Preventing mediastinitis surgical site
infections: Executive summary of the
Association for Professionals in
Infection Con...
surgery), and large breasts.7
Of these risk factors, obe-
sity, diabetes, and previous hospitalization have the
strongest ...
the prevention of mediastinitis SSI and implementing
protocols to ensure that these standards are met for ev-
ery cardiac ...
of 3

Preventing mediastinitis surgical site infections executive summary of the association for professionals in infection control and epidemiology’s elimination guide

Infections
Published on: Mar 4, 2016
Published in: Health & Medicine      
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Transcripts - Preventing mediastinitis surgical site infections executive summary of the association for professionals in infection control and epidemiology’s elimination guide

  • 1. Preventing mediastinitis surgical site infections: Executive summary of the Association for Professionals in Infection Control and Epidemiology’s elimination guide Terri Rebmann, PhD, RN, CIC,a and Kathleen Kohut, RN, MS, CIC, CNORb St. Louis, Missouri; and Charlotte, North Carolina This article is an executive summary of the Association for Professionals in Infection Control and Epidemiology’s elimination guide for mediastinitis surgical site infections. Infection preventionists are encouraged to obtain the original, full-length elimination guide for more thorough coverage of mediastinitis surgical site infection prevention. Key Words: Health care-associated infection; infection prevention. Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. (Am J Infect Control 2011;39:529-31.) Mediastinitis is a serious health care–associated in- fection (HAI) that can develop after cardiac surgical procedures. An estimated 427,000 coronary artery by- pass graft (CABG) surgeries are performed each year in the United States.1 The reported rate of mediastinitis surgical site infection (SSI) following CABG surgery ranges from 0.12% to 5%,2,3 and the associated mor- tality from such an infection can reach 40%.4 Medias- tinitis SSIs also increase the hospital length of stay by up to 30 days, triple the medical costs associated with hospitalization, and increase the risk for other HAIs, such as ventilator-associated pneumonia or catheter- related bloodstream infection. In addition to address- ing patient safety and satisfaction concerns, reducing the rate of mediastinitis SSI is vital to hospitals for fi- nancial reasons. The Centers for Medicare & Medicaid Services (CMS) is evolving into a value-based purchas- ing model that results in reduced reimbursement for certain HAIs, including mediastinitis SSIs. Private insurance agencies may eventually use similar pay- ment structures. In 1999, the Hospital Infection Control Practices Ad- visory Committee published a set of guidelines for pre- venting SSIs.5 The Surgical Care Improvement Project (SCIP) published clinical practice guidelines related to SSI prevention with the aim of reducing the incidence of SSIs by 25% by 2010.6 In 2009, the Association for Professionals in Infection Control and Epidemiology (APIC) published an elimination guide for the preven- tion of mediastinitis SSIs after cardiac surgery.7 This ar- ticle is an executive summary of that elimination guide; the full-length document, available through the APIC Web site, describes a comprehensive approach to de- veloping a mediastinitis SSI prevention program for hospitals. RISK FACTORS FOR MEDIASTINITIS SSI Mediastinitis SSIs can result from endogenous or ex- ogenous sources of microorganisms that invade the surgical site during surgery. Examples include the pa- tient’s normal flora, an existing infection at the time of surgery, contaminated fluids or surgical equipment, shedding from health care workers, and poor hand hy- giene practices. Certain factors increase the risk of infection, including a chronic medical condition (eg, renal failure, hypertension, chronic obstructive pulmo- nary disease, peripheral vascular disease, osteoporosis, diabetes), obesity, current or past history of smoking, hospitalization before surgery, older age, male sex, his- tory of CABG surgery (particularly emergency CABG From the Institute for Biosecurity, Division of Environmental and Occu- pational Health, School of Public Health, Saint Louis University, St. Louis, MOa ; and Independent consultant, Charlotte, NC.b Address correspondence to Terri Rebmann, PhD, RN, CIC, Institute of Biosecurity, Division of Environmental and Occupational Health, School of Public Health, Saint Louis University, 3545 Lafayette Ave, Room 463, St. Louis, MO 63104. E-mail: rebmannt@slu.edu. Conflict of interest: None to report. 0196-6553/$36.00 Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2010.10.014 529
