Preventing Surgical Site Infections Objectives Review microbiology basics

Preventing Surgical Site Infections

Objectives • Review microbiology basics of bacteria • Review infection control measures for isolation patients • Hand hygiene importance • Surgical Site Infection(SSI) surveillance • OR nurses role in SSI prevention • Discuss cleaning and disinfecting

Staphylococcus aureus • Gram-positive cocci, facultative anaerobe • Frequently found as part of the normal skin flora and in nasal passages • Most common species to cause Staph infections – successful at evading the immune system • Often the cause of surgical site infections • Spread of S. aureus is generally through human-tohuman contact

Streptococcus • Gram Positive, non-spore forming. • Group A Strep common in necrotizing fasciitis. • Part of normal skin flora. Most bacteria in the OR environment are shed from the skin of perioperative personnel.

Enterococcus spp. • Gram positive cocci, often occur in pairs or short chains, facultative anaerobes • Common organisms in the GI tract • High level of intrinsic antibiotic resistance • Found in SSI, UTI, bacterial endocarditis & septicemia. • Vancomycin-Resistant Enterococcus (VRE)

Escherichia coli • Gram negative rod, facultative anaerobe • Harmless strains are part of GI flora • Responsible for ~90% of UTIs

Mycobacteruim Tuberculosis • Non spore-forming bacillis • Can infect almost any tissue including skin, bone, lymph nodes, intestine. • Spread through upper respiratory tract and dispersed through the body by macrophages. • Patients without active infection are not infectious

Multi-Drug Resistant Organisms Gain resistance to antibiotics by: • Mutations • Sharing resistance genes • Inherent resistance

Vancomycin-Resistant Enterococcus (VRE) • VRE can be carried by healthy people • The most commonly transmitted by the contaminated hands of healthcare workers • Can remain viable in the environment for extended periods - Resistant to desiccation and temperature extremes Patients actively colonized or infected must be in contact precautions

MRSA • Any strain of Staphylococcus aureus that has developed resistance to beta-lactam antibiotics • Does not mean it is more virulent, however it is more difficult to treat with standard antibiotics • Healthcare provider-to-patient transfer is common, especially when hand hygiene is poor Patients actively colonized or infected must be in contact precautions

Colonized patients represent the major reservoir of MRSA Infected Colonized Countries that actively seek out and isolate MRSA colonized patients have very low rates of MRSA transmission

Creutzfeldt-Jakob Disease • Transmissible spongiform Encephalopathy • Disease causing organism is prion • Can be hereditary or occur spontaneously • 1% of cases are transmitted person-person, requires CNS tissue contact for transmission. • Resistant to conventional heat and chemical methods of sterilization. • Special sterilization practices or use of disposable instruments a must.

Do all health care workers “carry” MRSA? • 4 -6% of HCW colonized w/MRSA (2014) – As opposed to about 1% of general population – Not colonized does not mean you can’t transmit MRSA – Nor does it mean you cannot become colonized

Chain of Infection Causative Agent Susceptible Host MRSA Surgical, dialysis, cancer patient Portal of Entry Central line, wound, ventilator Reservoir Skin, wound, urine Portal of Exit Mode of Transmission Hands, equipment Secretions, cough, drains

• The body’s defenses are compromised during surgery • External barriers- skin • Inflammatory response • Immune response

Environment of Care An OR is more than just a room where everyone has a cool hat. • Surgical department is semi-restricted • Scrubs, Hat, Booties • An open OR is a restricted Environment • scrubs, hat, mask, and Booties • Temp 68 -73 degrees • Humidity 30 -60% • Smooth surfaces, easily wiped clean

Environment of Care ctd. AIRFLOW • OR suites arranged around a sterile core • Airflow from core to rooms to hallways (positive air pressure in OR relative to hallways) • 15 air exchanges per hour • Nurse controls movement through and around the OR • Best Practice: enter through core when open.

