Continuous Environmental Disinfection in the OR: A Case Study - PowerPoint PPT Presentation

Continuous Environmental Disinfection in the OR: A Case Study

Objectives Discuss our TJR SSI prevention journey Discuss risk factor mitigation strategies: • Patient Related • Pre-operative • Intra-operative • Post-operative • Post Acute Discuss our experience with continuous disinfection technology

Maury Regional Medical Center • a 255-bed facility serving more than 200,000 people in southern Middle Tennessee • Part of a three hospital system that includes outpatient surgery centers, numerous physician practices, and additional facilities across southern Middle TN • Performs more than 900 TJR each year • Goal of zero surgical site infections

Background It has been well documented that surgical site infection (SSI) after lower extremity total joint replacement (TJR) produces devastating complications that can take months to heal. The combination of the length and complexity of the surgery along with the presence of an implant puts these patients at high risk for SSI. Even with improvements in surgical techniques and implant designs, periprosthetic joint infection (PJI) continues to remain a major cause of implant failure and need for revision. Around 1 million TJR performed each year Infection rate of the implant is appx. 1% Maradit Kremers H, et al. Prevalence of total hip (THA) and total knee (TKA) arthroplasty in the United States. Presentation at: American Academy of Orthopaedic Surgeons Annual Meeting; 2014; New Orleans, La.

Our Surgery Program according to Carechex

Why does one infection matter?

SSI involving implants are often not adequately treated with a single procedure. •Requiring multiple operations and antibiotics. •It is difficult to eradicate a pathogen within a prosthetic device.

Risk Factors – Patient Related • Comorbidities such as: • Diabetes • Immunocompromised status • Obesity • Cigarette Smoking • Personal Hygiene • Home Environment

Pre-operative Infection Prevention •Test for intranasal MRSA/MSSA •Home chlorhexidine (CHG) applications •Nasal decolonization •Blood glucose control •Cessation of tobacco use •TJR Education Pre-surgery: •Clippers for hair removal – prior to OR •CHG application

Pre-op/Intraoperative Infection Prevention • Antimicrobial prophylaxis • Correct antibiotic and dose for weight ü Attention to local resistance • Infusion timed for maximum tissue saturation at time of cut • Vancomycin for MRSA + patient • CHG prep – appropriate amount, let dry • Redose if appropriate according to antibiotic half life • Attention to temperature and glucose

Intraoperative Infection Prevention • Surgical environment • Restricted areas - foot traffic, doors being opened when case opens • Room ventilation – positive pressure; air exchanges • Surgical attire – scrubs, warm-up jacket, masks, hoods, caps • In between case and terminal cleaning process revamp to standardized work • Quality checks with fluorescent marker and UV flashlight

Postoperative Infection Prevention • Silver technology dressing applied in OR • Dressing not changed unless drainage mandates • Necessary dressing changes done using sterile technique • Patient education regarding leaving dressing intact

Post Acute Infection Prevention • Home Health and Skilled Nurse Facility Education • Do not remove dressing unless drainage mandates • Call surgeon for any issues with incision in the first 7 days • Ensure SNF, HH has orders for how and when to change dressings • Ensure SNF, HH stocks silver technology dressing for changes in first 7 days

What more can we do?

Review of data regarding air quality and contamination • Staph aureus is common pathogen for SSI • Staph aureus is common pathogen on healthcare workers hair and skin. • 10 million skin particles are shed from skin every day • The act of walking releases 1,000 skin particles per minute • approximately 10% of skin cells carry viable microorganisms that can pose a threat of SSI to perioperative patients

Partnership with Indigo-Clean • UV light for disinfection has been used for years in other applications • Automated disinfection technology • Does not require additional staff to operate • Continuous disinfection when unoccupied and occupied • Not harmful to healthcare workers

Study Design • ~500 sq. ft. • Primarily used for orthopaedic applications • Sampling conducted over 30 day period in two rooms • 15 days prior to installation • 15 days after installation • Contact agar (BPA) media used • Sampling performed on M, W, F of each week • 50 samples per room per sampling day

Installation

View at 5am Lights are on a motion detector and timer. When the room is unoccupied for 30 minutes, the lights automatically switch from mixed white disinfection mode to Indigo disinfection mode

Study Design Samples taken after terminal clean and before first biomed entry of the day 25 sites per OR, 2 culture plates per site combination of high touch and static sites

Surface pictures and description of high touch areas *highest colony counts Front of Door Anesthesia Handle* Screen* Boom Nurses chair* Light* Control Top of Computer*

Surface pictures and description of culture areas Anesthesia Front of Bovie Chair arms Machine Mouse L & R Anesthesia desk Keyboard Top of IV Lower corners of warmer Inside phone Anesthesia handle machine Top of syringe bin Door handle To gloves Handle of fluid Collection machine

Total Colony Count 100 200 300 400 500 600 700 800 900 0 Study Results 4 -Oct 5 -Oct 6 -Oct 7 -Oct 8 -Oct 9 -Oct 10 -Oct 11 -Oct 12 -Oct OR1 13 -Oct 14 -Oct OR2 15 -Oct 16 -Oct Linear (OR1) 17 -Oct 18 -Oct Lights installed 19 -Oct 20 -Oct Linear (OR2) 21 -Oct 22 -Oct 23 -Oct 24 -Oct 25 -Oct 26 -Oct 27-Oct 28 -Oct 29 -Oct 30 -Oct 31 -Oct

Clinical Results for Indigo-Clean “Compared to the baseline, we saw an average, daily reduction of 88% in the operating room where Indigo- Clean was installed despite the fact that the room was used 54% more than in the baseline period.” - Lynnelle Murrell, Director, Infection Prevention, Maury Regional Hospital

Conclusion • SSI prevention requires multiple activities throughout the entire perioperative and postoperative time. • We have to keep asking “What more can we do?” • Indigo-Clean lights provide another means of protection for our patients by continuously reducing bacteria in the OR environment • Continuous disinfection may provide greater benefit in outcomes when paired with a robust SSI prevention program • Further study needed regarding outcomes, and ongoing degrees of contamination and disinfection during OR use.

For More Information Contact Lynnelle Murrell @ lymurrell@mauryregional.com