1. Establishing a Culture of Safety:
Working Toward Zero
Orthopedic SSIs
Maureen Spencer, RN, M.Ed, CIC
Infection Preventionist Consultant
Boston, MA
Email: maureen_spncr@yahoo.com
www.workingtowardzero.com
www.creativehandhygiene.com

2. Example of Working Toward Zero Team Members
 The teams:
 Surgical Site Infections: Director Surgical Services, OR Manager, SPD Director, Infection
Control Manager, Two Surgeons, VP Patient Care Services, Director of Nursing, Nursing
Manager, Clinical Educator, Microbiology Lab Director
 Ventilator Associated Pneumonia: ICU Hospitalist, ICU Nurse Manager, ICU Nurse, Director of
Anesthesia, ICU Clinical Educator, Respiratory Therapy, Infection Control Manager, Micro Lab
 Central Line Assoc Bloodstream Infections: Surgeon who inserted most central lines, ICU
Manager, Director of Anesthesia, ICU Clinical Educator, ICU Nurse, Infection Control Manager
 Catheter Assoc UTI: Clinical Educator, Infection Control Manager, Chief Urology, Lab Director
 MRSA Elimination: Infection Control Manager, Pre-admission testing, OR Director,
Microbiology Lab Director, Two Surgeons, Director of Nursing, Patient Access Director,
 Information Technology, ID physician
 C.difficile: Chiefs of Surgery and Gastroenterology, ICU Nurse Manager, Micro Lab Director,
Infection Control Manager
2

3. Post-op:
Irrigation? Incisional Patient
adhesive should education is
Consider using be the number extremely
Intraoperative: saline or new one consideration important since
CHG/alcohol CHG (0.05%) for wound many patients
skin prep, irrigant and closure – are discharged
antibacterial eliminate prevents early in the
Pre-op: sutures, expensive and dehiscence and post-op period
incisional toxic exogenous and have
Screen for MRSA bacitracin/polymi
and Staph aureus adhesive contamination to incisions that are
xin or antibiotic wound in the exudative
CHG pre-op irrigant
shower or cleanse If not used state of wound
with impregnated consider covering healing
cloths incision for length
Assure OR meets of hospitalization
AORN standards of
practice

4. MRSA and Staph aureus
Elimination Program Before Patients Enter
the Hospital for Surgery
Prescreening Process
Topical Decolonization Protocol
Vancomycin for MRSA
1. Kim D, Spencer M, Davidson S, et al. J Bone Joint Surg 2010;92:1820-6
2. Spencer M, Kim D, et al: AAOS, 2010
4

5. Provided Evidence: February 2006
Anonymous Nares Cultures To Prove to Administration Patients Are Colonized
With Staph aureus and MRSA
N = 133 patients anonymously surveyed and
cultured in OR after anesthetized
Purpose: to determine pre-op MRSA and Staph
aureus colonization rates for administration
Results:
38 – Staph aureus (29%)
*5 - MRSA ( 4%)
*all undiagnosed, no precautions used in OR,
PACU, postop nursing unit
*MRSA cases received Cefazolin for surgical
5 prophylaxis – THE WRONG ANTIBIOTIC!

6. Implemented Decolonization Protocol
• 5-day application of intranasal 2% mupirocin -
applied twice daily - for MRSA and Staph aureus
positive patients
• Prescription called in by Nurse Practitioner in
prescreening unit
• Daily body wash with chlorhexidine (purchased
by patient)
• MRSA Patients – Unique sticker system to notify
Pre-surgery Unit of Vancomycin surgical
prophylaxis
6

7. 7

8. Pre-op MRSA and S. aureus Decolonization
 Results:
 Timeframe: July 17, 2006 through September 2010
 Infection rate: 20,065 patient screened
5,988 (23%) positive for Staph aureus
1,027 ( 4%) positive for MRSA
 Effectiveness: Repeat nasal screens on MRSA patients
revealed 77% eradication
8

