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“ Preventing Surgical Infections When Moving From the Acute Hospital to the Community”

“ Preventing Surgical Infections When Moving From the Acute Hospital to the Community”. Hilary Humphreys The Royal College of Surgeons in Ireland & Beaumont Hospital, Dublin, Ireland Association for Perioperative Practice, 48 th Congress & Exhibition, Birmingham, UK. 18 th October 2012.

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“ Preventing Surgical Infections When Moving From the Acute Hospital to the Community”

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  1. “Preventing Surgical Infections When Moving From the Acute Hospital to the Community” Hilary Humphreys The Royal College of Surgeons in Ireland & Beaumont Hospital, Dublin, Ireland Association for Perioperative Practice, 48th Congress & Exhibition, Birmingham, UK. 18th October 2012

  2. Declaration The views expressed are in a personal but professional capacity & do not necessarily reflect those of the RCSI or Beaumont Hospital, Dublin I have recent research collaborations with Steris Corporation, Inov8 Science, Pfizer & Cepheid. I have also recently received lecture & other fees from Novartis, AstraZenca & Astellas

  3. Outline • Surgical site infection - importance - prevention 2. Operating theatre - practices - environment 3. Evolution of surgery • Healthcare Infection Society (HIS) Guidelines • Survey of minor surgical procedures • Recent guidelines • Conclusions

  4. Surgical Site Infection (SSI) Importance Prevention

  5. Importance of SSI • Surgical site infections are the second most common cause of HCAI • Clean extra-abdominal surgery (2-5%) • Intra-abdominal operations (up to 20%) • Approximately 500,000 SSIs occur annually in the US alone (CDC data)

  6. Impact of SSI • Patients who develop SSIs are • 60% more likely to spend time in an intensive care unit (ICU) • Five times more likely to be readmitted • Two times more likely to die • Overall care costs are substantially increased • Evidence suggests that the most important factor in determining SSI rates in surgical practice is the competence of the surgical team

  7. Costs of SSI • Consecutive surgical procedures, 2000-01 in Basel, Switzerland • Nested, matched case-control • Excluded outside hospital costs (Swiss francs) Infect Control Hosp Epidemiol 2008; 29: 623-629

  8. Public Reporting & Performance Indicators HICPAC SSI associated with cost, morbidity & mortality Prevention guidelines exist 100,000 Lives Campaign/Surgical Care Improvement Project SSI amenable to interventions Am J Infect Control 2005; 217-26 JAMA 200; 295: 324-327 Clin Microbiol Infect 2008; 14: 892-894

  9. Preventing SSI Surgeon 2010;8:96-100 20-30% of HCAI are preventable Modern surgical practice is multidisciplinary Several infection control programmes aimed at nurses & surgical intensive care staff have proven effective There exists a lack of infection prevention programmes aimed at surgeons

  10. NNIS - Post Discharge Surveillance(Clin Infect Dis 2001; 33: S69-77) 46% of SSI detected during current admission, 16% through post-discharge surveillance and 38% on readmission

  11. Prevention of SSI - NICE • Development of SSI depends on contamination of the wound site • Microorganism often derived from patient (endogenous) • S. aureus most commonly cultured from SSI, anaerobes or Enterobacteriaceae if viscus opened & coagulase negative staphylococci, if prosthetic surgery

  12. Healthcare Bundle for SSI Pre-Operative e.g. hair removal, staff theatre wear antibiotic prophylaxis Intra-Operative e.g. hand decontamination antiseptic skin preparation wound irrigation Post-Operative e.g. changing dressings no topical antimicrobial agents debridement

  13. Operating Theatre Practices Environment

  14. Historical Perspective 18th Century dedicated room for demonstration purposes 1846 anaesthesia 1930-’50 artificial ventilation to prevent airborne bacteria 1960-’70 ultraclean theatres & body exhaust suits > 2000 portable laminar flow technology, UV air treatment

  15. What is an operating theatre? • A designated area where surgery is performed • A restricted area where additional precautions are taken to minimise the complications of surgery • A ventilated facility

  16. What is an Operating Theatre? • Restricted access; minimise numbers • Ventilation to remove airborne contamination; each minute, humans shed up to 10,000 bacteria • An area with strict protocols, e.g. asepsis & discipline, in theatre & in the preparation room

