1、1Surgical Site Infection Collaborative2January 1 September 2, 200113 orthopedic surgeons involved in 36 musculoskeletal cases that developed infections3#of Days Between Total Joint Replacement InfectionsJanuary 1, 2002 through June 200302387165742609411010203040506070809010002/28/02Total Hip03/22/02
2、TotalKnee06/17/02Total Hip06/18/02Total Hip06/19/02TotalKnee06/23/02TotalKnee07/02/02TotalKnee07/18/02TotalKnee09/13/02TotalKnee10/25/02Total Hip12/25/02Total Hip(?Infection)4012345671999200020012002Hip Prosthesis Risk 0Hip Prosthesis Risk 1Linear (Hip Prosthesis Risk 0)Linear (Hip Prosthesis Risk 1
3、)Trending of Hip Prosthesis Infection RatesNNIS Risk 1NNIS Risk 05Trending of Knee Prosthesis Infection Rates0123456789101999200020012002Total Knee Risk 0Total Knee Risk 1Linear (Total Knee Risk 1)Linear (Total Knee Risk 0)NNIS Risk 1NNIS Risk 26Surveillance Focus IncludedASA scoreLength of surgeryN
4、umber of personnel in OR suiteMicroorganism culturedTiming of preoperative antibiotic7Time Line of Events01/28/02Orthopedic surgical infections report presented to Infection Control Committee03/06/0204/15/0205/02/0205/09/0205/16/02Meeting with key players regarding surgical wound infectionsTeleconfe
5、rence Multifactorial Interventions to Prevent Surgical Site InfectionsInfection 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 c
6、hoiceInfection Control Nurse and Hospital Epidemiologist meet with orthopedic surgeons regarding ortho infections in 20018Time Line of Events06/24/02Infection Control Nurse and Hospital Epidemiologist meet with Board Members to discuss ortho surgical wound infectionsMeeting with key players to discu
7、ss ortho surgical wound infectionsDiscussion regarding ortho surgical infections deferred at Ortho Dept. MeetingOrtho surgeon addressed the issue of ortho infections briefly at department meetingMeeting with Hospital CEO and key players regarding ortho infectionsHospital Epidemiologist presents reco
8、mmendations at Ortho Q.A. Meeting10/17/0209/16/0212/16/0212/30/0210/28/0209/30/02Orthopedic infections on Ortho Dept. Meeting agenda, discussion deferred910Recommendations Employ chlorhexadine 4% / isopropyl alcohol as skin prep Use clippers for hair removal Maintain a core body temperature of 36c t
9、hroughout 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 antibio
10、tics within 24 hours11Team 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 C
11、ure, 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 Lin
12、da Haralson, RN L&D/Peds/NICU Nurse Manager Cecilia Bray, RN Womens/Gen. Surgery Nurse Manager12Timely Antibiotics AdministeredAnesthesia/Nursing responsibleDevelopment of protocol for administration within 30 minutes prior to incisionv2 gms of antibiotic for adults over age 16vRepeat intraoperative
13、 dosing at 3 hours13Percent of Cases with Antibiotics Within One Hour020406080100Qtr 2 2003 (n=74)Qtr 3 2003 (n=61)Qtr 4 2003 (n=75)Qtr 1 2004 (n=78)Qtr 2 2004 (n=66)Qtr 3 2004 (n=59)Qtr 4 2004 (n=69)Qtr 1 2005 (n=84)Qtr 2 2005 (n=89)QuarterPercent02468101214161820Number of Missed OpportunitiesMisse
14、d OpsGoalTrackingAntibiotics Within One Hour14Appropriate Antibiotics GivenInitiation of Antibiotic Review of perioperative antibioticsDevelopment of Penicillin Allergy Algorithm15Appropriate Antibiotics Given16Antibiotic Prophylaxis Given within 30 minutes of cut timeException: Vancomycin and Levof
15、loxacin v1 hr infusion timevInfusion must be finished prior to cut Recommended durationvdiscontinue within 24hrs11)Bratzler DW, et al. Antimicrobial Prophylaxis for Surgery: An advisory statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004;38:1706-17152
16、)Antimicrobial prophylaxis for surgery. Treatment Guidelines from the Medical letter, 2004; 2(20):27-32.17Orthopedic 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.18Penici
17、llin 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
18、, or systemic swelling?NoUse VancomycinUse CefazolinUse CefazolinYesNoNoNoYesYesDid the patient develop hives (raised, itchy, systemic welts) during a treatment course?Yes1920Antibiotics Discontinued in 24 HoursNurse Manager provided SSI collaborative PowerPoint presentation to Surgical Services sta
19、ff - 3/31/03Physician Champion provided SSI collaborative slide presentation to orthopedic surgeons and anesthesia 4/21/03Orthopedic Section voted to revise order sheet to discontinue antibiotics in 24 hours 5/27/0321Orthopedic Post-op Orders Page 2 of 2.Antiemetic Protocol.Respiratory:qIf on Oxygen
20、, oximetry every 8 hrs, D/C O2 when SAT 92%qRespiratory Care, evaluate and treat q Incentive Spirometry.Activity: q Bed Rest q OOB this PM q Chair TIDqPhysical Therapy: Begin treatment: qthis P.M. qin A.M. _WB affected extremityqTotal Hip Protocol _ WB affected extremityqTotal Knee Protocol _ WB aff