9. Pre-op MRSA and S. aureus Decolonization
 Results: % MRSA and S. aureus SSI
Inpatient # of Surgical
Time Period %MRSA/MSSA
Surgeries Infections
FY06
10/01/05-07/16/06* 5,293* 24* 0.45%*
*Historical Controls
FY07
07/17/06-09/30/07 7,019 6 0.08%
FY08
10/01/07-09/30/08 6,323 7 0.11%
FY09
10/01/08-09/30/09 6,364 11 0.17%
FY10
10/01/10-09/30/10 6,437 6 0.09%
9

10. Pre-op MRSA Decolonization
 Results: % MRSA SSI in Screened Patients
Inpatient # MRSA #Infect/#MRSA
Time Period MRSA%
Surgeries SSIs +
FY06
10/01/05-07/16/06 5,293 10 (NA) 0.19% NA
FY07
07/17/06-09/30/07 7,019 3 (3+) 0.04% 3/309 (0.97%)
FY08
10/01/07-09/30/08 6,245 4 (2+) 0.06% 2/242 (0.83%)
FY09
10/01/08-09/30/09 6,336 6* (2+) 0.09% 2/234 (0.85%)
FY10
10/01/10-09/30/10 6,437 1 (1+) 0.01% 1/266 (0.37%)
* isolates have been sent for pulse field gel electrophoresis
10 5 of the 6 isolates were available for PFGE and were not related genetically

11. Pre-op Staph aureus Decolonization
 Results: % S. aureus (MSSA) SSI in Screened Patients
Inpatient # MSSA #Infect/#MSSA
Time Period MSSA%
Surgeries SSIs +
FY06
10/01/05-07/16/06 5,293 14 (NA) 0.26% NA
FY07
07/17/06-09/30/07 7,019 3 (3+) 0.04% 3/1588 (0.19%)
FY08
10/01/07-09/30/08 6,245 3 (1+) 0.05% 1/ 1422 (0.07%)
FY09
10/01/08-09/30/09 6,336 5 (1+) 0.08% 3/1403 (0.21%)
FY10
10/01/10-09/30/10 6,437 6 (1+) 0.09% 1/1450 (0.06%)
11

12. OR Risk Factors:
Contamination from OR Staff
• Reviewed orderlies and room turnover procedures
• Improved traffic control
– new signage and monitoring system
keep room doors closed and minimize traffic
• Eliminate surgical caps – do not cover hair!
• Cloth cap use – if worn, must be covered in OR room
with disposable cap - hair coverage monitored
– Hair harbors organisms
– Staff sweat in cloth caps
– How often do they get washed? Hospital laundered
– Where are they stored?
– Would you eat a meal with hair in it?
– Why allow hair to potentially fall into
surgical incisions?
12

13. OR Risk Factors:
Cleaning/Sterilization of Instruments
• Inspection of Orthopedic Instruments
– Lumens, grooves, sorting, hand cleaning,
disassembly required – massive kits
– Many instruments cannot be disassembled
• Instituted better pre-soaking and rinsing of
tissue and blood from the instruments in the
operating room before decontamination
• There was a recent outbreak investigated by
CDC of shoulder infections - found shavers and
cannulas with biofilm and tissue observed inside
instruments with small camera
13

14. Pathogens survive on surfaces
Organism Survival period
Clostridium difficile 35- >200 days.2,7,8
Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days.1,5,10
Vancomycin-resistant enterococcus (VRE) 58- >200 days.2,3,4
Escherichia coli >150- 480 days.7,9
Acinetobacter 150- >300 days.7,11
Klebsiella >10- 900 days.6,7
Salmonella typhimurium 10 days- 4.2 years.7
Mycobacterium tuberculosis 120 days.7
Candida albicans 120 days.7
Most viruses from the respiratory tract (eg: corona, Few days.7
coxsackie, influenza, SARS, rhino virus)
Viruses from the gastrointestinal tract (eg: astrovirus, HAV, 60- 90 days.7
polio- or rota virus)
Blood-borne viruses (eg: HBV or HIV) >7 days.5
1. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5. 7. Kramer et al. 2006. BMC Infect Dis. 6:130.
2. BIOQUELL trials, unpublished data. 8. Otter and French. 2009. J Clin Microbiol. 47:205-7.
3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2 9. Smith et al. 1996. J Med. 27: 293-302.
4. Boyce. 2007. J Hosp Infect. 65:50-4. 10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4.
5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200. 11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.
6. French et al. 2004. ICAAC.