  • 2. surgery), and large breasts.7 Of these risk factors, obe- sity, diabetes, and previous hospitalization have the strongest evidence linking them to the development of mediastinitis SSI.7 MEDIASTINITIS SSI SURVEILLANCE The first step in creating an effective surveillance program for mediastinitis SSIs is to determine whether all cardiac surgeries or only the highest-risk proce- dures (ie, CABG with both chest and donor site inci- sion) will be monitored. It is important to note that interventions aimed at lowering the rate of mediastini- tis SSIs in patients who have undergone CABG should have a positive impact on infection rates for other car- diac surgeries as well. Focusing only on CABG patients can save facilities time and resources while still im- proving outcomes in all cardiac patients. Case findings can be complex, and infection preventionists are en- couraged to use a variety of surveillance methods (eg, monitoring culture reports, antibiotic utilization lists, medical records review) and to validate the most effective means of capturing SSIs. Less effective sur- veillance methods can be discontinued to maximize resources. Definitions published by the National Healthcare Safety Network (NSHN) should be used for mediastinitis SSI surveillance.8 Surveillance for mediastinitis SSIs re- quires following CABG patients for 1 year after the pro- cedure, which involves an implantable device in the form of sternal wires. Leg incisions are followed for 30 days. It is prudent for infection preventionists to consult with a hospital epidemiologist or infectious dis- ease physician to verify each case of mediastinitis SSI. Standardized data collection forms are used to organize the data and increase the efficiency of data collection. When available, electronic data sources are optimal to maximize resources. The APIC elimination guide provides an example data collection form for cardiac surgeries that can be used by SSI infection prevention programs. Rates of mediastinitis SSI are calculated based on the surveillance data collected, using the number of SSIs as the numeratorand the numberofsimilarsurgicalproce- dures as the denominator and multiplying by 100.7 SSI rates should be calculated separately for each of the 3 types of NHSN-defined cardiac surgical procedures and stratified by risk index. It is also important to assess the epidemiology of mediastinitis SSIs for the facility, which might provide clues as to the source of infection and identify potential interventions that can help prevent future cases. For example, a trend toward increasing gram-negative organisms might indicate a potential environmental source and trigger an investi- gation into surgical equipment reprocessing procedures or possible sources of contaminated solutions, and an increase in SSIs due to gram-positive organisms might warrant an investigation into skin antisepsis pro- tocols or staff compliance with surgical attire.7 Given the low number of CABG surgeries performed at most facilities, infection preventionists should calcu- late cumulative mediastinitis SSI rates. Any trends noted should then drive future process improvement projects. Evaluating mediastinitis SSI rates on a monthly basis can be misleading because of small sample sizes. A health care facility’s mediastinitis SSI rate should be evaluated against internal (ie, the facility’s historical rate) and external (ie, NHSN) benchmarks, calculating a P value to identify whether a statistically significant change in the rate has occurred. Comparison with the internal benchmark is more critical than comparison with the NHSN rate, especially if an upward trend in in- fection rate is noted. Outcome reports are generated to delineate the num- ber of cases of mediastinitis SSI as well as the infection rate. All data should be risk-stratified, and surgeon- specific rates may be included in the report, especially if one surgeon is an outlier. Generating surgeon-specific rates can be an effective strategy for assessing whether a surgical practice/team might be associated with a higher infection rate. These reports will be better re- ceived if cardiac surgeons are involved in the decision as to which procedures are monitored, the data are re- ported in a manner that ensures confidentiality, and the rates are not used to direct blame at the surgical practice/team. The APIC elimination guide provides several examples of outcome report formats, including various methods for illustrating data in a manner that enhances interpretability. MEDIASTINITIS SSI PREVENTION PROGRAM Mediastinitis SSI prevention programs require an understanding of at-risk populations, effective surveil- lance, accurate data analysis, dissemination of findings to key stakeholders, and involvement in outcome im- provement projects. SSI prevention program interven- tions fall into 3 categories: (1) mitigating the risk of nonmodifiable patient factors, (2) monitoring com- pliance with standards of care, and (3) implementing evidence-based improvement programs. Nonmodifi- able patient characteristics are factors that cannot be reduced or eliminated before surgery, such as having a chronic underlying illness, being male, or having a history of a previous CABG surgery. Patient care plans for preoperative and postoperative interventions that mitigate the risk of these nonmodifiable patient factors are essential to reduce associated complications. Monitoring compliance with standards of care in- volves implementing evidence-based interventions for 530 Rebmann and Kohut American Journal of Infection Control August 2011
