-外科感染(英文)Surgical-Si课件

SurgicalSiteInfectionCollaborative1January1–September2,200113orthopedicsurgeonsinvolvedin36musculoskeletalcasesthatdevelopedinfections2#ofDaysBetweenTotalJointReplacementInfections

January1,2002throughJune20033TrendingofHipProsthesisInfectionRatesNNISRisk1NNISRisk04TrendingofKneeProsthesisInfectionRatesNNISRisk1NNISRisk25SurveillanceFocusIncludedASAscoreLengthofsurgeryNumberofpersonnelinORsuiteMicroorganismculturedTimingofpreoperativeantibiotic6TimeLineofEvents01/28/02OrthopedicsurgicalinfectionsreportpresentedtoInfectionControlCommittee03/06/0204/15/0205/02/0205/09/0205/16/02MeetingwithkeyplayersregardingsurgicalwoundinfectionsTeleconference–MultifactorialInterventionstoPreventSurgicalSiteInfectionsInfectionControlNurseandHospitalEpidemiologistperformandvideotapeasurgicalscrubusingchlorhexadine4%/isopropylalcoholMemosenttoorthopedicsurgeonsrecommendingchlorhexadine4%/isopropylalcoholasskinprepofchoiceInfectionControlNurseandHospitalEpidemiologistmeetwithorthopedicsurgeonsregardingorthoinfectionsin20017TimeLineofEvents06/24/02InfectionControlNurseandHospitalEpidemiologistmeetwithBoardMemberstodiscussorthosurgicalwoundinfectionsMeetingwithkeyplayerstodiscussorthosurgicalwoundinfectionsDiscussionregardingorthosurgicalinfectionsdeferredatOrthoDept.MeetingOrthosurgeonaddressedtheissueoforthoinfectionsbrieflyatdepartmentmeetingMeetingwithHospitalCEOandkeyplayersregardingorthoinfectionsHospitalEpidemiologistpresentsrecommendationsatOrthoQ.A.Meeting10/17/0209/16/0212/16/0212/30/0210/28/0209/30/02OrthopedicinfectionsonOrthoDept.Meetingagenda,discussiondeferred89RecommendationsEmploychlorhexadine4%/isopropylalcoholasskinprepUseclippersforhairremovalMaintainacorebodytemperatureof>36ºcthroughoutsurgeryAdministeroxygenat80%/50%intra-operativelyandat80%bysealedmask/conventionalnon-rebreathermaskforfirsttwohoursofrecoveryTestbloodglucosethirtyminutesafterincisiontimeAdministerappropriateantibioticwithin30minutesofincisiontimeDiscontinueantibioticswithin24hours10TeamMembersRaymondPalesch,MD–OrthopedicSurgeon,TraumaMedicalDirectorNeilBarg,MD–HospitalEpidemiologistCarlOlden,MD–MedicalStaffQualityAmyCrook,MD–AnesthesiologistMarioDomenzain,MD–OB/GYNPaulNovak,CRNAKenEakin,RN–SurgicalServicesSupervisorKristyCure,RN–SurgicalServicesNurseManagerConnieConklin,RN–Ortho/Neuro/IVTxNurseManagerGayScott,RN,CIC–InfectionControlNurseGregMatsuura,Pharm-DKayAnyan,RHIA–DirectorMedicalStaffServicesLindaBluhm,CPHQ–DirectorPerformanceImprovementSandyDahl,RN–VPNursing&PatientCareLindaHaralson,RN–L&D/Peds/NICUNurseManagerCeciliaBray,RN–Women’s/Gen.SurgeryNurseManager11TimelyAntibioticsAdministeredAnesthesia/NursingresponsibleDevelopmentofprotocolforadministrationwithin30minutespriortoincision2gmsofantibioticforadultsoverage16Repeatintraoperativedosingat3hours12AntibioticsWithinOneHour13AppropriateAntibioticsGivenInitiationofAntibioticReviewofperioperativeantibioticsDevelopmentofPenicillinAllergyAlgorithm14AppropriateAntibioticsGiven15AntibioticProphylaxisGivenwithin30minutesofcuttimeException:VancomycinandLevofloxacin1hrinfusiontimeInfusionmustbefinishedpriortocutRecommendeddurationdiscontinuewithin24hrs1BratzlerDW,etal.AntimicrobialProphylaxisforSurgery:AnadvisorystatementfromtheNationalSurgicalInfectionPreventionProject.ClinicalInfectiousDiseases2004;38:1706-1715Antimicrobialprophylaxisforsurgery.TreatmentGuidelinesfromtheMedicalletter,2004;2(20):27-32.16OrthopedicAntibioticProphylaxis2gmsCefazolinIVwithin30minutesofincisioninallpatientsoverage16.IfPenicillinallergicuseVancomycin1gmIVovera60minuteinfusiontime.17PenicillinAllergy