15. Why Better Environmental Cleaning?
Prior room occupancy increases risk
Study Healthcare associated pathogen Likelihood of patient acquiring HAI
based on prior room occupancy
(comparing a previously ‘positive’
room with a previously ‘negative’
room)
Martinez 20031 VRE – cultured within room 2.6x
VRE – prior room occupant 1.6x
Huang 20062
MRSA – prior room occupant 1.3x
VRE – cultured within room 1.9x
VRE – prior room occupant 2.2x
Drees 20083
VRE – prior room occupant in previous two
2.0x
weeks
Shaughnessy 20084 C. difficile – prior room occupant 2.4x
A. baumannii – prior room occupant 3.8x
Nseir 20105
P. aeruginosa – prior room occupant 2.1x
1. Martinez et al. Arch Intern Med 2003; 163: 1905-12.
2. Huang et al. Arch Intern Med 2006; 166: 1945-51.
3. Drees et al. Clin Infect Dis 2008; 46: 678-85.
4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194.
5. Nseir et al. Clin Microbiol Infect 2010 (in press).

16. Rates of Surface Contamination (in hospitals) with MSRA,
VRE, and C. Difficile
Blood Pressure
Cuff: Windowsill:
VRE 14% C. Difficile 33%
Commode:
Overbed Table:
C. Difficile 41%
MRSA 40%
VRE 20% Patient Gowns:
MRSA 51%
Bedrail:
MRSA 29% Floors:
VRE 28% MRSA 55%
C. Difficile 19% C. Difficile 48%
Bedsheets:
MRSA 53%
Did you know that every time you get a new roommate, there is an
VRE 40%
increase of 3-10% that you will acquire an HAI.
Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med.
2006 Oct 9;166(18):1945-51
Boyce J.M. et al.: Environmental contamination due to methicillin-resistant Staphylococcus aureus: Possible infection control implications. Infect Control Hosp Epidemiol 18:622-627, Sep. 1997.
Slaughter S., et al.: A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care
unit. Ann Intern Med 125: 448-456, Sep 15, 1996.
Samore M.H., et al.: Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 100:32-40, Jan. 1996.

17. Environmental Disinfection – Joint
Commission and CMS Focus on Surveys
 Developed cleaning schedules for Patient Care
Services – what equipment, how
cleaned/disinfected, how often, by who, contact
times for disinfectants?
 Eliminate dirty buckets of water and string mops
 institute micro fiber cloths and mops
 Assure staff know proper cleaning technique:
 left to right, high to low, clean to dirty with
competencies
 Daily check sheet for terminal cleaning of OR at
night and for all precaution cases
17

18. Decontamination of Portable Equipment
with Contracted Services
 Ultrasonic scrub
 Movable carts
 Tables
 Poles
 Small equipment
 1500 pieces cleaned
 OR, radiology, nursing
 Cost: ~$20,000 / year
APIC 2005 Poster
M Spencer, at al: The E=MC2 Project: Environment = Maintaining Cleanliness: A Multidisciplinary Approach To
Establish a Routine Cleaning Schedule for Medical Equipment.
18

19. SSI risk can be addressed by
controlling risk factors
 Precautions are already in place to control the risk of bacterial
contamination throughout the peri-operative period
 However, additional controllable risk factors remain – wound
closure provides an opportunity to address these risks
Controlled Risks Potentially Uncontrolled Risks
 Scrubbing in ☐ Bacterial colonization of the suture
 Gowning ☐ Contamination of the incisional site
 Skin antisepsis after the wound is closed
 Controlling OR environment ☐ Entry of bacteria from the skin during
 Sterilizing instruments wound closure
 Using minimally invasive techniques ☐ Bacterial infiltration due to dehiscence
19

20. Uncontrolled Risk Factor:
Bacterial colonization of the suture
 Like all foreign bodies, sutures can be colonized by bacteria:
 Implants provide nidus for attachment of bacteria1
 Bacterial colonization can lead to biofilm formation1
 Biofilm formation increases the difficulty of treating an infection2
On an implant, such as a
suture, it takes only 100
staphylococci per gram of
tissue for an SSI to develop3
Contamination Colonization Biofilm
Formation
1. Ward KH et al. J Med Microbiol. 1992;36: 406-413.
2. Kathju S et al Surg infect. 2009;10:457-461
20
3. Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27:97-134..