Transmission-Based Precautions • Contact - Spread through direct or indirect contact - MRSA, ESBL, VRE, C. diff. , RSV, Shingles - Place signs on OR doors, notify housekeeping personnel. -Don’t forget PACU -Terminal clean after case. “When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient's body are contained and covered. ”- CDC

Transmission-Based Precautions • Droplet - Airborne particles larger than 5 microns do not remain suspended in the air for long periods - 3 foot rule, mask patient (unless intubated) - Bacterial meningitis, influenza, B. pertussis -Use door signs and terminal clean room -Transport same as contact precaution but with surgical mask on the patient. -Don’t forget PACU

Airborne Precautions If an OR must be positively pressurized to protect our patients, how do we handle TB patients? – Gold Standard is a negative pressure anteroom If that isn’t available… – Intubate/Extubate in a negative pressure room and transport using a ventilator with HEPA filter. What if it’s an Airway case? – Wear N 95 mask while in the OR – Keep OR closed for min 28 minutes following case – Keep doors closed during case – Supplemental air cleaning with portable HEPA – Don’t forget…

Contact Enteric -Hand washing on room egress with soap and water. May use alcohol based hand sanitizer on entry. -All environmental cleaning to be done with bleach based products. -Must be transferred or discharged and room terminally cleaned with bleach before resolution of contact enteric precautions. -C diff, norovirus.

Hand Hygiene • Hands contaminated with transient bacteria are a primary means for transmission leading to infection. while • Transient flora are microorganisms that colonize the superficial layers of the skin. These are acquired by HCW caring for patients and from coming into contact with contaminated surfaces where patients reside. Hands with broken skin are more susceptible to becoming colonized with transient bacteria, including MDROs. An outbreak involved a cardiac surgeon’s infected fingernail. When cultured, it grew Psuedomonas aeruginos. Two patients treated by the surgeon developed a surgical site infection with the same strain of P. aueruginosa. (AORN Guidelines 2012)

Hand Hygiene • Short fingernails are a must. Longer nails have increased bacterial load, are harder to keep clean. • No Artificial nails of any kind • No fingernail polish, gel nails or overlays. • Chipped nail polish harbor bacteria and can cause gloves to rip. • No rings! There is a strong link between wearings and hand contamination. (AORN Guidelines, 2012)

Hand Hygiene • Skin irritation, dermatitis from frequent hand washing is common. Use plenty of lotion to keep skin intact. ONLY use hospital provided lotion. • If you have cuts, abrasions, weeping dermatitis on exposed skin you should NOT be providing direct patient care. You are at risk for acquiring and transmitting infection.

Surgical Hand Antisepsis Persistent antimicrobial activity is important Alcohol has no persistent effect, CHG is most effective Remove all jewelry Remove all debris from under fingernails under running water Scrub hands and forearms for the recommended time (3 -5 minutes, depending on product guidelines) Scrubs longer than the manufacturers guidelines are unnecessary

HAND HYGIENE THE SINGLE MOST IMPORTANT MEASURE TO PREVENT THE TRANSMISSION OF INFECTION Partnering to Heal | HHS. gov

Break?

Surgical Site Infections (SSIs)

Surgical Site Infections… Account for 14 -16% of all nosocomial infections among hospitalized patients Account for 38% of nosocomial infections among surgical patients Occur in 2 -5% of extra-abdominal operations, and 20% of intraabdominal operations Cost an average of $25, 546 per affected patient Are preventable!

