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Cynosure Health


									Today’s Webinar will begin at
        11:00 PST

Welcome from Barb DeBaun, RN, MSN, CIC

Please do not put your phone on hold; use
the mute function or *6
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Interactive question session
If time permits, we will open up the phone
lines at the conclusion of the presentation
Introducing Sue Barnes, RN,
          BSN, CIC

Beyond SCIP – SSI Prevention

      Sue Barnes RN, BSN, CIC
         National Program Leader
      Infection Prevention & Control
             Kaiser Permanente

1. Discuss strategies to optimize 4
   specific SCIP measures, beyond
   regulatory compliance
2. Discuss 11 products and practices
   above and beyond SCIP – i.e. “plus”
3. Provide resources and references
   relative to “plus” measures

                      SCIP Measures

 SCIP INF 1 Prophylactic antibiotic received within one hour prior
  to surgical incision
 SCIP INF 2 Prophylactic antibiotic selection for surgical patients
 SCIP INF 3 Prophylactic antibiotics discontinued within 24 hours
  after surgery end time (48 hours for cardiac patients)
 SCIP INF 4 Cardiac surgery patients with controlled 6 a.m. post op
  serum glucose (200 mg/dL)
 SCIP INF 6 Surgical patients with appropriate hair removal
 SCIP INF 7 Colorectal surgical patients with immediate
  postoperative normothermia
 SCIP INF 9 Urinary catheter removed on post op day 1
 SCIP INF 10 Surgery patients with perioperative temperature

    3 grams Ancef for Bariatric Patients
1. Freeman JT, Anderson DJ, Hartwig MG, Sexton DJ.
   “Surgical site infections following bariatric surgery in
   community hospitals: a weighty concern?” Obes Surg.
   2011 Jul;21(7):836-40.
2. Pevzner L, Swank M, Krepel C, Wing DA, Chan K,
   Edmiston CE Jr. “Effects of maternal obesity on tissue
   concentrations of prophylactic cefazolin during
   cesarean delivery”. Obstet Gynecol. 2011
3. Roe JL, Fuentes JM, Mullins ME. “Under dosing of
   common antibiotics for obese patients in the ED”. Am
   J Emerg Med. 2011 Dec 12. [Epub ahead of print]

            SAFE Pre-op Hair Removal
 Removal outside of OR or clipper with
 Pre op patient teaching no leg shaving
 Disposable clipper head or reprocess b/w
1. Adisa AO, Lawal OO, Adejuyigbe O. “Evaluation of two methods
   of preoperative hair removal and their relationship to
   postoperative wound infection”. J Infect Dev Ctries. 2011 Oct
2. Broekman ML, van Beijnum J, Peul WC, Regli L. “Neurosurgery
   and shaving: what's the evidence?” J Neurosurg. 2011
   Oct;115(4):670-8. Epub 2011 Jul 1.
3. Diana M, Hübner M, Eisenring MC, Zanetti G, Troillet N,
   Demartines N. “Measures to prevent surgical site infections: what
   surgeons (should) do”. World J Surg. 2011 Feb;35(2):280-8.
 Unless your patient looks like this,
     consider NOT clipping hair

 Mangram AJ et al. Guideline for prevention of surgical site infection, 1999.
Hospital Infection Control Practices Advisory Committee. Infect Control Hosp
                  Epidemiol 1999; 20:250‐278; quiz 279‐280.
1. Esnaola NF, Cole DJ. “Perioperative normothermia
   during major surgery: is it important?” Adv Surg.
2. Hart SR, Bordes B, Hart J, Corsino D, Harmon D.
   “Unintended perioperative hypothermia”. Ochsner J.
   2011 Fall;11(3):259-70.
3. Moola S, Lockwood C. “Effectiveness of strategies for
   the management and/or prevention of hypothermia
   within the adult perioperative environment”. Int J Evid
   Based Healthc. 2011 Dec;9(4):337-45.