21. Why Plus Suture?
OR Air Current Contamination
In teaching hospitals:
Surgeon leaves room
Resident, Physician Assistant or Nurse
Practitioner work on incision
Circulating Nurse counts sponges and
starts room breakdown
Scrub Technician starts breaking down
tables and preparing instruments for
Central Processing
Anesthesia move in and out of room
Instrument representative might leave
room and Visitors may leave room

22. Potential for Contamination of Sutures at
End of Case
Air settling plates in the operating room at
the last hour of a total joint case
Suture with Staphylococcus colonies

23. Plus Antibacterial Sutures:
Impact in a Real-World Setting
 Plus sutures not only kill bacteria on the suture, but also create an
inhospitable environment around the suture
 NEBH studied the “zone of inhibition” around the suture
 A pure culture—0.5 MacFarland Broth—of S. aureus was
prepared on a culture plate
 An antibacterial suture was aseptically cut, planted on the
culture plate, and incubated for 24 hrs
Traditional suture
Antimicrobial suture
23 5 day zone of inhibition 10 day zone of inhibition

24. Plus Antibacterial Sutures:
Impact in a Real-World Setting
 NEBH One Year Prospective Study of 3800 Total Joints
and Antimicrobial Sutures
 In July 2005, implemented a full-year evaluation of
antibacterial sutures usage in an orthopedic setting
 Changed product over July 4th holiday and did not tell
all surgeons (only those involved with study)
 At the end of the year-long trial period:
 45% reduction in SSIs caused by Staph aureus and
MRSA
 Infection rate dropped from 0.5
0.4
0.44% to 0.33% with three less infections 0.2 0.3
Series1
0.1
0
FY05 FY06
NAON Poster Presentation - 2010
24
 Spencer M, et al: Reducing the Risk of Orthopedic Infections: The Role of Innovative Suture Technology

25. Articles Related To Antibacterial Sutures
 *Justinger, C, et al. Antibiotic coating of abdominal closure
sutures and wound infection. Surgery 2009;145:330-4. (*RCT)
 Rothenburger S, et al. In vitro antimicrobial evaluation of Coated
VICRYL* Plus Antibacterial Suture (coated polyglactin 910 with
triclosan) using zone of inhibition assays. Surg Infect 2002;3 Suppl 1:S79-
87
 Ford HR, et al. Intraoperative handling and wound healing: controlled
clinical trial comparing coated VICRYL plus antibacterial suture (coated
polyglactin 910 suture with triclosan) with coated VICRYL suture (coated
polyglactin 910 suture). Surgical Infections. 6(3):313-21, 2005.
 Edmiston CE, et al. Bacterial adherence to surgical sutures: can
antibacterial-coated sutures reduce the risk of microbial contamination?
Journal of the American College of Surgeons. 203(4):481-9, 2006 Oct

26. Innovative wound closure technologies
can address risk factors for SSIs
 Topical Skin Adhesive provides a microbial barrier during the
critical wound healing period
SSI Risk Factor Innovative Technology
 Bacterial colonization of the suture  Antibacterial Sutures
 Contamination of the incisional site after the  Chlorhexidine/alcohol skin prep
wound is closed  Prevention of Dehiscence and
 Entry of bacteria from the skin during Exogenous Contamination with
wound closure Topical Skin Adhesive or
 Bacterial infiltration due to dehiscence Antimicrobial Dressings
26

