1. www.saferhealthcarenow.ca
Cuts Like a New Knife - Current Practice and Emerging
Evidence in Preventing Surgical Site Infections

2. www.saferhealthcarenow.ca
Did you Join the Call Correctly?
You Joined
Correctly!
There IS a
phone icon
beside your
name.
You Joined
Incorrectly!
There is NO
phone icon
beside your
name.
If you joined incorrectly and there is NO phone icon
beside your name, click the audio button on the right-
hand side of the screen, below the participant list
Please join the audio conference using a phone for better audio quality.
1. For direct lines, choose “Call me at a new number”
2. For lines with extension , choose “I will call in” and dial the
audio conference toll-free number found on the Session
Info tab, and when prompted, enter the access code and
attendee ID

3. www.saferhealthcarenow.ca
WebEx
Please use the chat to ask
questions during the presentation,
or raise hand when we pause for
questions.

4. www.saferhealthcarenow.ca

5. www.saferhealthcarenow.ca
Host and Presenters
Marlies van Dijk Dr. Claude Laflamme
Paule BernierAnne MacLaurinNadine Glenn
Dr. Giuseppe Papia

6. Greetings from CPSI
6
Kim Stelmacovich, Senior Director

7. Patient Safety Forward with Four
• The Canadian Patient Safety Institute has a new 2013-2018
Business Plan
• Four goals to move us forward
• Four Clinical Priority Areas
• http://www.patientsafetyinstitute.ca/English/About/PatientSafety
ForwardWith4/Pages/default.aspx?utm_source=CPSI&utm_medium
=HomeSideAd&utm_campaign=ForwardWithFour

8. Forward with Four
Four goals
 Provide leadership on the
establishment of a National
Integrated Patient Safety
Strategy
 Inspire and sustain patient safety
knowledge within the system, and
through innovation, enable
transformational change
 Build and influence patient safety
capability at organizational and
system levels
 Engage all audiences across the
health system in the national
patient safety agenda
Four Clinical Priority Areas
1. Medication safety
2. Surgical care safety
3. Infection Prevention &
Control
4. Home care safety

9. SSI Prevention
Emerging Evidence
Claude Laflamme MD, FRCPC, MHSc
Medical Director, Cardiac Anesthesia
Sunnybrook Health Sciences Centre
Assistant Professor
University of Toronto

10. Disclosure
• Charles E. Edmiston Jr., PhD., CIC,
Milwaukee
• Frank Mazza, Vice President/Chief Patient
Safety Officer
Associate Chief Medical Officer
Seton Family of Hospitals, Austin
• Paula Mendes, RN, CPN(c)
Perioperative Professional Services
Specialist, 3M, London

11. © 3M 2013. All Rights Reserved

13. AIPI 2013

15. Updated Recommendations for
SSI Prevention
• Annals of Surgery June 2011
• Recommendations from CDC 1999
• Review of current literature has been done to update the
recommendations
• Adherence to the proposed guidelines could reduce wound
infections significantly.
– Target of less than 0.5% in clean wounds
– Target of less than 1% in clean-contaminated wounds
– Target of less than 2% in highly contaminated wounds
– Decrease costs to less than one-half of the current amount
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

16. Multiple factors play a Role in SSI
(CDC)
• Reduction in contamination (asepsis) OR environment
• Preoperative bathing with antiseptic agents
• Hair Removal
• Skin decontamination
• Incise drapes
• Reduction in consequences of contamination (antisepsis) sutures
– Suture composition
• Tissue damage and foreign bodies
– Use of electrocautery
• Drains
– Drains that exit through a working incision increases SSI
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

17. Multiple factors play a Role in SSI
• Prophylactic topical antimicrobials
– Topical antibiotics are effective
– Using other antimicrobials (PI/CHG) to decontaminate wounds are not
effective and has been shown to inhibit wound healing and increase
SSI.
• Systemic prophylactic antibiotics
– Preoperative antibiotics is among the most important of the currently
available methods to prevent SSI.
– 30 min before incision except for vancomycin (1-2 hours before
incision)
– Redosing is important (short acting, body size, and renal function)
• Improvement of host defense influence of body temperature
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

