Author Archives: Victoria Steelman PhD, RN, CNOR, FAAN

Feb 7, 2017

Patient Safety: What Patients and Families Can Do To Prevent Surgical Site Infections

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When an infection occurs after surgery in the part of the body where surgery was performed, it is called a surgical site infection. These infections are not common, but they do occur in about 1 to 3 patients out of 100 who have surgery. Doctors, nurses and other members of the healthcare team are focusing on preventing these infections, by implementing practices that you may or may not know, including:

  • Washing their hands before each patient contact,
  • Sterilizing surgical instruments,
  • Washing their hands and arms before surgery,
  • Wearing hair coverings, masks, gowns and gloves during surgery,
  • Giving you antibiotics, if appropriate, right before your surgery,
  • If they need to remove hair where your incision will be, using a clipper instead of a razor, and
  • Washing your skin with a special soap, an antiseptic, to kill germs.

But, they cannot prevent infections without your help.

What can I do at home before surgery?

  • Before surgery, discuss any health problems with your physician. Allergies, diabetes, vascular disease, implants, obesity, and sleep apnea are some of the things that can affect your surgery, your treatment, and your recovery.
  • Make sure that you inform your doctor of any recent infections or any open sores.
  • Quit smoking. People who smoke are more likely to get a surgical site infection. Talk to your doctor about ways to successfully quit.
  • If you don’t have a thermometer, get one. You may need one after surgery.
  • If your physician or hospital gives you or instructs you to use a special soap for showering, or antiseptic wipes, follow the instructions for use. If you weren’t given or instructed to use a special soap, shower with soap and water the day of your surgery.
  • Do not shave the area where your incision will be.
  • If you use a CPAP machine, take it with you to the hospital/ambulatory surgery center.

It is very important for you to discuss your health issues with your doctor. For your incision to heal, it needs oxygen. So, the healthcare team needs to take precautions if you have sleep apnea. If you have had a recent infection, or have an open sore, surgery might need to be postponed to keep you safe. Most surgical site infections are from microorganisms on the skin, so making sure that your skin is clean is very important.

What can I do in the hospital or ambulatory surgery center before surgery?

  • Wash your hands.
  • Speak up:
    If someone tries to use a razor to shave your incision site.
    If you do not see a provider wash his/her hands before touching you.

It might seem uncomfortable to speak up. But, your nurses and doctors want to do the right thing, and if they forget to wash their hands, they want you to remind them. Say something like, “I was told to remind anyone caring for me to wash their hands if I didn’t see them do it.”

What can I do after surgery?

  • Wash your hands, especially after using the toilet or blowing your nose.
  • Ask family and friends to wash their hands when they enter your room.
  • Speak up if you do not see a provider wash his/her hands.
  • Listen to the instructions preparing you for after you leave the hospital, and have someone else with you to also listen to this important information.
  • Ask questions if you are unsure of anything.

Surgery is likely a stressful experience for you. And, you may not be able to retain all of the information that you are given. Having a second set of ears to listen to instructions is very helpful.

What can I do at home after surgery?

  • Wash your hands.
  • Ask family and friends to wash their hands when they enter your room.
  • Do not let family and friends touch your incision or dressing.
  • Follow the instructions given to you at the hospital or ambulatory surgery center.
  • If you are given antibiotics, take the pills as instructed, and take all of the pills.
  • Notify your physician immediately if you notice any symptoms of infection such as:
    Redness or swelling around the incision.
    Drainage of cloudy fluid from your incision.
    Fever.

If you have any questions, call the contact number on your discharge instructions.

Having a young family member make a “high five” sign saying “Please wash your hands,” is a creative way to engage the whole family. And having a bottle of hand antiseptic nearby makes it easy. If you are given an antibiotic, it is very important that you take every pill, even if you feel fine. If you don’t do this, the microorganisms can become resistant to antibiotics and very difficult to treat. It is not unusual to have questions after surgery. You might not think of these while you are in the hospital. We want you to call if you have questions. You aren’t bothering the doctor or nurse. We want you to do this.

Patients and healthcare providers are partners in preventing surgical site infections. We are doing a lot, but we need your help so that you can have a positive surgical experience, heal well, and have the best possible outcome.