27. Antisepsis with Chlorhexidine
 2% CHG/70% alcohol skin preparation
(tinted orange)
 Has a lasting effect on the skin
 ~ 2 days postop
 Iodophors are fast kill but no long term
effect
 CHG dry time is 3 minutes (to prevent
fires)
• Evidence that chlorhexidine/alcohol achieves
better skin antisepsis than iodophor
Darouiche et al NEJM 2010
Ostrander et al JBJS Am 2005
Saltzman et al JBJS Am 2009
27

28. Post-op Skin Issues in Orthopedics
Anterior fusion with tape burns
Contaminated steri-strips
Posterior fusion with contaminated steri-strips Staples increase infection rate

29. Associated Wound Infection or Separation After
Cesarean Delivery: Sutures vs Staples
 Prospective, randomized study of 435 c-section patients1
 197 patients: staples
 219 patients: 4-0 MONOCRYL™ (poliglecaprone 25) Suture on PS2 needle
– Wound separation rate: 17% (staples) vs. 5 % (sutures)
– Wound complication rate: 22% (staples) vs. 9% (sutures)
– Staple closure was a significant independent risk factor for wound
separation after adjustment for all other factors (GDM, BMI >30, incision
type, etc)
 Meta-analysis of 6 studies with a total of 1487 c-section patients2
 803 patients: staples
 684 patients: subcuticular suture closure
– Staple closure was associated with a two-fold increase in risk of wound
infection or separation
1. Basha et al. Am J Obstet Gynecol. 2010;203:285.e1.
2. Tuuli et al. Obset Gynecol. 2011;117:682.

30. The risk for infection after joint surgery is higher with staples vs traditional
stitches, according to the results of a meta-analysis reported in the March
16 2010 issue of the BMJ.
 In 6 publications reporting on a total of 683 wounds, 332 patients underwent
wound closure with sutures, and 351 underwent closure with staples.
 Compared with suture closure, staple closure was associated with more
than triple the risk for the development of a superficial wound
infection after orthopaedic surgery (RR, 3.83; 95% CI, 1.38 – 10.68; P =
.01).
 When hip surgery was analyzed as a separate subgroup, the risk for the
development of a wound infection was 4 times greater with use of
staples vs use of sutures (RR, 4.79, 95% CI, 1.24 – 18.47; P = .02). Suture
closure and staple closure did not differ significantly in development of
inflammation, discharge, dehiscence, necrosis, or allergic reaction.
 “The Medical Journal of Australia” has recently updated its guidelines for skin
closure in the treatment of hip fractures, and they state that superficial wound
complication rates are higher for wounds closed with metallic staples than for
wounds closed with subcuticular vicryl.

31. Obesity and Surgical Incision
 Incision collects fluid – serum,
blood - growth medium for
organisms
 Spine fusions -incisions close to the
buttocks or neck
 Heavy perspiration common
 Body fluid contamination from
bedpans/commodes
 Friction and sliding - skin tears and
blisters
 Itchy skin - due to pain medications
- skin breakdown
31

32. Topical Skin Adhesive: A Proven Microbial
Barrier
 Provides a flexible, protective microbial barrier that moves with the patient,
preventing breakage and acting like a temporary “skin”1,2
 Adhesive demonstrates inhibition of gram-positive bacteria (MRSA and MRSE) and
gram-negative bacteria (E coli) in vitro2-4
 Provides greater than 99% protection for 72 hours against organisms commonly
responsible for SSIs2,3:
 S. epidermidis
 E. coli
 S. aureus
 Pseudomonas aeruginosa
 Enterococcus faecium
No fractures,
1. Quinn et al. JAMA. 1997;277:1527-1530 wound failure
2. Bhende et al. Surg Infect (Larchmt). 2002;3:251-257. or dehiscence
3. Narang et al. J Cutan Med Surg. 2003;7:13.
4. World Health Organization. WHO Guidelines for Safe Surgery 2009. 2009.
32

33. Topical Skin Adhesive: Benefits Beyond Risk
Reduction
 For Hospital Staff
 No time spent removing staples or sutures
 Reduced hospitalization costs
 Reduces number of suture set ups
 Simplifies post-op wound checks
 Reduces number of wound dressings
 For Patients
 7 days of wound healing strength in
less than 95 seconds of application
 Shower immediately
 Outstanding cosmesis
 Reduced follow-up
 Less pain and anxiety
33