  17. Theatre Ventilation • During walking, 104skin scales shed per minute; 10% with microbes • Air supply should be free of dust & particles; air intake distant from weather, sources of dust • ~ 20 air changes per hour • Pressure gradients from sterile areas to other parts of the complex

  18. Healthcare Infection Society (HIS) Guidelines

  19. Healthcare Infection Society (HIS) • Hospital Infection Society founded in the 1980s to provide a focus for the study & prevention of healthcare-associated infection • Medical microbiologists & others, mainly in the UK & Ireland • Journal of Hospital Infection (JHI), international meeting every 2- 4 years, courses & working groups • Input to national policy

  20. HIS Guidelines • HIS-led but seek to involve other disciplines & organisations, e.g. British Society of Antimicrobial Chemotherapy, Infection Prevention Society, Intensive Care Society, etc • Final drafts approved by HIS Council (trustees) & published in JHI • Increasingly free & fully available online • Reviews of the literature rather than meta-analyses, or systematic reviews

  21. Post-Commissioning CheckUltraclean Ventilated (UCV) Theatre Can/should monitor in newly-commissioned theatre; less than 10 cfu m-3 air 30cm from wound (1 cfu if body-exhaust suits); 20cfu at clean zone perimeter (10 if body exhaust suits) - BUT again, what can be changed if over-limit?

  22. Theatre Practices & RitualsJ Hosp Infect 2002; 51: 241-55 • Chlorhexidine showers do not reduce SSI Category 1 • No benefit from the use of adhesive or other wound edge guards Category 1 • Wear double gloves to protect wearer Category 1 • Avoid shaving, if possible, use depilatory creams or clippers if not possible Category 1

  23. Survey of Minor Surgical Procedures

  24. Survey of Operating Theatre Ventilation & Minimally Invasive Surgery Background • Issue arose while drafting documents on rituals & commissioning • Direction followed after literature search was unsatisfactory • Move from conventional operating theatres to other facilities Method • Questionnaire circulated in 2001 to HIS members in UK • Used Formic automatic data entry software system J Hosp Infect 2005: 61: 112-122

  25. Survey of Operating Theatre Ventilation & Minimally Invasive Surgery Results • 186/550 (39%) replies; 23 duplicates, 162 in total • 58% from DGHs, 35% from university/tertiary referral, 3% from private hospitals • 80% had designated theatres for orthopaedic surgery but did not ask about UCV • ~ 50% had designated theatres for ENT, ophthalmic, plastic /burns, neurosurgery, cardiac J Hosp Infect 2005; 61: 112-122

  26. Survey of Operating theatre VentilationMinimally Invasive Surgery (MIS) Conclusions • Confusion as to the facilities for MIS & what should be carried out in UCV theatre • Complementarity between theatre ventilation & good practice, e.g. antibiotic prophylaxis • Need for debate about what & where • Risk assessment of high-risk procedures in what type of theatre ventilation J Hosp Infect 2005; 61: 112-122

  27. Evolution of Surgery

  28. What is surgery? • That branch of medicine which treats diseases, injuries & deformities by manual or operative methods. The work performed by a surgeon • What is an operation? • Any act performed with instruments or by the hands of a surgeon; a surgical procedure Dorlands, Illustrated Medical Dictionary

  29. A Minor Procedure • What is minor surgery? • Does it depend on, - location, e.g. hand versus brain - depth of incision, e.g. excision of rodent ulcerversus mastectomy - time required, e.g. 10 minutes versus 90 minutes - who does it, plastic surgeon versus dermatologist - risk to patient, hernia repair in a 19 year old male as day surgery versus 86 year old male with DM, IHD, dementia, etc.

  30. A Minor Procedure • There are distinctions between minor and major procedures, open & closed procedures, invasive & minimally invasive surgery • The differences are often not clear or adequately defined • “Non-surgeons” now carry out “surgical procedures,” e.g. radiologists

  31. SSI & Laparoscopy in Switzerland Ann Surg 2008; 247: 627-632

  32. Laminar Flow & Prosthetic Joint Infections • Systematic review of articles in last 10 years • Four studies failed to show a benefit & some showed an ↑ SSI rate after surgery J Hosp Infect 2012; 81: 73-78

