Lost in Translation

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Lost in Translation

• Ambulatory Surgery Centers
• Surgical site Infections tracking

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Why?

• Many outpatient centers are not accredited.
• Staff are not educated on infection prevention
• Patients do not return to the outpatient setting
  if they develop an infection

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Lack of Accreditation

• Accrediting bodies
• Joint Commission
• AAAHC (Accreditation Association of American
  Health Care)
• AAAASF (American Association for Accreditation of
  Ambulatory Surgery Facilities)

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Staff Education

• Infection Prevention
• Preoperative Assessment
• Day of Surgery considerations
• Patient Enters Room
• Incision
• Patient leaves Room
• Follow-up

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Preoperative Assessment

• Risk Assessment and Management

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Schedule Operation

• Minimize preoperative stay
• Patient education
• Preop shower instructions

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Day of Surgery Considerations

• Antibiotics
• Hair Removal
• Normothermia
• The Environment-Housekeeping

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Antibiotics

• Antibiotics should be based on site-specific
  flora responsible for postoperative would
  infection

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Hair Removal
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Normothermia Management

• Improves patient satisfaction and physical
  comfort along with improving clinical benefits
  that can improve patient outcomes.

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Ventilation
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Housekeeping
THINK HIGH TOUCH AREAS NEED CLEANING
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Day of Operation(continued)

• Room set up
• Personnel and patient attire
• Surgical scrub
• Transporting sterile instruments supplies
• Sterile storage
• Traffic Control

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Room Set up
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Personnel Surgical Attire
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Surgical Attire cont.

• Protective eyewear is required for all scrubs
• All hair is covered in the OR
• Clean laundered scrubs for all surgical
  procedures

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Patient attire
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Surgical Scrub
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Transporting sterile instruments
supplies(continued)
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Sterile storage
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Patient enters room

• Antiseptic skin preparation
• Sterile drapes

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Who Should Prep The Patient?

• AORN Recommends
• Personnel Knowledgeable about the patient and
  skilled in skin preparation techniques should
  prepare the surgical site in a manner that
  preserves skin integrity and prevents injury to
  the skin.2

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Review of Antimicrobial Agents
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Application
Apply preoperative antiseptic skin preparation
in concentric circles moving toward the
periphery. The prepared area must be large enough
to extend the incision or create new incisions or
drain sites, if necessary.
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Application

• Isolate known sources of contamination from the
  surgical site (e.g., colostomy sites, perineum).2
• Prevent antiseptic from pooling beneath patient,
  tourniquet, electrodes, E.S.U. dispersive
  electrode to reduce the risk of chemical burns.2
• Use gentle preparation technique when prepping
  fragile skin (e.g., infants, elderly, steroid use
  ) and patients with certain medical conditions
  (e.g., diabetes, ulcerations open wounds)2

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Application

• Avoid using chlorahexidine, alcohol or
  alcohol-based prep on mucous membranes exposed
  tissue or none intact skin
• Allow sufficient contact time for the antiseptic
  agent to reach maximum efficacy before applying
  sterile drapes.
• Do not allow alcohol or alcohol containing
  antiseptic agents to pool
• Allow alcohol or alcohol containing antiseptic
  agents to dry completely before applying sterile
  drapes to prevent the possibility of fire.

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Sterile Drapes
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Patient leaves room

• Instrument reprocessing
• Removing soiled linens and surgical attire
• Environmental cleaning
• Wound management
• Patient education

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Instrument Reprocessing
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Instrument Reprocessing(continued)
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Instrument Reprocessing(continued)
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Instrument Reprocessing(continued)
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Removing soiled linens and surgical attire

• Removal of soiled linens

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Environmental Cleaning
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Environmental Cleaning
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Wound Management

• Hands must be cared for by handwashing with soap
  and water or by hand antisepsis with
  alcohol-based handrubs (if hands are not visibly
  soiled) Before and after patient contact. (APIC
  Handwashing guideline)
• Protect with a sterile dressing for 24 to 48
  hours postoperatively an incision that has been
  closed primarily. (CDC)
• When an incision dressing must be changed, use
  sterile technique. (CDC)

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Patient Education

• Educate the patient and family regarding proper
  incision care, symptoms of SSI and the need to
  report such symptoms. (CDC)

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Follow-up

• Surgical Site Surveillance
• Outbreak Investigation

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Best Practice Sources

• American Association of Nurse Anesthetists (AANA)
• American College of Surgeons (ACS)
• American Institute of Architects (AIA)
• American Society of Anesthesiologists (ASA)

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Best Practice Sources(Continued)

• Association for Professionals in Infection
  Control and Epidemiology (APIC)
• Association for the Advancement of Medical
  Instrumentation (AAMI)
• Association of periOperative Registered Nurses
  (AORN)

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Best Practice Sources(Continued)

• Centers for Disease Control (CDC)
• Federal Department Agriculture (FDA)
• Society for Healthcare Epidemiology of America
  (SHEA)
• Surgical Infection Society (SIS)
• Joint Commission

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CDC Rankings

• Category IA.Strongly recommended for
  implementation
• and supported by well-designed experimental,
  clinical,
• or epidemiological studies.
• Category IB.Strongly recommended for
  implementation
• and supported by some experimental, clinical, or
  epidemiological studies and strong theoretical
  rationale.
• Category II. Suggested for implementation and
  supported
• by suggestive clinical or epidemiological
  studies or
• theoretical rationale.
• No recommendation unresolved issue. Practices
  for
• which insufficient evidence or no consensus
  regarding efficacy exists.

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CMSCenters for Medicare Medicaid Services
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References

• CDC Guideline For Prevention Of Surgical Site
  Infection
• 2008 AORN Recommended Practices, And Guidelines
  (p 603-606)
• FDA TFM - Tentative Final Monograph for
  Healthcare Antiseptic Drug (21 CFR Parts 333
  369)
• Infection Control Today Frain, J., June, 2008
• Infection Control Today McCaughey, B. June,2008
• Infection Control Today, Bockman, T. , April 2008
• Journal of Bone and Joint Surgery Ritter,
  Prevention of Perioperative Infection 1999

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