18. Multiple factors play a Role in SSI
• Effect of oxygen therapy
– O2 should start with induction, but optimal concentrations and duration
of therapy have not been established. Current data suggests it should be
given at least 2 hrs after closure.
• Glucose control
– Hyperglycemia is a risk factor for SSI independent of diabetes.
– Close monitoring is essential.
• Transfusions and fluid management
– Blood transfusions increase the risk of infection in surgical patients.
• Smoking
– Increases surgical wound infection
• Delayed primary closure
– Benefit of delayed primary closure in highly contaminated wounds
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

19. Reduction in Contamination (Asepsis)
OR Environment
• CDC guidelines and regulations from various accrediting agencies are
good resources for providing details related to effective techniques
– Air handling (HEPA filters, Laminar Air flow)
– Cleaning of environmental surfaces
– Sterilization techniques
– Activities of surgical team members (limit traffic and idle conversations)
– Surgical attire (perforations of surgical gloves are major source of
contamination, and gown strike-through – sleeves/abd area also a potential
source)
– Drapes
– Asepsis
• The above should be regarded as recommendations set in stone.
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

20. Preoperative Bathing with Antiseptic
Agents
• Infections in clean surgery are most often caused by skin
organisms
• Preoperative bathing with chlorhexidine
– Reduces pathogenic organisms on the skin but has a non-significant
reduction in wound infections
• Chlorhexidine
– Shown to reduce the number of organisms at the incision site better
than using povidone iodine or soap and water
– Showering the night before and the morning of surgery is more
effective in colony reduction than a single shower
• Cleansing with a chlorhexidine impregnate cloth just before
operation will provide additional removal of dirt and further
reduction in skin bacteria
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

21. Presurgical Skin Preparations as a
Pathway
to Improving Surgical Outcomes
• Reducing the risk of SSI in orthopaedic surgery
• Standardized precleansing initiative (CHG cloths) in total joint
patients (night before/morning of surgery)
• SSI rate prior to intervention – 3.2% (N=727)
• SSI rate post intervention – 1.6% (N=824) 50% reduction
Eiselt – Orthopaedic Nursing 2009;28:141-145
• Bundling risk reduction strategies – Quality initiative
• MRSA prescreening in orthopaedic, obstetric, bariatric patients
– decolonization
• Presurgical antisepsis (CHG cloths) prior to surgery
• Preintervention SSI rate 1.6% (N=17/1,095) vs postintervention
SSI rate 0.57% (N=7/1,225 ) >60% reduction
• MRSA SSI rate 0.73% vs 0.16% >75% reduction
Lipke VL, Hyott AS. AORNJ 2010’;62:288-296

22. Best Practice # 1: All patients undergoing
an elective surgical procedure will take at
least 2 CHG antiseptic shower/cleansings
using a standardized regimen

23. Hair Removal
• NOT removing hair is associated with least infection
• When it is deemed by the surgeon that hair should be
removed, shaving should never be used
• Clipping the hair with care to avoid skin damage is to be the
most satisfactory method
• Most studies support hair removal done immediately before
operation
– Associated with lower infection rate
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

24. Skin Decontamination
• Alcohol
– Used as a skin disinfectant for more than 150 years
– Remains the most effective short-term antimicrobial but it is highly
flammable
– Provides no persistent antimicrobial activity
• Chlorhexidine is more effective in reduction of skin bacterial vs.
povidone iodine
– Chlorhexidine and alcohol provide even better reduction of bacteria
• Hand scrubs
– Using a chlorhexidine/alcohol based product will provide the greatest
reduction in skin bacteria
• The best reduction in microbes at the operative site seems to be with
an iodine povacrylex/alcohol or chlorhexidine/alcohol based products
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