  • 3. the prevention of mediastinitis SSI and implementing protocols to ensure that these standards are met for ev- ery cardiac surgical patient and during every procedure. Finally, health care facilities should implement process improvement programs that are based on relevant re- search findings. These programs may address facility- specific protocols or policies that affect mediastinitis SSI rates, such as monitoring aseptic technique prac- tices and communicating these findings back to the surgical team. The APIC elimination guide describes a successful program that has greatly reduced or elimi- nated the rate of mediastinitis SSIs and delineates the strategies used, including creation of a multidis- ciplinary process improvement team to address SSI prevention; implementing ‘‘plan, do, check, act’’ meth- odology; identifying and implementing an action plan; and conducting a cost–benefit analysis of the pro- gram. Details of this program are provided in the APIC elimination guide.7 MEDIASTINITIS SSI PREVENTION Interventions to reduce or eliminate mediastinitis SSIs should address the potential endogenous and ex- ogenous sources of infection. In addition, mediastinitis SSI prevention interventions should address current standards of care. In brief, the SCIP standards cover the selection, dosing, and timing of appropriate anti- biotic prophylaxis; discontinuation of prophylaxis within 48 hours after surgery; controlling blood glu- cose level by 6 a.m. on postoperative day 1; and appro- priately removing hair from the surgical site. Details of the SCIP standards are provided in the literature6 and in the APIC elimination guide for mediastinitis SSIs.7 Other critical interventions aimed at preventing medi- astinitis SSIs include adhering to hand hygiene proto- cols; maintaining appropriate surgical skin antisepsis; using aseptic technique; following the Hospital Infec- tion Control Practices Advisory Committee’s recom- mendations for proper surgical technique;5 managing the postoperative site, including the use of appropriate postoperative dressing materials; promoting a preoper- ative shower program; and providing nasal decoloniza- tion with intranasal mupirocin. Evidence supporting these interventions and information on implementing them are provided in the APIC elimination guide for mediastinitis SSIs.7 SUMMARY This article provides a brief overview of the APIC elimination guide for mediastinitis SSIs. Infection pre- ventionists are encouraged to obtain the original, full- length elimination guide from the APIC for more thorough coverage of mediastinitis SSI prevention strate- gies. Mediastinitis SSI prevention is a vital component of hospital infection prevention programs for those facili- ties that perform cardiac surgical procedures. Interven- tions for preventing mediastinitis SSIs need to be incorporated into these hospital’s infection prevention programs.Policiesandprotocolsshouldreflectthesepre- vention strategies, such as monitoring staff for compli- ance and providing antibiotic prophylaxis. Surveillance is necessary to measure mediastinitis SSI rates and to provide the data that drive appropriate process improve- ments aimed at preventing this serious and preventable complication in patients undergoing cardiac surgery. References 1. American Heart Association. What is coronary artery bypass surgery? Available from: http://www.americanheart.org/downloadable/heart/ 119626671501548%20WhatIsCornryBypsSrgry_9-07.pdf. Accessed May 18, 2010. 2. Division of Healthcare Quality Promotion, National Center for Infec- tious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470-85. 3. Swenne CL, Linholm C, Borowiec J, Carlsson M. Surgical site infections within 60 days of coronary artery bypass graft surgery. J Hosp Infect 2004;57:14-24. 4. Lucet JC. Surgical site infection after cardiac surgery: a simplified surveillance method. Infect Control Hosp Epidemiol 2006;27:1393-6. 5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Hospital In- fection Control Practices Advisory Committee (HICPAC). Guideline for the prevention of surgical site infection. Infect Control Hosp Epide- miol 1999;20:247-80. 6. Colorado Foundation for Medical Care. Surgical Care Improvement Project. Available from: http://www.cfmc.org/hospital/hospital_scip .htm. Accessed May 18, 2010. 7. Kohut K. Guide for the prevention of mediastinitis surgical site infec- tions following cardiac surgery: an elimination guide. Available from: http://www.apic.org/AM/Template.cfm?Section5APIC_Elimination_Gui des&Template5/CM/HTMLDisplay.cfm&ContentID514743. Accessed May 18, 2010. 8. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32. www.ajicjournal.org Vol. 39 No. 6 Rebmann and Kohut 531

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