外科感染（英文ppt）surgical site infection

1、1,Surgical Site Infection Collaborative,,2,January 1 – September 2, 2001,13 orthopedic surgeons involved in 36 musculoskeletal cases that developed infections,3,#of Days Between Total Joint Replacement InfectionsJanuary

2、 1, 2002 through June 2003,4,Trending of Hip Prosthesis Infection Rates,,,,NNIS Risk 1,NNIS Risk 0,5,Trending of Knee Prosthesis Infection Rates,,,,NNIS Risk 1,NNIS Risk 2,6,Surveillance Focus Included,ASA scoreLength o

3、f surgeryNumber of personnel in OR suiteMicroorganism culturedTiming of preoperative antibiotic,7,Time Line of Events,01/28/02,Orthopedic surgical infections report presented to Infection Control Committee,03/06/02,04

4、/15/02,05/02/02,05/09/02,05/16/02,Meeting with key players regarding surgical wound infections,Teleconference – Multifactorial Interventions to Prevent Surgical Site Infections,,,,,,,,Infection Control Nurse and Hospital

5、 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 choice,Infection Control N

6、urse and Hospital Epidemiologist meet with orthopedic surgeons regarding ortho infections in 2001,8,Time Line of Events,06/24/02,Infection Control Nurse and Hospital Epidemiologist meet with Board Members to discuss orth

7、o surgical wound infections,Meeting with key players to discuss ortho surgical wound infections,Discussion regarding ortho surgical infections deferred at Ortho Dept. Meeting,Ortho surgeon addressed the issue of ortho in

8、fections briefly at department meeting,Meeting with Hospital CEO and key players regarding ortho infections,Hospital Epidemiologist presents recommendations at Ortho Q.A. Meeting,,,,,,,,,10/17/02,09/16/02,12/16/02,12/30/

9、02,10/28/02,09/30/02,Orthopedic infections on Ortho Dept. Meeting agenda, discussion deferred,9,10,Recommendations,Employ chlorhexadine 4% / isopropyl alcohol as skin prepUse clippers for hair removalMaintain a core bo

10、dy temperature of > 36ºc throughout surgeryAdminister oxygen at 80% / 50% intra-operatively and at 80% by sealed mask/conventional non-rebreather mask for first two hours of recoveryTest blood glucose thirty mi

11、nutes after incision timeAdminister appropriate antibiotic within 30 minutes of incision timeDiscontinue antibiotics within 24 hours,11,Team Members,Raymond Palesch, MD – Orthopedic Surgeon, Trauma Medical DirectorNei

12、l Barg, MD – Hospital EpidemiologistCarl Olden, MD – Medical Staff QualityAmy Crook, MD – AnesthesiologistMario Domenzain, MD – OB/GYN Paul Novak, CRNAKen Eakin, RN – Surgical Services SupervisorKristy Cure, RN – S

13、urgical Services Nurse Manager,Connie Conklin, RN – Ortho/Neuro/IV Tx Nurse ManagerGay Scott, RN, CIC – Infection Control NurseGreg Matsuura, Pharm-DKay Anyan, RHIA – Director Medical Staff ServicesLinda Bluhm, CPHQ

14、– Director Performance ImprovementSandy Dahl, RN – VP Nursing & Patient CareLinda Haralson, RN – L&D/Peds/NICU Nurse ManagerCecilia Bray, RN – Women’s/Gen. Surgery Nurse Manager,12,Timely Antibiotics Administe

15、red,Anesthesia/Nursing responsibleDevelopment of protocol for administration within 30 minutes prior to incision2 gms of antibiotic for adults over age 16Repeat intraoperative dosing at 3 hours,13,Antibiotics Within

16、One Hour,,14,Appropriate Antibiotics Given,Initiation of Antibiotic Review of perioperative antibioticsDevelopment of Penicillin Allergy Algorithm,15,Appropriate Antibiotics Given,,16,Antibiotic Prophylaxis,Given withi

17、n 30 minutes of cut timeException: Vancomycin and Levofloxacin 1 hr infusion timeInfusion must be finished prior to cutRecommended durationdiscontinue within 24hrs1,Bratzler DW, et al. Antimicrobial Prophylaxis for

18、Surgery: An advisory statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004;38:1706-1715Antimicrobial prophylaxis for surgery. Treatment Guidelines from the Medical letter,

19、2004; 2(20):27-32.,17,Orthopedic 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.,18,Penici

20、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 penicill

21、in reaction was it?,Did the patient develop severe hypotension, respiratory distress, or systemic swelling?,No,Use Vancomycin,Use Cefazolin,Use Cefazolin,Yes,No,No,No,Yes,Yes,,,,,,,,,Did the patient develop hives (raised