26. Antiseptic Skin Preparation
SHN RECOMMENDATIONS
• To maximize its efficacy, CHG alcohol skin prep should not be
washed off following surgery.
• In order to prevent a fire hazard, it is imperative that CHG-
alcohol skin prep be allowed to air dry for at least 3 minutes,
or longer if there is excessive hair insitu.
• Povidone-iodine should be used as a skin preparation in
emergent cases when there is not enough time to allow CHG-
alcohol solution to completely dry before incision.
• Chlorhexidine-alcohol solutions must not be used for
procedures involving the ear, eye, mouth or neural tissue.
Safer Healthcare Now, Getting Started Kit: Prevent Surgical Site Infections,
How to Guide, May 2007/2010

27. Incise Drapes
• Use of an adhesive antimicrobial incise drape may or may not
decrease the incidence of wound infection;
– Depending upon the composition of the drape
– Preparation of the skin and adherence to the wound edges.
• Technique is important
• With proper application of the incise drape to prevent lifting
from the skin edge, contamination of the wound with skin
organisms is not possible.
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

28. Antibiotic doses and redosing
Am J Health-Syst Phar- Vol 70 Feb 1, 2013 p.195-283

29. Effect of Maternal Obesity on Tissue Concentration
Of Prophylactic Cefazolin During Cesarean Delivery
Pevzner L, Edmiston CE, et al. Obstet & Gynecol 2011;117:877-882

30. Best Practice # 2: All surgical patients
will receive a minimum dose of 2 gr
unless their BMI is >30 – Then the
correct dose is 3 gr

31. Improvement of Host Defense
Maintaining Normothermia
• Mild hypothermia 34-36 degrees celcius has a large number
of adverse effects
– Increased blood loss and transfusion requirements
– Prolonged ICU and hospital LOS
– Increase in morbid myocardial events
– Increase in wound infection
• Hypothermia increases the development of wound infection
due to the adverse effects on the physiological and
immunologic functions necessary to kill contaminating
bacteria
Mahoney CB, Odom J. Maintaining intraoperative normothermia: A meta-analysis
of outcomes with costs. AANA Journal. 1999;67(2):155-164.

32. Hypothermia and SSI

33. *Adapted from: Sessler, Anesthesiology 2000
1hr
0
-1
-2
-3
0 2 4 6
ΔCoreTemp(°C)
Elapsed Time (h)
-1.6°C
Anesthesia-Induced Hypothermia
Characteristic Patterns of General Anesthesia-Induced
Hypothermia

34.  Impaired thermoregulation under anesthesia
 Heat redistribution
 Heat loss:
 Convection
 Conduction
 Evaporation
 Radiation
Culprits of Perioperative Hypothermia

35. American College of Surgeons Vol. 209 No 4 October 2009

36. Perioperative Normothermia
Normothermia (core temperature 36⁰C–38⁰C) should be maintained
preoperatively, intraoperatively, and in PACU by implementing any
combination of the following:
• Warmed forced-air blankets when surgery is expected to last >30 minutes
• Warmed Intravenous fluids for abdominal surgeries of >1 hour duration
• Fluid warming is an important adjunct therapy.
• Warmed lavage liquids for colorectal surgery
• Increase the ambient temperature in the operating room to 20⁰C-24⁰C
• Hats and booties on patients during surgery
• Pre-warming should be initiated between 30 minutes to 2 hours prior to
major surgery.
Safer Healthcare Now, Getting Started Kit: Prevent Surgical Site Infections,
How to Guide, May 2007/2010