 Glucose Control = minimizing extremes
1. Chi A, Lissauer ME, Kirchoffner J, Scalea TM, Johnson SB. “Effect
   of glycemic state on hospital mortality in critically ill surgical
   patients”. Am Surg. 2011 Nov;77(11):1483-9.
2. Martinez EA, Chavez-Valdez R, Holt NF, Grogan KL, Khalifeh KW,
   Slater T, Winner LE, Moyer J, Lehmann CU. “Successful
   implementation of a perioperative glycemic control protocol in
   cardiac surgery: barrier analysis and intervention using lean six
   sigma”. Anesthesiol Res Pract. 2011;2011:565069. Epub 2011 Sep
3. Pichardo-Lowden A, Gabbay RA. “Management of Hyperglycemia
   During the Perioperative Period”. Curr Diab Rep. 2011 Nov 12.
   [Epub ahead of print]
4. Stawicki S, Schuster D, Liu J, Kamal J, Erdal S, Gerlach A,
   Whitmill M, Lindsey D, Murphy C, Steinberg S, Cook C. “The
   glucogram: A new quantitative tool for glycemic analysis in the
   surgical intensive care unit”. Int J Crit Illn Inj Sci. 2011 Jan;1(1):5-
“Plus” Measures for SSI Prevention

                Attire - Surgical

 Eliminate or cover cloth
  skull cap when in surgery
 Double gloving
 Change sterile gloves
  before closing
 Permit ONLY scrubs
  laundered by hospital
 Red caps for visitors

                      Attire - Surgical

 Double Gloving: Phillips S. “The comparison of double gloving
  to single gloving in the theatre environment.” J Perioper
  Pract. 2011 Jan;21(1):10-5.
 Changing gloves: Epstein NE. “Preoperative, intraoperative,
  and postoperative measures to further reduce spinal infections.”
  Surg Neurol Int. 2011 Feb 21;2:17.
 Hair coverage :Frey K, Ross T. eds. Surgical Technology for the
  Surgical Technologist: A Positive Care Approach. 3rd ed. Clifton
  Park, NY: Delmar Cengage; 2008.
 Scrubs: Belkin NL. Home laundering of soiled surgical scrubs.
  American Journal of Infection Control. 2001; 29: 58-64.

Blood – Minimizing Transfusions

            Blood - Minimizing Transfusions

1.   Young H. Et al. “Statewide collaboration to evaluate the effects of
     blood loss and transfusion on surgical site infection after
     hysterectomy”. ICHE Jan 2012, Vol. 33, No 1 pp 90-93.
2.   Schwarzkopf R et al. “Effects of Perioperative Blood Product Use
     on Surgical Site Infection Following Thoracic and Lumbar Spinal
     Surgery”. Spine. 2010;35(3):340-346.
3.   Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection:
     the incidence, timing, and predisposing factors. Clin Orthop Relat
     Res. 2008; 466(7):1710-1715.
4.   Talbot TR et al. “Perioperative Blood Transfusion Is Predictive of
     Poststernotomy Surgical Site Infection: Marker for Morbidity or True
     Immunosuppressant?” Clinical Infectious Diseases 2004;

Drains, Drapes, Dressings

            Drains, Drapes and Dressings

1.   DRESSING - Epstein NE. “Preoperative, intraoperative, and
     postoperative measures to further reduce spinal infections.” Surg
     Neurol Int. 2011 Feb 21;2:17.
2.   DRESSING - Krieger BR, Davis DM, Sanchez JE, Mateka JJ,
     Nfonsam VN, Frattini JC, Marcet JE. “The use of silver nylon dressing
     in preventing surgical site infections following colon and rectal
     surgery”. Dis Colon Rectum. 2011 Aug;54(8):1014-9.
3.   DRAINS - Rao SB, Vasquez G, Harrop J, Maltenfort M, Stein N,
     Kaliyadan G, Klibert F, Epstein R, Sharan A, Vaccaro A, Flomenberg
     P. “Risk factors for surgical site infections following spinal fusion
     procedures: a case-control study”. Clin Infect Dis. 2011 Oct;53(7):686-
4.   DRAPE - Kramer A, Assadian O, Lademann J. “Prevention of
     postoperative wound infections by covering the surgical field with
     iodine-impregnated incision drape (Ioban 2)”. GMS Krankenhhyg
     Interdiszip. 2010 Sep 21;5(2).
Hand Scrub – Brushless & Dual Agent

   Hand Scrub - Brushless & Dual Agent

 Olson LK et al. “Prospective, randomized in vivo
  comparison of a dual-active waterless antiseptic versus
  two alcohol-only waterless antiseptics for surgical hand
  antisepsis”. American Journal of Infection Control
  Volume 40, Issue 2, March 2012, Pages 155–159.
 Usavadee Asdornwised “An Evaluation of Brush,
  Brushless, and Waterless Surgical Hand Scrubs among
  Health Care Workers in Operating Rooms at a University
  Hospital in Thailand “. J Nurs Sci Vol.29 No.3 July-
  September 2011.