34. Incisional Adhesive on Total Knee Incision

35. Clinical Use of Incisionial Adhesive
Hip: Sealed with adhesive
covered with gauze and
transparent dressing for
incision protection
Knee: Sealed with incisional
adhesive, covered with Telfa
and a transparent dressing Healed incision
for incision protection

36. Incisional Adhesive and Total
Shoulder Replacements
Total Shoulder Rates
2.5
2
1.5
1
0.5
0
2003 2004 2005 2006 2007 2008 2009 2010
• Propionibacterium acnes related total shoulder infections (TSR)
• Eliminated the use of staples for TSR
• Instituted the use of incisional adhesive
• Covered dressing until day of discharge for protection

37. Selected Publications: DERMABOND® Topical
Skin Adhesive in Orthopedic Surgery
Procedure Reference No. of Patients Key Findings
• Patients followed for >7 months
Primary hip arthroplasty1 Khurana et al. 2008 93 • No infections
• 1 wound dehiscence
• Patients followed for >5 months
Lumbar and cervical spine 200
Hall and Bailes. 2005 • Only 1 documented SSI
procedures2 Retrospective
• High patient satisfaction
• Surgeon preference to reduce urinary
Total hip arthroplasty for Kregor et al. 2008 and fecal contamination of wound
Retrospective
femoral neck fracture3 and allow patients to shower
immediately
1. Khurana et al. Acta Orthop Belg. 2008;74:349.
2. Hall and Bailes. Neurosurgery. 2005;56(suppl 1):147.
3. Kregor et al. Techniques Ortho. 2008;23:312.

38. DERMABOND ADVANCED™ Topical Skin Adhesive
A protective barrier that adds strength and reduces bacteria
• Has been shown in ex vivo studies to have superior tensile strength versus other octyl
and butyl based products
• Creates a microbial barrier against organisms commonly responsible for SSIs *
Innovative
*Staphylococcus epidermidis, Staphylococcus aureus, Escherichia coli, Enterococcus faecium and Pseudomonas aeruginosa
Data on File. Ethicon, Inc.

39. Comparison of TSA Components Among Currently
Available Agents
DERMABOND
ADVANCED™
Topical Skin derma+flex® QS™ Histoacryl®
Components Adhesive SurgiSeal™ (octylseal™) INDERMIL® (Repara) LiquiBand® Skinstitch®
Octyl
adhesive
Plasticizers ?
Inert storage
vial,
stabilizer, and
no
refrigeration
Initiator and
heat-
dissipating
agent
High-
viscosity
formulation
The third-party trademarks used herein are trademarks of their respective owners.
Data on file: Ethicon Inc.

40. Evidence-Based Performance
 The largest randomized clinical trial database of any TSA
 8x the number of patients vs the leading competitor
Total Number Total Number of
Product of RCTs Patients Treated
DERMABOND®
40 4075
Topical Skin Adhesive
Histoacryl® 6 534
INDERMIL® 2 150
LiquiBand® 1 78
SurgiSeal® 0 0
derma+flex® QS™
0 0
(octylseal™)
No RCTs identified for any other competitors.
RCTs only; reasons for exclusion were language of publication other than German or English, nonhuman studies, case series or
case reports, and inappropriate indication.
The third-party trademarks used herein are trademarks of their respective owners.
RCT = randomized controlled trials.
Data on file: Ethicon Inc, Literature Search 2/2011 PubMed

41. New, innovative, minimally invasive
DERMABOND™ PRINEO™ Skin Closure System
 A unique combination of
2 components
• A 2-octyl cyanoacrylate topical skin
adhesive for proven strength and
microbial protection1,2
– Sets in approximately 60 seconds
when applied to mesh
– 2-hour working time3
• A flexible, self-adhesive polyester mesh
for superior approximation and healing1,3
– Contains initiator that accelerates
polymerization of liquid adhesive
– Each dispenser contains 60 cm of tape
1. DERMABOND™ PRINEO™ IFU. PM72449C. STATUS 6/2010.
41 2. Shapiro AJ et al. Am Surg. 2001;67(11): 1113‐1115.
3. Data on file. Ethicon, Inc.