37. Best Practice # 3: Core temperature
less then 36 degree celsius at the end
of surgery is a failure

38. Cutting Edge Evidence

39. Making an Evidence-Based Argument for
Antimicrobial (Triclosan) Coated Sutures
1. Ford et al. Pediatric surgery- Surg Infect 2005;3:313
2. Rozzelle et al. Cerebro-spinal shunt surgery – J Neurosurg Pediatr
2008;2:111-1117.
3. Mingmalairak et al. Appendectomy – J Med Assoc Thai 2009;92:770-775.
4. Zhuang et al. Abdominal surgery – J Clin Rehab Tiss Eng Res
2009;13:4045-4048.
5. Zhang et al. Radical mastectomy – Chin Med J 2011;124:719-724.
6. Galal et al. General, GI surgery - Am J Surg 2011;202:133-138.
7. Rasic et al. Colorectal surgery – Colleg. Antropologicum 2011;35:439-443.
8. Williams et al. Breast CA surgery – Surg Infect 2011;12:469-474.
9. Barac et al. Colorectal surgery – Surg Infect 2011;12:483-489.
10.Isik et al. Cardiac surgery – Heart Surg Forum 2012;15:E40-E45.
11.Turtainen et al. Lower limb revascularization surgery – World J Surgery
2012; May 23 [Epub ahead of print].
12.Seim BE et al. Cardiac surgery – Interact Cardiovasc Thorac Surg 2012:
June 12 [Epub ahead of print].
13.Nakamura T, et al. Colorectal surgery – Surgery 2013 [Epub ahead of print].
14.Laas E, et al. Breast surgery – Int J Breast Cancer 2012 [Epub ahead of
print].

40. Edmiston, Daoud, Leaper, Submitted: 2012 Surgery

41. Checklist /Recommendation
1. The guidelines provided by the CDC and accrediting agents
such as JACO have been followed. These include effective
techniques for asepsis, air handling, cleaning of
environmental surfaces, sterilization techniques, activities of
surgical team members and surgical attire.
2. All members of the operative team have double gloved and
changed gloves when any perforation is identified. Gowns
and drapes have been used which prevent liquid penetration.
3. Preoperative showering with chlorhexidine within a few
hours of the operation and the night before has been done
and preoperative cleansing of the operative site with a
chlorhexidine-impregnated cloth just before entering the
operating room.
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

42. Checklist /Recommendation
4. When hair removal is done, clippers have been used shortly
before operation.
5. Reduction of skin organisms of both the surgical team and
patient have been done using a combination of alcohol and
chlorhexidine although other effective products including
alcohol with iodophors are acceptable.
6. An antimicrobial incise drape has been used at operative
sites where it is technically feasible to get good adherence to
the skin.
7. Suture material has been selected which resists infection.
8. Dead spaces have been obliterated, where possible.
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

43. Checklist /Recommendation
9. Minimal trauma to the wound itself by gentle handling of
tissues and limited use of electrocautery has been
accomplished.
10. Conduit drains and drainage through a working incision have
not been used.
11. Prophylactic topical antibiotic solution have been used
vigorously by pressure irrigation several times during an
operation and before closure in all but the simplest cases to
remove clots and devitalized tissues and to ensure high-
tissue levels of antibiotic.
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

44. Checklist /Recommendation
12. Prophylactic systemic antibiotics have been used according to
guidelines in all surgical cases where the incidence of infections
exceeds approximately 0.5% or when any foreign body is
implanted.
13. Core temperature has been maintained at 36°C or higher
throughout the perioperative period.
14. Inspired oxygen has been given at a sufficient concentration to
maintain subcutaneous oxygen concentrations of approximately
100 mm Hg and pulse oxygen readings above 96.
15. All diabetic and hyperglycemic patients have received tight glucose
control during the perioperative period and for 2 to 3 days
afterward in high-risk patients.
Alexander et. al., Updated Recommendations fro Control of Surgical Site Infections; Annals of
Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins

47. Where?
Newfoundland - 2
Quebec - 1
Ontario - 3
British Columbia – 24
Coming!?
Alberta
Saskatchewan
Atlantic Canada

51. What’s Next!
• Lots of opportunity in the system
• Obligation
• Reducing SSIs is doable
• New Evidence Emerging
• Successful strategies focus on front
line/clinician ownership

54. www.saferhealthcarenow.ca
Surgical Safety Checklist

55. www.saferhealthcarenow.ca
Merci - Questions?

56. www.saferhealthcarenow.ca
Poll
Poll