May 19, 2016

The Prevention of Perioperative Hypothermia Toolkit

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Guest blogger: Victoria M. Steelman, PhD, RN, CNOR, FAAN Associate Professor, College of Nursing, The University of Iowa Disclosure: Victoria M. Steelman, PhD, RN, CNOR, FAAN has served as a consultant for 3M and VitaHEAT. This article is sponsored by 3M.

The Prevention of Perioperative Hypothermia Toolkit

I am sometimes asked, “Is perioperative hypothermia really a big deal?” The answer is “yes, it is.” Most patients undergoing surgery will become hypothermia unless we use effective interventions to prevent it.

Why is preventing perioperative hypothermia important?

It is important to prevent perioperative hypothermia because it is associated with negative patient outcomes. Perioperative hypothermia increases:

  • surgical site infection risk,1
  • morbid cardiac events,2
  • blood loss,3,4
  • length of stay in the recovery room,5 and
  • impairment of drug metabolism.5

All of this increases the cost of healthcare.

Why does hypothermia occur?

One common misconception is that perioperative hypothermia is caused by the operating room being cool, and if the room temperature is increased, hypothermia will not occur. This is a myth. Although the room temperature plays a role, anesthesia plays the primary role. General and regional anesthesia impair the normal thermoregulatory responses.6 Upon induction of anesthesia, heat is redistributed from the core to the peripheral tissues, which are much (2-4oC) cooler. This causes the core temperature to drop significantly during the first hour of anesthesia.7 Anesthesia also impairs the body’s ability to respond to cold. Normally, the body would respond to a drop in temperature of 0.4oC. An anesthetized patient does not respond until there is a 4oC drop in core temperature.So, the patient does not produce enough heat to overcome the initial hypothermia.

Will using cotton blankets prevent hypothermia?

Passive warming with blankets retains heat. But, because the anesthetized patient is unable to produce enough heat, retention of heat alone is inadequate. Applying heated cotton blankets is only slightly more effective, and the benefit only lasts 10 minutes.9 In a randomized clinical trial, applying heated cotton blankets failed to prevent hypothermia.10

Will heating insufflation gases for laparoscopy prevent hypothermia?

Another commonly used, ineffective way of preventing hypothermia is heating the carbon dioxide used for insufflation during laparoscopy. A meta-analysis of 16 randomized clinical trials found that heating CO2 gas had no effect on core temperature, and there was no evidence to support the use of heated CO2 gas, with our without humidification, for laparoscopic surgery.11

How can we prevent hypothermia?

Applying heat to actively warm the patient is required to prevent perioperative hypothermia. The most common method of active warming is forced air warming (FAW), which distributes warm air over the skin surface, heating peripheral tissues, and minimizing core-to-periphery temperature gradient. Intraoperative FAW is more effective in maintaining body temperature than cotton blankets,10,12  reflective blankets,12 or thermo-lite® insulation.12,13

What patients should receive active warming?

Patients undergoing surgery that will be at least 30 minutes long, with general or regional anesthesia (spinal, epidural) should be actively warmed.

When should we use active warming?

To be most effective, active warming should be initiated preoperatively for at least 30 minutes and also used intraoperatively. Actively warming the patient preoperatively minimizes heat lost during redistribution of heat from the core to periphery upon induction of anesthesia, and minimizes the incidence of hypothermia.14-16

Why are hospitals not using these evidence-based practices?

Unfortunately, active warming is not always used when needed and is often not used correctly. First, practitioners are not knowledgeable enough about perioperative hypothermia, and do not always consider it a priority. Secondly, they do not understand the importance of prewarming the patient, and often start active warming after induction of anesthesia. Third, there was a quality performance measure that has been retired that required active warming or normothermia. Practitioners were in compliance with the measure even if they used active warming incorrectly, starting it after induction of anesthesia, and the patient became hypothermic.17 Actual evaluation of patient outcomes and reducing the incidence of hypothermia were not emphasized, resulting in a “checklist mentality”. And, lastly, complacency is an incredibly strong force, and a concentrated effort is required to make a change in practice.

How can we get practitioners to use this evidence to prevent perioperative hypothermia?

We need to use a combination of strategies to engage busy professionals and integrate a change into their work processes. For that reason, a team at the University of Iowa developed the Prevention of Perioperative Hypothermia Toolkit©. Use of this toolkit has been tested for the past two years, and refined with lessons learned. The toolkit includes is a list of steps for planning the implementation of changes. The second component is a template for a risk assessment, a Healthcare Failure Mode and Effect Analysis (HFMEA), to identify potential issues that can arise during implementation. The next component is an educational program that can be modified with taped statements of support from key perioperative leaders in the setting. A list of data elements to use for modifying the electronic documentation system is included to allow for the generation of reports. And, there are spreadsheets that can be used as templates for audit and feedback.