  33. Day Surgery; Operational Guide • Modernisation funding of £31m 2002/03, £37m, 2003/04 • Patients prefer to recover in their homes • Self-contained unit with own admission suite, wards, theatre & recovery area; stay-in rate higher if not a free-standing unit, 2.4% vs 14% • Operating theatres are required to be the same specification as in-patient theatres – 40m2 with clean & dirty facilities, full lighting, x-ray, piped gases, scavenging, etc. • DoH, 2002

  34. Day Surgery; Operational Guide • 25 Basket procedures (Audit Commission), e.g. circumcision, arthroscopy, etc • BADS ‘trolley of procedures,’ e.g. laparoscopic hernia repair, tympanoplasty DoH, 2002

  35. Day Case & Short Stay Surgery Target is 75% for elective surgery The patient must be admitted & discharged on the same day

  36. Day Case & Short Stay Surgery • Self-contained unit separate from wards & theatres • Theatre & recovery should be equipped + staffed to same standards as in-patient facility • Remoteness & stand alone units; staffing • Operating hours, privacy, proximity of beds to theatres, etc but no mention of theatre ventilation standards Assoc of Anaesth of GB & Ireland, Br Assoc Day Surgery 2011

  37. Day Surgery British Association of Day Surgery

  38. Level of Service Classification Association of Perioperative Practice

  39. SSI & Day Surgery • 1 patient (0.65%) developed incisional infection due to Staphylococcus schleiferi after hernia repair • 1 patient (2.27%) developed incisional infection due to S. aureus after lipoma excision • 1 patient (3.7%) developed infection after pilonidal cyst due to group A streptococci, wound left open in 7 patient & P. aeruginosa, E. coli, S. epidermidis, Proteus vulgaris & Streptococcus costellalis recovered but none required antibiotics Surg Infect 2006; 7: S121-123

  40. Recent Guidelines

  41. MIS, Minor Surgery & Theatre Facilities It won’t go away! HIS request to re-look at this in 2009

  42. MIS, Minor Surgery & Theatre Facilities • Multi-disciplinary one-day meeting • Presentations, e.g. surgical perspective engineering, etc • Discussion • Document circulated & agreed • Consultation process x 2 • Consensus, HIS Council approved & submitted for publication J Hosp Infect 2012; 80: 103-109

  43. HIS Working Group, November 2009 • Microbiology, surgery, radiology, engineering, nursing represented • Review evidence for infections after minor & minimally invasive surgery • Consensus recommendations on: • Basic facilities • Ventilation • Professional practice • Training & education • Research & audit

  44. General Principles • To protect patients & staff (removal of gases) • Difficult to be dogmatic as risk of infection varies & may be unpredictable • Recommendations for the design of new facilities, e.g. interventional radiology • Based on best practice, evidence, current guidelines & consensus/expert opinion • Raise awareness of issues & prevention of infection

  45. Definition Minimal access intervention (MAI) Therapeutic or diagnostic procedures, under LA or GA, small operative site, e.g. laparoscopic colectomy & may proceed to open surgery Minor surgical procedure (MSP) Carried out under LA, superficial & small operative site, e.g. incision of ingrown toe nail

  46. General Specifications-I Ceilings & walls Non-porous, easy to clean. No suspended ceiling Windows Non-openable, if ventilated. Fly screen if open. Maximinise privacy Doors Self-closing with a vision panel but maximise privacy Floors Durable, easy to clean & coving desirable

  47. General specifications - II Instruments Single use desirable Dedicated secure facility if re-usable with space for storage Minimise deposition of dust Separate area for laying-up not required Scrub-up Hands free taps/faucets Disposable towels May be within operative facility Waste Separate & secure area compliant with current guidelines

  48. Ventilation MAI 15 air changes/hour for removal of gases & microbiologically adequate; avoids deposition of airborne particles especially if sterile prosthesis EN 779 F7 filter Pressure differential of ≥ 5Pa between operating facility & surrounding area Indicator panel, 18-22oC & 20-60% humidity MSP Natural ventilation

  49. General Specifications - III • Good lighting • Access to PACS for x-rays, etc • Facilities for collection & storage of specimens in temperature controlled conditions • Emergency lighting in case of loss of power

  50. Other Issues Masks not usually required but face protection if splashing likely Surgical checklist Alcohol hand rubs between cases; scrub at start Gloves & plastic apron for MSP; full precautions for MAI Evidence of competency/training Audit & surveillance

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