Patient • Diabetes • Morbid obesity • Nicotine use • Steroid use • Malnutrition • Prolonged preoperative hospital stay • Comorbidities • Perioperative transfusion • Immunosuppressive therapy, neutropenia Factors

Surgical Site Infection Surveillance • • Total knee replacements Total hip replacements Laminectomy Fusion All cardiac with open chest C-section Colectomy Abdominal hysterectomy

Defining Surgical Site Infections

Superficial Incisional SSI • Occurs within 30 days of surgery • Involves skin or subcutaneous tissue • Patient has at least one of the following: i. Purulent Drainage ii. Identified organisms iii. Pain/tenderness, edema, redness or heat iv. Opened by the surgeon , and culture positive or not cultured v. Diagnosed by the surgeon or attending physician

Deep Incisional SSI • Occurs within 30 or 90 days after surgical procedure AND • Involves deep soft tissues (fascial and muscle layers) AND • Patient has at least one of the following: i. iii. iv. Purulent drainage Incision spontaneously dehisces or is opened by surgeon and is culture positive or not cultured, and the patient has fever or pain/tenderness Abscess found on direct exam, during re-op, or by examination by histopathology or radiology Diagnosis by surgeon or attending physician

Organ/Space SSI • Occurs within 30 -90 days of surgery • Involves any part of the body (excluding skin, fascia, or muscle layers) • One of the following symptoms: i. iii. iv. Purulent drainage Incision spontaneously dehisces or is opened by surgeon and is culture positive or not cultured, and the patient has fever or pain/tenderness Abscess found on direct exam, during re-op, or by examination by histopathology or radiology Diagnosis by surgeon or attending physician

And meets at least one criteria for site below. Code Site BONE Osteomyelitis MED Mediastinitis BRST Breast abscess or mastitis MEN Meningitis or ventriculitis CARD Myocarditis or pericarditis ORAL Oral cavity (mouth, tongue, or gums) DISC Disc space OUTI Other infections of the urinary tract EAR Ear, mastoid OREP EMET Endometritis ENDO Endocarditis Other infections of the male or female reproductive tract EYE Eye, other than conjunctivitis PJI Periprosthetic Joint Infection GIT GI tract SINU Sinusitis HEP Hepatitis SA JNT Joint or bursa Spinal abscess without meningitis IAB Intraabdominal, not specified UR Upper respiratory tract IC Intracranial, brain abscess or dura VASC Arterial or venous infection LUNG Other infections of the respiratory tract VCUF Vaginal cuff

Preoperative Prevention Strategies SCIP (Surgical Care Improvement Project) Measures to Prevent Infections: FYI…. 100% compliance with SCIP measures is essential for complete re-imbursement by CMS • Administer the appropriate prophylactic antibiotic within one hour prior to surgical incision for included surgeries • CABG, Cardiac or Vascular procedures • Hip/Knee Arthroplasty • Colon • Hysterectomy • Discontinue prophylactic antibiotics within 24 hr of surgery end time (48 hours for cardiac patients).

Perioperative Prevention Strategies SCIP (Surgical Care Improvement Project) Measures to Prevent Infections: • Glucose Control • Control serum glucose in cardiac surgery patients < 200 mg/dl @ 0600 post-operative days 1 and 2 • Hair Removal • Use national guideline approved method for surgical site hair removal • Avoid shaving with razors • Use clippers

Preoperative Prevention Strategies SCIP (Surgical Care Improvement Project) Measures to Prevent Infections: • Ensuring Normothermia Perioperative hypothermia occurs when a patient’s core body temp falls below 36 C and is associated with increased SSIs, longer hospital stays, and other negative outcomes Use warming devices to ensure patient temp >36 C in or near the OR and upon arrival to PACU • Foley Catheter Removal Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day one

Cleaning and Disinfecting “The responsibility for verifying a clean surgical environment rests with perioperative nurses. ” • OR RN should assess the environment frequently for cleanliness and take action where needed • All flat surfaces should be damp dusted before the first scheduled procedure of the day • OR suites should be cleaned after each procedure • Damaged or worn coverings need to be discarded and replaced • Patient transport devices, including straps and attachments need to be cleaned after each use

Remember that you are the patient’s advocate! It’s your job to ensure the team is adhering to aseptic practices, and that you safeguard your patients privacy and ensure their safety.