SSI Collaborative

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Surgical Site Infection Collaborative: 

Surgical Site Infection Collaborative

January 1 – September 2, 2001: 

January 1 – September 2, 2001 13 orthopedic surgeons involved in 36 musculoskeletal cases that developed infections

#of Days Between Total Joint Replacement Infections January 1, 2002 through June 2003: 

#of Days Between Total Joint Replacement Infections January 1, 2002 through June 2003

Trending of Hip Prosthesis Infection Rates: 

Trending of Hip Prosthesis Infection Rates NNIS Risk 1 NNIS Risk 0

Trending of Knee Prosthesis Infection Rates: 

Trending of Knee Prosthesis Infection Rates NNIS Risk 1 NNIS Risk 2

Surveillance Focus Included: 

Surveillance Focus Included ASA score Length of surgery Number of personnel in OR suite Microorganism cultured Timing of preoperative antibiotic

Time Line of Events: 

Time Line of Events 01/28/02 Orthopedic surgical infections report presented to Infection Control Committee 03/06/02 04/15/02 05/02/02 05/09/02 05/16/02 Meeting with key players regarding surgical wound infections Teleconference – Multifactorial Interventions to Prevent Surgical Site Infections Infection Control Nurse and Hospital Epidemiologist perform and videotape a surgical scrub using chlorhexadine 4%/isopropyl alcohol Memo sent to orthopedic surgeons recommending chlorhexadine 4%/isopropyl alcohol as skin prep of choice Infection Control Nurse and Hospital Epidemiologist meet with orthopedic surgeons regarding ortho infections in 2001

Time Line of Events: 

Time Line of Events 06/24/02 Infection Control Nurse and Hospital Epidemiologist meet with Board Members to discuss ortho surgical wound infections Meeting with key players to discuss ortho surgical wound infections Discussion regarding ortho surgical infections deferred at Ortho Dept. Meeting Ortho surgeon addressed the issue of ortho infections briefly at department meeting Meeting with Hospital CEO and key players regarding ortho infections Hospital Epidemiologist presents recommendations at Ortho Q.A. Meeting 10/17/02 09/16/02 12/16/02 12/30/02 10/28/02 09/30/02 Orthopedic infections on Ortho Dept. Meeting agenda, discussion deferred

Recommendations: 

Recommendations Employ chlorhexadine 4% / isopropyl alcohol as skin prep Use clippers for hair removal Maintain a core body temperature of > 36ºc throughout surgery Administer oxygen at 80% / 50% intra-operatively and at 80% by sealed mask/conventional non-rebreather mask for first two hours of recovery Test blood glucose thirty minutes after incision time Administer appropriate antibiotic within 30 minutes of incision time Discontinue antibiotics within 24 hours

Team Members: 

Team Members Raymond Palesch, MD – Orthopedic Surgeon, Trauma Medical Director Neil Barg, MD – Hospital Epidemiologist Carl Olden, MD – Medical Staff Quality Amy Crook, MD – Anesthesiologist Mario Domenzain, MD – OB/GYN Paul Novak, CRNA Ken Eakin, RN – Surgical Services Supervisor Kristy Cure, RN – Surgical Services Nurse Manager Connie Conklin, RN – Ortho/Neuro/IV Tx Nurse Manager Gay Scott, RN, CIC – Infection Control Nurse Greg Matsuura, Pharm-D Kay Anyan, RHIA – Director Medical Staff Services Linda Bluhm, CPHQ – Director Performance Improvement Sandy Dahl, RN – VP Nursing & Patient Care Linda Haralson, RN – L&D/Peds/NICU Nurse Manager Cecilia Bray, RN – Women’s/Gen. Surgery Nurse Manager

Timely Antibiotics Administered: 

Timely Antibiotics Administered Anesthesia/Nursing responsible Development of protocol for administration within 30 minutes prior to incision 2 gms of antibiotic for adults over age 16 Repeat intraoperative dosing at 3 hours

Antibiotics Within One Hour: 

Antibiotics Within One Hour

Appropriate Antibiotics Given: 

Appropriate Antibiotics Given Initiation of Antibiotic Review of perioperative antibiotics Development of Penicillin Allergy Algorithm

Appropriate Antibiotics Given: 

Appropriate Antibiotics Given

Antibiotic Prophylaxis : 

Antibiotic Prophylaxis Given within 30 minutes of cut time Exception: Vancomycin and Levofloxacin 1 hr infusion time Infusion must be finished prior to cut Recommended duration discontinue within 24hrs1 Bratzler DW, et al. Antimicrobial Prophylaxis for Surgery: An advisory statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004;38:1706-1715 Antimicrobial prophylaxis for surgery. Treatment Guidelines from the Medical letter, 2004; 2(20):27-32.

Orthopedic Antibiotic Prophylaxis : 

Orthopedic Antibiotic Prophylaxis 2gms Cefazolin IV within 30 minutes of incision in all patients over age 16. If Penicillin allergic use Vancomycin 1gm IV over a 60 minute infusion time.