Irrigation: Intra-operative

           Irrigation: Intra-operative
1. COPIOUS IRRIGATION - Watanabe M, Sakai D, Matsuyama
   D, Yamamoto Y, Sato M, Mochida J. “Risk factors for surgical
   site infection following spine surgery: efficacy of
   intraoperative saline irrigation”. J Neurosurg Spine. 2010
2. CHG - Han Y, Giannitsios D, Duke K, Steffen T, Burman M.
   “Biomechanical analysis of chlorhexidine power irrigation to
   disinfect contaminated anterior cruciate ligament grafts”. Am J
   Sports Med. 2011 Jul;39(7):1528-33.
3. PULSATILE - Nikfarjam M, Kimchi ET, Gusani NJ, Avella DM,
   Shereef S, Staveley-O'Carroll KF. “Reduction of surgical site
   infections by use of pulsatile lavage irrigation after prolonged
   intra-abdominal surgical procedures”. Am J Surg. 2009
4. OPHTHALMOLOGY - Fernandes M, Pathengay A. “Reduction of
   anterior chamber contamination rate after cataract surgery by
   intraoperative surface irrigation with 0.25% povidone-iodine”. Am
   J Ophthalmol. 2011 Aug;152(2):320; author reply 320-1.
                 OR Observations

“Almost no matter what experimental conditions were imposed, increases
   in output occurred….The investigators had obviously influenced the
subjects’ behavior merely by studying that behavior, and this phenomenon
 has become known as the Hawthorne effect.” (Kelly Shaver, Principles of
               Social Psychology, 2nd ed., Winthrop, 1981)
Oxygen - Supplemental

               O2 - Supplemental

 Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr.
  “Perioperative supplemental oxygen therapy and
  surgical site infection: a meta-analysis of randomized
  controlled trials.” Arch Surg. 2009 Apr;144(4):359-66;
  discussion 366-7.
 James T. Lee, MD, PhD “Supplemental Oxygen and
  Risk of Surgical Site Infection”JAMA
 Hopf H, Hunt T, Rosen N. “Supplemental Oxygen and
  Risk of Surgical Site Infection”.
  JAMA. 2004;291(16):1956.

            Skin Antisepsis

Estimates of costs/mortality associated with infections

                         Skin Antisepsis
1. SKIN - Lee I, Agarwal RK, Lee BY, Fishman NO, Umscheid CA.
   “Systematic review and cost analysis comparing use of chlorhexidine with
   use of iodine for preoperative skin antisepsis to prevent surgical site
   infection”. Infect Control Hosp Epidemiol. 2010 Dec;31(12):1219-29.
2. SKIN- Bailey RR, Stuckey DR, Norman BA, Duggan AP, Bacon KM,
   Connor DL, Lee I, Muder RR, Lee BY Economic value of dispensing home-
   based preoperative chlorhexidine bathing cloths to prevent surgical site
   infection. Infect Control Hosp Epidemiol. 2011 May;32(5):465-71.
3. NASAL - Pofahl WE, Ramsey KM, Nobles DL, Cochran MK, Goettler C.
   “Importance of methicillin-resistant Staphylococcus aureus eradication in
   carriers to prevent postoperative methicillin-resistant Staphylococcus
   aureus surgical site infection”. Am Surg. 2011 Jan;77(1):27-31.
4. ORAL - Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol
   BA. “Prevention of nosocomial infections after cardiac surgery by
   decontamination of the nasopharynx and oropharynx with chlorhexidine; a
   prospective, randomised study”. Ned Tijdschr Geneeskd. 2008 Mar

Skin Antisepsis: Pre-op bathing
       with CHG cloths

      Also used as pre-op skin prep for
           emergency C-sections
Skin Closure

                      Skin Closure
1. Fraeman KH, Reynolds MW, Vaughn BB, Hart JC. “Patient
   outcomes associated with 2-octyl cyanoacrylate topical skin
   adhesive in coronary artery bypass graft surgery”. Surg Infect
   (Larchmt). 2011 Aug;12(4):307-16.
2. Singer AJ, Chale S, Giardano P, Hocker M, Cairns C,
   Hamilton R, Nadkarni M, Mills AM, Hollander JE. “Evaluation
   of a novel wound closure device: a multicenter randomized
   controlled trial”. Acad Emerg Med. 2011 Oct;18(10):1060-4.
3. Iyer A, Gilfillan I, Thakur S, Sharma S. “Reduction of surgical
   site infection using a microbial sealant: a randomized trial”. J
   Thorac Cardiovasc Surg. 2011 Aug;142(2):438-42..
4. Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ.
   “Randomized trial of antimicrobial-coated sutures to prevent
   surgical site infection after breast cancer surgery”.Surg Infect
   (Larchmt). 2011 Dec;12(6):469-74.