The Prevention of Perioperative Hypothermia Toolkit© is available free of charge.

For more information, watch the 3M webinar Strategies for Infusing Evidence-based Practices for Prevention of Perioperative Hypothermia.

The Prevention of Perioperative Hypothermia (PPH) Toolkit was funded by the Agency for Healthcare Research and Quality, grant 3 IR18HS021422-01A1.

Dr. Steelman has been a perioperative nurse for over 25 years. As a perioperative advanced practice nurse at the University of Iowa Hospitals and Clinics, she focused on implementing evidence-based practice changes for 20 years. She is currently Associate Professor in the College of Nursing at the University of Iowa where she teaches graduate students evidence-based practice. Her program of research focuses on perioperative safety and quality. She has extensively published and presented about issues related safe patient care in the operating room, including five research studies focusing on prevention of retained surgical sponges. She is well recognized for her contributions and received AORN’s Outstanding Achievement awards for Research and Evidence-based Practice. In 2008, she received the AORN’s highest award, the Award for Excellence in recognition of her contributions to perioperative nursing. In 2007, she was inducted into the American Academy of Nursing in recognition of the national and global impact of her work. 

REFERENCES

1. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209-1215.

2. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA. 1997;277:1127-1134.

3. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet. 1996;347:289-292.

4. Winkler M, Akca O, Birkenberg B, et al. Aggressive warming reduces blood loss during hip arthroplasty. Anesth Analg. 2000;91:978-984.

5. Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology. 1997;87:1318-1323.

6. Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology. 2008;109:318-338.

7. Sessler DI. Perioperative heat balance. Anesthesiology. 2000;92:578-596.

8. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol. 2008;22:659-668.

9. Sessler DI, Schroeder M. Heat loss in humans covered with cotton hospital blankets. Anesth Analg. 1993;77:73-77.

10. Fossum S, Hays J, Henson MM. A comparison study on the effects of prewarming patients in the outpatient surgery setting. J Perianesth Nurs. 2001;16:187-194.

11. Birch DW, Manouchehri N, Shi X, Hadi G, Karmali S. Heated CO(2) with or without humidification for minimally invasive abdominal surgery. Cochrane Database Syst Rev. 2011;(1):CD007821.

12. Ng SF, Oo CS, Loh KH, Lim PY, Chan YH, Ong BC. A comparative study of three warming interventions to determine the most effective in maintaining perioperative normothermia. Anesth Analg. 2003;96:171-176.

13. Borms SF, Engelen SL, Himpe DG, Suy MR, Theunissen WJ. Bair hugger forced-air warming maintains normothermia more effectively than thermo-lite insulation. J Clin Anesth. 1994;6:303-307.

14. Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of prewarming on post-induction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general anaesthesia. Br J Anaesth. 2008;101:627-631.

15. Horn EP, Schroeder F, Gottschalk A, et al. Active warming during cesarean delivery. Anesth Analg. 2002;94:409-414.

16. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR,Jr. Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery. J Clin Anesth. 2003;15:119-125.

17. Steelman, V. M., Perkhounkova, Y. S., & Lemke, J. H. The gap between compliance with the quality performance measure “Perioperative Temperature Management” and normothermia. J Healthc Qual. 2014 January 13. PMID: 24417607. doi: 10.1111/jhq.12063.

Mar 8, 2016

Key Elements for Reducing the Risk of Surgical Site Infection

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Key elements for reducing surgical site infections

Establishing and maintaining an effective program for prevention of surgical site infection is a primary responsibility of the perioperative team. The effectiveness of this program depends upon a comprehensive approach. The Centers for Disease Control and Prevention’s Surgical Site Infection (SSI) Prevention Toolkit1 presents these core strategies:

  1. Administer antibiotics prophylaxis in accordance with evidence-based standards
    • Within 1 hour prior to incision ( 2 hours for vancomycin)
    • Select the antibiotic based on surgical procedure and common pathogens
    • Discontinue antibiotics within 24 hours after surgery end time (48 hours for cardiac surgery)
  2. Identify and treat remote infections before elective surgeries
  3. Do not remove hair at the operative site unless it will interfere with the operation, and if necessary, not with a razor
  4. Use an appropriate antiseptic skin preparation
  5. Maintain normothermia
  6. For colorectal surgery, mechanically prep the colon and administer oral antimicrobial agents in divided doses on the day of surgery
  7. Limit traffic in the OR and keep the OR doors closed during surgery
  8. Protect the incision with a dressing for 24-48 hours.
  9. For cardiac surgery, control blood glucose levels at <200mg/dL.