22、, itchy, systemic welts) during a treatment course?,Yes,,19,20,Antibiotics Discontinued in 24 Hours,Nurse Manager provided SSI collaborative PowerPoint presentation to Surgical Services staff - 3/31/03Physician Champion

23、 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 – 5/27/03,21,Orthopedic Post-op Orders

24、 Page 2 of 2.Antiemetic Protocol.Respiratory:If on Oxygen, oximetry every 8 hrs, D/C O2 when SAT >92%Respiratory Care, evaluate and treat ? Incentive Spiromet

25、ry.Activity: ? Bed Rest ? OOB this PM ? Chair TIDPhysical Therapy: Begin treatment: ?this P.M. ?in A.M. _______________WB affected extremityTotal Hip Protocol ______________________ WB affected extremit

26、yTotal Knee Protocol ____________________ WB affected extremityElevate affected extremity ? 6” above heart level ? heart level ? stockinette ? calves elevated on pillowsCPM _____________________________________

27、________________________________________________________________________________________________Other ____________________________________________________________________________________________________________________

28、_________________.Misc:X-Ray _____________________________________________________________________________________________________________________________________Dressing ______________________________________________

29、____________________________________________________________________________________AutotransfusionDiscontinue Hemovac ? 24 hours post-op ? 48 hours post-opR/C or straight cath PRN inability to void – Discontinu

30、e R/C 48 hrs post-op, reinsert PRN. C&S PRNTEDS Protocol ? SCD Protocol ? Abduction BolsterSS consult – Discharge PlanningCold TherapyIce pack to affected area 20-30 minutes 3 times/shift (do not place ic

31、e bag directly on skin)Physician’s Signature: _______________________________________________________________________ Date/Time: ______________________________________________,22,Antibiotic Discontinued in 24 Hours,23

32、,Hair Removed Appropriately,Two clippers stocked in each OR suiteRe-inserviced staff via poster boardsSpecific staff member assigned responsibility for stockingUse of clippers implemented for other surgical procedures

33、,24,Hair Removed Appropriately,,25,Normothermia,Calibration checked on forced air warming machines and adjustedForced air warming machines placed on preventative maintenance schedulePre-op warming blanketsIncrease of

34、room temperature abandonedAbandoned cooling vests for surgeons after trialSpace hats in pre-opUnderbody warmers in OR,26,Body Temperatures,,27,Supplemental Oxygen,Implemented use of non-rebreather mask at high flowPa

35、tient education regarding rationale in pre-op holding areasSet standard mask removal time at 2 hours post arrival to patient roomNon-rebreather mask application to patient with initiation of oxygen flowUtilization of

36、timer abandoned,28,Supplemental Oxygen Perioperatively,29,Patient Satisfaction Non-Rebreather Mask,Interview each patient post discontinuation246 out of 255 patients were satisfied with the use of the non-rebreather ma

37、sk (96.5%),30,Chlorhexadine 4%/Alcohol PrepMarch 19, 2003 – February 29, 2004,Total Knee/Total Joint Recommendations,31,31,32,Other Inpatient Ortho,Started July 2003,33,Neuro Surgery,Started November 2003,34,,,,,,,,,,,,

38、,March 2003Ortho Hips and Knees,July 2003Other Ortho,,November 2003 Neuro,January 2004C-Sections,May 2004OB/GYN,November 2004Colon,February 2005 General Surgery and Urology,September 2005Wound Care, Podiatry, an

39、d Plastics,SSI Collaborative 3 Year Plan,35,Appropriate Prophylactic Antibiotic Selected,36,Percent of Abx Given Within 1 Hour of Incision,37,Percent of Prophylactic Abx Discontinued Within 24 Hours After Surgery End Tim

40、e,38,38,39,Trending of Total Hip Infection Rates,,,NNIS Rate: 0.88,NNIS Rate 1.61,40,Trending of Total Knee Infection Rates,,NNIS Rate: 1.26,,NNIS Rate: 0.87,,41,Recommendations,Employ chlorhexadine 4% / isopropyl alco

41、hol as skin prepUse clippers for hair removalMaintain a core body temperature of > 36ºc throughout surgeryAdminister oxygen at 80% / 50% intra-operatively and at 80% by sealed mask/conventional non-rebreather

42、mask for first two hours of recoveryTest blood glucose thirty minutes after incision timeAdminister appropriate antibiotic within 30 minutes of incision timeDiscontinue antibiotics within 24 hours,42,43,Surgical Site