8% SSI in Geriatric Hip Hemiarthroplasties in 2012
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Morbidities Quality of Life Hospital length of stay by 7 -14 days Likelihood of ICU admission by 60%
Median total direct Costs by 300%
Risks of Rehospitalization & Death
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Surgical Site Infection (SSI)= Dreadful Complication (Mangram A, Horan T, Pearson M, et al. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247–78. Katarincic JA et al. Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review. J Am Acad Orthop Surg 2018 Jan.)
What to Do?
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Pre-operative Preparation
Post-operative
Preparation
Intra-operative
Preparation
Multidisciplinary Teamwork Orthopaedic Surgeons +
Nurses
Operation Theatre
Infection Control Team
Infection Control Nurse
(ICN)
Microbiologist
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Methodology • Objective:
◦ To reduce surgical site infection (SSI) in hemiarthroplasty operation in
geriatric hip fracture patient
• Target group:
◦ > 65 years old
◦ Fracture neck of femur
◦ Hemiarthroplasty operation
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
• MRSA screening
◦ Performed for all potential hemiarthroplasty cases for Hip fractures
◦ For positive cases:
◦ Vancomycin is used as prophylactic antibiotics.
◦ Decolonization is carried out
A. Pre-operative Preparation
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Preoperative Skin Preparation by Chlorhexidine Bathing
1 day before operation / on operation day
B. Intra-operative Preparation
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Strict Observation of Hand Washing Guideline
Limitation of Traffic
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Step I. Povidine iodine disinfection before draping
Step II. Double-sponge disinfection with povidine iodine upon water-tight draping
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Step III. Coverage of the knee to distal region with a sterile plastic sheet wrapped by crepe bandage
Step IV. ChloraPrep with tint (Chlorhexidine gluconate and isopropyl alcohol) with time allowed for alcohol evaporation
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Step V. Circumferential iodophor impregnated plastic adhesive drape ('Ioban') covering the hip and thigh region
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VI. Surgical wound dressed with Aquacel Adhesive tape after wound closure
C. Post-operative Care
• Dressing care:
◦ Change dressing immediately after soaked or contaminated
• Wound Inspection Precautions:
◦ Surgical wound should NOT be left unattended for inspection.
◦ Unnecessary wound inspection in early post-operative period should be
avoided.
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Total of 496 Hemiarthroplasties (2008-2017Q3)
Chi-square test p=0.082
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ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
IHD 5%
AF/ warfarin 3% Lipid
3%
DM 15%
HT 15% CVA/
Parkinon's disease
11% ESRF/RF
5% RA/SLE
1%
GIB 2%
Liver failure 5%
steroid 0%
Dementia 8%
Psy problem 3%
Coagulopathy 2%
CHF 2%
others 18%
Medical Comorbidities 2008-2017
No. of comorbidities /
patient 2008-
17Q3 2008-2012
2013-17 Q3
1 2 1 1 2 12 7 5 3 2 2 0 4 7 5 2 5 3 1 2 6 2 1 1
One 7%
Two 43%
3 7%
Four 25%
Five 11%
Six 7%
No. of comorbidities / patients 2008-2017
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
3.31
1.95
3.95
1.6
7.25
3.55
0
1
2
3
4
5
6
7
8
2008-2012 2013-17 Q3
Superficial Infection
Deep Infection
Overall Infection rate
Average Yearly Infection Rate (%)
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
14.28571429
3.636363636
10.34482759
0
8
4
6
2.702702703 3.174603175
1.851851852
AHNH overall mean=5.24
HA overall =1.598 0
2
4
6
8
10
12
14
16
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Q1-Q3
SSI r
ate
(%)
AHNH Surgical Site Infection Surveillance (AMA & Unipolar Hip Arthroplasty) 2008 - 2017 Q3
Infection rate of AMA/Unipolar hip arthroplasty (%) AHNH Overall mean of AMA & UHA
HA overall mean for HPRO 2016
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
79%
21%
Antibiotic Alone
SurgicalDebridement
Treatment of Superficial Wound Infections
100%
Removal of Implant and Surgical Debridements
Treatment of Deep Wound Infections
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Bacteriology of AMA/ Unipolar Hip Arthroplasty
2008-2017
2008-2012
2013-2017 Q3
Acinetobacter species 2 2
Enterococcus species 1 1
Klebsiella species 1 1
Pseudomonas Species 3 2 1
Staphylococcus aureus 3 2 1
MRSA 6 3 3
Staphylococcus CNS 4 4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008-2017 2008-2012 2013-2017 Q3
2
2 1
1
1
1
3
2
1 3
2
1
6
3
3
4
4
Bacteriology of AMA / Uniploar Hip Arthroplasty
Staphylococcus CNS
MRSA
Staphylococcus aureus
Pseudomonas Species
Klebsiella species
Enterococcus species
Acinetobacter species
Discussion • The Bundle Approach cannot 100% eliminate
SSI, BUT….
• Decreasing trend of Overall SSI
• Decreasing trend in Deep wound infection in consecutive 2 years since 2015
ALICE HO MIU LING NETHERSOLE HOSPITAL, NTEC
Conclusions • The bundle approach has shown to achieve an effective
and sustained decrease in SSIs in Hemiarthroplasty operations for geriatric hip fracture patients
• The result needs shared efforts, mutual communications, support and understandings of multidisciplinary teams
Reference:
1.Acklin YP, Widmer AF, Renner RM, Frei R, Gross T. Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach. Injury. 2011 Feb;42(2):209-16.
2.Fairclough JA, Johnson D, Mackie I. The prevention of wound contamination by skin organisms by the pre-operative application of an iodophor impregnated plastic adhesive drape. J Int Med Res. 1986;14(2):105-9.
3.Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden. Patient Saf Surg. 2012 Jun 14;6(1):11.
4.Katarincic JA, Fantry A, DePasse JM, Feller R. Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review. J Am Acad Orthop Surg. 2018 Jan 1;26(1):14-25.
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