These core strategies are helpful in prioritizing a program for prevention of surgical site infection. But, I hear some lingering questions.

When should preoperative antibiotics be administered?

Most surgeons, anesthesia providers, and perioperative nurses are familiar with the importance of preoperative antibiotic prophylaxis. The SCIP guidelines have been in place for many years, and focus on appropriate antibiotic choice, appropriate timing of preoperative antibiotics, and appropriate discontinuation of antibiotics. These indicate that cephalosporin should be given within 60 minutes prior to incision and vancomycin within 120 minutes. But, is this best practice, or would administration even closer to the time of incision be even better? Some research has found that when cephalosporins are administered within 30 minutes of incision, the infection rates were lower.1,2 However, the American Society of Health-System Pharmacists, Inc. has reviewed this evidence and found it to be not robust enough to make a change, and continue to recommend the time frame of within 60 minutes prior to incision for cephalosporins and 120 minutes for vancomycin in their clinical practice guideline.2

Should we be redosing antibiotics during surgery?

Redosing is sometimes needed to ensure that there is an adequate serum concentration of the antibiotics during the procedure. The next dose should be given if the procedure exceeds two half-lives of the antibiotic, measured from the time of the initial dose, or there is excessive blood loss. For example:

Recommended Redosing Intervals for Antibiotics2

Antibiotic Half-life in Adults with Normal Renal Function Recommended Intraoperative Redosing (from preoperative dose)
Cefozolin 1.2 – 2.2 hours 4 hours
Cefoxitin 0.7 – 1.1 hours 2 hours
Clindamycin 2 – 4 hours 6 hours
Vancomycin 4 – 8 hours

So, you can see that if cefozolin is given 30 minutes before surgery, redosing of cefozolin is not necessary during a surgery that lasts less than 3.5 hours. And redosing with vancomycin during surgery is not recommended.

Is it important to warm patients preoperatively?

General, spinal, and epidural anesthesia profoundly impair the patient’s thermoregulatory response. Upon induction or start of anesthesia, heat is redistributed from the core to the peripheral tissues, which are much (2-4oC) cooler. This causes a drop in the core temperature called redistribution hypothermia.3 Anesthesia also profoundly impairs the patient’s ability to respond to cold. Normally, the body would respond to a small drop in core temperature (0.4oC), and generate more heat. An anesthetized patient does not respond until there is a significant drop in core temperature, 10 times greater than the non-anesthetized patient.So, the patient does not produce enough heat to overcome the redistribution hypothermia.

Because anesthetized patients are unable to respond effectively and produce the heat needed, retaining heat with blankets is not enough, even blankets warmed in a warming cabinet. Active warming, or applying heat to the patient’s skin, is required. If we do this after induction/start of anesthesia, redistribution hypothermia has already occurred and we are “behind the eight ball” with prevention. In order to effectively prevent hypothermia, we need to prevent redistribution hypothermia by actively warming the patient for at least 30 minutes prior to anesthesia start. Warming the patient preoperatively (in addition to intraoperatively) minimizes the incidence of hypothermia and is much more effective than just using active warming during surgery.5-7

REFERENCES

  1. Berrios-Torres, S.I., Surgical Site Infection (SSI) Toolkit. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention. 2009. http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf. Accessed 12/21/2015.
  2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.
  3. Sessler DI. Perioperative heat balance. Anesthesiology. 2000;92(2):578-596.
  4. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best practice & research.Clinical anaesthesiology. 2008;22(4):659-668.
  5. Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of prewarming on post-induction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general anaesthesia. Br J Anaesth. 2008;101:627-631.
  6. Horn EP, Schroeder F, Gottschalk A, et al. Active warming during cesarean delivery. Anesth Analg. 2002;94:409-414.
  7. Vanni SM, Braz JR, Modolo NS, Amorim RB, Rodrigues GR,Jr. Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery. J Clin Anesth. 2003;15:119-125.