Reducing Traffic in the OR

                 Reducing OR Traffic

1.   Dunbar MJ, Richardson G. “Minimizing infection risk:
     fortune favors the prepared mind.”Orthopedics. 2011 Sep
2.   Lynch RJ, Englesbe MJ, Sturm L, Bitar A, Budhiraj K, Kolla
     S, Polyachenko Y, Duck MG, Campbell DA Jr.
     “Measurement of foot traffic in the operating room:
     implications for infection control”. Am J Med Qual. 2009
3.   Young RS, O'Regan DJ. “Cardiac surgical theatre traffic:
     time for traffic calming measures?” Interact Cardiovasc
     Thorac Surg. 2010 Apr;10(4):526-9.

Wound edge protector

                 Wound Edge Protector

1.   Green C, Molony D, Cashman J, Burke T, Masterson E.
     “Another string.... but no bow”. Acta Orthop Belg. 2011
2.   Kadowaki Y, Kurokawa T, Tamura R, Okamoto T, Ishido N,
     Mori T. “Lap-Protector and Circular Stapler Are Useful in
     Cystogastrostomy for Large Pancreatic Pseudocyst with
     Severe Infection”. Case Rep Gastroenterol. 2010 Jul
3.   Nakamura Y, Matsumoto S, Tajiri T, Uchida E. “A safe
     technique for laparoscopic distal pancreatectomy involving a
     large cystic tumor”. J Nihon Med Sch. 2011;78(6):374-8.

1.   AORN/APIC ASC Toolkit/library contents
2.   APIC Cost Calculator
3.   APIC/SHEA Compendium http://www.shea-
4.   KP Patient Story Video Clip
5.   KP Infection Prevention “Plus Measures” Toolkit
                                  Surgical Site Infection (SSI) Prevention
The following standard bundle of prevention measures (supported by category 1 level evidence) are recommended in:
 SHEA/APIC C ompendium:
 IHI How To Guide: http://www.IHI SSI Prevention How To Guide
   1.    Appropriate use of antibiotics
   2.    Appropriate use of prophy lactic antibiotics
   3.    Appropriate hair removal
   4.    C ontrolled 6 AM postoperative serum glucose in cardiac surgery patients
   5.    Immediate postoperative normothermia for colorectal surgery patients
   6.    Pre op antiseptic shower category (1B HIC PAC guidelines SSI Prevention)

If zero infections have not sustained, consider adding one or more of the following “PLUS” prevention measures (less than

 Measure                                         References                  Product Order Info          Tools

 1 . A ntibiotic prophylaxis:                                                N/A                         N/A
         A. For Bariatric surgery use 3 grams
                                                           3 gms ancef
             ancef routinely instead of 2 pre-         references 2012.doc
             operatively                         A
 2. A ntisepsis – skin and oral:                                             A CHG skin prep:            Patient instructions
     A. Surgical skin prep:                                                    http://www.chloraprep.c   C HG C loths
                                                       CHG skin prep
         C hlorhexidine/alcohol (C hloraprep)            2012.doc              om/
     B. Pre op CHG (chlorhexidine) bathing       A                           B CHG cloth product
                                                                                                          C:\Documents and
                                                                                                         Settings\DNSSAB\My Documents\My Documents\PDF Docs\PDF Docs\IHI\Plus Measures Toolkit\N

         cloths                                                                info: http://www.Sage
     C . Decolonization MRSA - test and                                        C HG C loths              Decolonization
                                                  CHG Cloths 2012.doc
         decolonize + MRSA patients prior to                                 C Mupirocin: KP             Guidelines
         high risk procedures                                                  pharmacy                   C:\Documents and
                                                                                                         Settings\DNSSAB\My Documents\My Documents\Word Docs A-P\MRO\Guidelines\MRSA Decolonization Re

                                                                               3M Nasal A ntiseptic:
                                                        Decolonization          3M™Skin and Nasal
                                                     references 2012 .doc
                                                 C                              Antiseptic (Povidone-

Thanks for your time!
  Any Questions?

 Next Beyond SCIP Webinar

May 17th: 12:30-1:30 PST
Pascal Fuchshuber, MD, PhD, FACS
The Power of NSQIP data to drive change
and improvement

Cynosure Quality Swap Meet
      May 21, 2012
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