21、ected extremityqElevate affected extremity q 6” above heart level q heart level q stockinette q calves elevated on pillowsqCPM _qOther _.Misc:qX-Ray _qDressing _qAutotransfusionqDiscontinue Hemovac q 24 hours post-op q 48 hours post-opqR/C or straight cath PRN inability to void Discontinue R/C 48 hr
22、s post-op, reinsert PRN. C&S PRNqTEDS Protocol q SCD Protocol q Abduction BolsterqSS consult Discharge PlanningqCold TherapyqIce pack to affected area 20-30 minutes 3 times/shift (do not place ice bag directly on skin)Physicians Signature: _ Date/Time: _22Antibiotic Discontinued in 24 Hours Percent
23、of Cases For Which Prophylactic Antibiotics Were Discontinued Within 24 Hours020406080100Qtr 2 2003 (n=74)Qtr 3 2003 (n=61)Qtr 4 2003 (n=75)Qtr 1 2004 (n=78)Qtr 2 2004 (n=66)Qtr 3 2004 (n=59)Qtr 4 2004 (n=69)Qtr 1 2005 (n=84)Qtr 2 2005 (n=89)QuarterPercent048121620242832Number of Missed Opportunitie
24、sMissed OpportunitiesGoalTracking23Hair Removed AppropriatelyTwo clippers stocked in each OR suiteRe-inserviced staff via poster boardsSpecific staff member assigned responsibility for stockingUse of clippers implemented for other surgical procedures24Percent of Patients With Hair Removed Appropriat
25、ely0102030405060708090100Qtr 2 2003 (n=74)Qtr 3 2003 (n=61)Qtr 4 2003 (n=75)Qtr 1 2004 (n=78)Qtr 2 2004 (n=66)Qtr 3 2004 (n=59)Qtr 4 2004 (n=69)Qtr 1 2005 (n=84)Qtr 2 2005 (n=89)MonthPercent02468101214161820Number of Missed OpportunitiesMissed OpsGoalTrackingHair Removed Appropriately25NormothermiaC
26、alibration checked on forced air warming machines and adjustedForced air warming machines placed on preventative maintenance schedulePre-op warming blanketsIncrease of room temperature abandonedAbandoned cooling vests for surgeons after trialSpace hats in pre-opUnderbody warmers in OR26Body Temperat
27、ures27Supplemental OxygenImplemented use of non-rebreather mask at high flowvPatient education regarding rationale in pre-op holding areasvSet standard mask removal time at 2 hours post arrival to patient roomvNon-rebreather mask application to patient with initiation of oxygen flowvUtilization of t
28、imer abandoned28Supplemental Oxygen PerioperativelyPercent of Cases With Supplemental Oxygen Perioperatively0102030405060708090100Qtr 2 2003 (n=74)Qtr 3 2003 (n=60)Qtr 4 2003 (n=75)Qtr 1 2004 (n=78)Qtr 2 2004 (n=66)Qtr 3 2004 (n=59)Qtr 4 2004 (n=69)Qtr 1 2005 (n=84)Qtr 2 2005 (n=89)MonthPercent02468
29、101214161820Number of Missed OpportunitiesMissed OpsGoalTracking* Information on mask time is not available for one patient in Qtr 3 200329Patient Satisfaction Non-Rebreather MaskInterview each patient post discontinuationv246 out of 255 patients were satisfied with the use of the non-rebreather mas
30、k (96.5%)30Chlorhexadine 4%/Alcohol PrepMarch 19, 2003 February 29, 2004RecommendationNumber%Cases Reviewed258Chlorhexadine 4%/alcohol prep23591.1%Betadine Scrub + alcohol prep166.8%Total Knee/Total Joint Recommendations313132Other Inpatient OrthoStarted July 200333Neuro SurgeryStarted November 2003
31、34March 2003Ortho Hips and KneesJuly 2003Other OrthoNovember 2003 NeuroJanuary 2004C-SectionsMay 2004OB/GYN November 2004ColonFebruary 2005 General Surgery and UrologySeptember 2005Wound Care, Podiatry, and PlasticsSSI Collaborative 3 Year Plan35Appropriate Prophylactic Antibiotic SelectedSurgery Ty
32、pe# Successes# CasesPercentOverall Rate90692198%Hip and Knee Arthroplasty(2nd Qtr 2003 2nd Qtr 2005)65065599%Hysterectomy(3rd Qtr 2004 2nd Qtr 2005)24925996%Colon Surgery(May, 2005 July, 2005)77100%36Percent of Abx Given Within 1 Hour of IncisionSurgery Type# Successes# CasesPercentOverall Rate91292
33、199%Hip and Knee Arthroplasty(2nd Qtr 2003 2nd Qtr 2005)65265599.5%Hysterectomy(3rd Qtr 2004 2nd Qtr 2005)25425998%Colon Surgery(May, 2005 July, 2005)6786%37Percent of Prophylactic Abx Discontinued Within 24 Hours After Surgery End TimeSurgery Type# Successes# CasesPercentOverall Rate82992190%Hip an
34、d Knee Arthroplasty(2nd Qtr 2003 2nd Qtr 2005)58265589%Hysterectomy(3rd Qtr 2004 2nd Qtr 2005)24325994%Colon Surgery(May, 2005 July, 2005)4757%383839Trending of Total Hip Infection Rates00.511.522.533.544.5200220032004rate of infectionRisk index 0Risk index 1NNIS Rate: 0.88NNIS Rate 1.61400123456789
35、10200220032004rate of infectionRisk index 0Risk index 1Trending of Total Knee Infection RatesNNIS Rate: 1.26NNIS Rate: 0.8741Recommendations Employ chlorhexadine 4% / isopropyl alcohol as skin prep Use clippers for hair removal Maintain a core body temperature of 36c throughout surgery Administer ox
36、ygen 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 hours4243Surgical Site Infection Collaborative