Penicillin Allergy Assessment Tool (Elective Orthopedic Surgery): 

Penicillin Allergy Assessment Tool (Elective Orthopedic Surgery) Has the patient been able to tolerate a cephalosporin without an allergic reaction? Does the patient have a reported cephalosporin allergy? What type of penicillin reaction was it? Did the patient develop severe hypotension, respiratory distress, or systemic swelling? No Use Vancomycin Use Cefazolin Use Cefazolin Yes No No No Yes Yes Did the patient develop hives (raised, itchy, systemic welts) during a treatment course? Yes

Antibiotics Discontinued in 24 Hours: 

Antibiotics Discontinued in 24 Hours Nurse Manager provided SSI collaborative PowerPoint presentation to Surgical Services staff - 3/31/03 Physician Champion provided SSI collaborative slide presentation to orthopedic surgeons and anesthesia – 4/21/03 Orthopedic Section voted to revise order sheet to discontinue antibiotics in 24 hours – 5/27/03

Slide21: 

Orthopedic Post-op Orders Page 2 of 2 .Antiemetic Protocol .Respiratory: If on Oxygen, oximetry every 8 hrs, D/C O2 when SAT >92% Respiratory Care, evaluate and treat  Incentive Spirometry .Activity:  Bed Rest  OOB this PM  Chair TID Physical Therapy: Begin treatment: this P.M. in A.M. _______________WB affected extremity Total Hip Protocol ______________________ WB affected extremity Total Knee Protocol ____________________ WB affected extremity Elevate affected extremity  6” above heart level  heart level  stockinette  calves elevated on pillows CPM _____________________________________________________________________________________________________________________________________ Other _____________________________________________________________________________________________________________________________________ .Misc: X-Ray _____________________________________________________________________________________________________________________________________ Dressing __________________________________________________________________________________________________________________________________ Autotransfusion Discontinue Hemovac  24 hours post-op  48 hours post-op R/C or straight cath PRN inability to void – Discontinue R/C 48 hrs post-op, reinsert PRN. C&S PRN TEDS Protocol  SCD Protocol  Abduction Bolster SS consult – Discharge Planning Cold Therapy Ice pack to affected area 20-30 minutes 3 times/shift (do not place ice bag directly on skin) Physician’s Signature: _______________________________________________________________________ Date/Time: ______________________________________________

Antibiotic Discontinued in 24 Hours: 

Antibiotic Discontinued in 24 Hours

Hair Removed Appropriately: 

Hair Removed Appropriately Two clippers stocked in each OR suite Re-inserviced staff via poster boards Specific staff member assigned responsibility for stocking Use of clippers implemented for other surgical procedures

Hair Removed Appropriately: 

Hair Removed Appropriately

Normothermia: 

Normothermia Calibration checked on forced air warming machines and adjusted Forced air warming machines placed on preventative maintenance schedule Pre-op warming blankets Increase of room temperature abandoned Abandoned cooling vests for surgeons after trial Space hats in pre-op Underbody warmers in OR

Body Temperatures: 

Body Temperatures

Supplemental Oxygen: 

Supplemental Oxygen Implemented use of non-rebreather mask at high flow Patient education regarding rationale in pre-op holding areas Set standard mask removal time at 2 hours post arrival to patient room Non-rebreather mask application to patient with initiation of oxygen flow Utilization of timer abandoned

Supplemental Oxygen Perioperatively: 

Supplemental Oxygen Perioperatively

Patient Satisfaction Non-Rebreather Mask: 

Patient Satisfaction Non-Rebreather Mask Interview each patient post discontinuation 246 out of 255 patients were satisfied with the use of the non-rebreather mask (96.5%)

Chlorhexadine 4%/Alcohol Prep March 19, 2003 – February 29, 2004: 

Chlorhexadine 4%/Alcohol Prep March 19, 2003 – February 29, 2004 Total Knee/Total Joint Recommendations

Slide31: 

31

Other Inpatient Ortho: 

Other Inpatient Ortho Started July 2003

Neuro Surgery: 

Neuro Surgery Started November 2003

Slide34: 

March 2003 Ortho Hips and Knees July 2003 Other Ortho November 2003 Neuro January 2004 C-Sections May 2004 OB/GYN November 2004 Colon February 2005 General Surgery and Urology September 2005 Wound Care, Podiatry, and Plastics SSI Collaborative 3 Year Plan

Appropriate Prophylactic Antibiotic Selected: 

Appropriate Prophylactic Antibiotic Selected

Percent of Abx Given Within 1 Hour of Incision: 

Percent of Abx Given Within 1 Hour of Incision

Percent of Prophylactic Abx Discontinued Within 24 Hours After Surgery End Time: 

Percent of Prophylactic Abx Discontinued Within 24 Hours After Surgery End Time

Slide38: 

38

Trending of Total Hip Infection Rates: 

Trending of Total Hip Infection Rates NNIS Rate: 0.88 NNIS Rate 1.61

Trending of Total Knee Infection Rates: 

Trending of Total Knee Infection Rates NNIS Rate: 1.26 NNIS Rate: 0.87

Recommendations: 

Recommendations Employ chlorhexadine 4% / isopropyl alcohol as skin prep Use clippers for hair removal Maintain a core body temperature of > 36ºc throughout surgery Administer oxygen at 80% / 50% intra-operatively and at 80% by sealed mask/conventional non-rebreather mask for first two hours of recovery Test blood glucose thirty minutes after incision time Administer appropriate antibiotic within 30 minutes of incision time Discontinue antibiotics within 24 hours

Surgical Site Infection Collaborative: 

Surgical Site Infection Collaborative

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