42. Minimally invasive closure that distributes tension
away from the wound
Traditional closure DERMABOND™ PRINEO™ Skin Closure
System
 Gently and evenly disperses tension across the entire area
of the incision, without penetrating the skin
42

43. DERMABOND™ PRINEO™ removal
Patient is shown 2 weeks after circumferential body lift and immediately
after removal of
DERMABOND™ PRINEO™ Skin Closure System.

44. Areas for Cost Savings

45. Surgical Incise Drapes
 Iodophor- impregnated incise
barrier drape
 No data to support these
drapes reduce SSI – although
do reduce bacteria on skin
 Surgeon preference based on
adhesion to skin and drapes
 Consider using non-
impregnated drapes and using
cost savings for other innovative
technologies
45

46. Use of plastic adhesive drapes during surgery
for preventing surgical site infection
Objective:
 Compared the effect of adhesive drapes used during surgery on surgical site
infection, cost, mortality and morbidity
 Five studies involving 3,082 participants comparing adhesive drapes with no
drape
 Two studies involving 1,113 participants comparing iodine-impregnated
adhesive drapes with no drape
Conclusion:
 A significantly higher proportion of patients in adhesive drape group
developed a surgical site infection when compared with no drape
 Iodine-impregnated adhesive drapes had no effect on the surgical site
infection rate
 Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006353

47. Bacitracin/Polymixin Irrigation
 Feb 2007 - stopped routine use of Bacitracin/Polymixin Irrigation
 Cost: > $110,000/year reduced to $10,000
 Limited use for revisions, allografts and infected cases (irrigation and
debridements)
 New irrigant available – FDA approved for mucous membranes with
0.05% CHG - Irrisept
Fletcher N, et al: Prevention of perioperative infections. J Bone
Joint Surg Am. 2007;89:1605-1618
47

48. IRRISEPT
Finally, an alternative to saline and antimicrobial irrigation
The first and only FDA-cleared cleansing and debridement system, containing
0.05% Chlorhexidine Gluconate (CHG) in Water for Irrigation
IrriSept O.R. (sterile packaging)
Irrigation Applicators:
Custom designed
applicators facilitate
cleansing for a variety of
applications
SplatterGuard® LT SplatterGuard® IrriProbe®
48

49. Review: Bundled Approach to Eliminating SSIs
1. Pre-screen inpatient surgeries for MRSA and Staph aureus (MSSA) using PCR
rapid molecular technology
2. Decolonization protocol for MRSA/MSSA positive patients (eg mupirocin 2%
ointment 2 x day, daily CHG wash x 5 days)
3. Preoperative shower with CHG (eg Hibiclens) or CHG washcloths (eg Sage) night
before/morning of surgery
4. Assure OR standards are being met (traffic control, surgical attire, surgical hand
scrub, sterilized instruments, room turnover and terminal cleaning, precautions in
OR)
5. Assure surgical prophylaxis is delivered for maximum tissue concentrations
6. Surgical skin prep with CHG/alcohol prep
7. Irrigation with CHG if necessary (eg Irrisept)
8. Antibacterial sutures (eg Ethicon)
9. Incisional Adhesive (octyl cyanoacrylate) (eg Dermabond and Prineo)
10. Post-op incision care instructions
11. Data driven, analysis and calculation of rates, communication/feedback

50. Reducing Risk Factors for SSIs:
Tools for success
 Institutional support
 Senior leadership and “C Suite” involvement
 “lead the effort” from top down
 Clear goals
 Structured program with clearly defined goal of
zero tolerance for HAIs
 Theoretical foundation to IP Program: Social
Learning Theory (Role Modeling, Self Efficacy,
Positive Deviance)
 Communication – effective and consistent
 Ongoing and creative education
 Financial support to Infection Prevention program
50

51. Thank You