AssessmentTool

(ElectiveOrthopedicSurgery)Hasthepatientbeenabletotolerateacephalosporinwithoutanallergicreaction?Doesthepatienthaveareportedcephalosporinallergy?Whattypeofpenicillinreactionwasit?Didthepatientdevelopseverehypotension,respiratorydistress,orsystemicswelling?NoUseVancomycinUseCefazolinUseCefazolinYesNoNoNoYesYesDidthepatientdevelophives(raised,itchy,systemicwelts)duringatreatmentcourse?Yes1819AntibioticsDiscontinuedin24HoursNurseManagerprovidedSSIcollaborativePowerPointpresentationtoSurgicalServicesstaff-3/31/03PhysicianChampionprovidedSSIcollaborativeslidepresentationtoorthopedicsurgeonsandanesthesia–4/21/03OrthopedicSectionvotedtoreviseordersheettodiscontinueantibioticsin24hours–5/27/0320OrthopedicPost-opOrdersPage2of2.AntiemeticProtocol.Respiratory:IfonOxygen,oximetryevery8hrs,D/CO2whenSAT>92%RespiratoryCare,evaluateandtreatIncentiveSpirometry.Activity:BedRestOOBthisPMChairTIDPhysicalTherapy:Begintreatment:thisP.M.inA.M._______________WBaffectedextremityTotalHipProtocol______________________WBaffectedextremityTotalKneeProtocol____________________WBaffectedextremityElevateaffectedextremity6”aboveheartlevelheartlevelstockinettecalveselevatedonpillowsCPM_____________________________________________________________________________________________________________________________________Other_____________________________________________________________________________________________________________________________________.Misc:X-Ray_____________________________________________________________________________________________________________________________________Dressing__________________________________________________________________________________________________________________________________AutotransfusionDiscontinueHemovac24hourspost-op48hourspost-opR/CorstraightcathPRNinabilitytovoid–DiscontinueR/C48hrspost-op,reinsertPRN.C&SPRNTEDSProtocolSCDProtocolAbductionBolsterSSconsult–DischargePlanningColdTherapyIcepacktoaffectedarea20-30minutes3times/shift(donotplaceicebagdirectlyonskin)Physician’sSignature:_______________________________________________________________________Date/Time:______________________________________________21AntibioticDiscontinuedin24Hours22HairRemovedAppropriatelyTwoclippersstockedineachORsuiteRe-inservicedstaffviaposterboardsSpecificstaffmemberassignedresponsibilityforstockingUseofclippersimplementedforothersurgicalprocedures23HairRemovedAppropriately24NormothermiaCalibrationcheckedonforcedairwarmingmachinesandadjustedForcedairwarmingmachinesplacedonpreventativemaintenanceschedulePre-opwarmingblanketsIncreaseofroomtemperatureabandonedAbandonedcoolingvestsforsurgeonsaftertrialSpacehatsinpre-opUnderbodywarmersinOR25BodyTemperatures26SupplementalOxygenImplementeduseofnon-rebreathermaskathighflowPatienteducationregardingrationaleinpre-opholdingareasSetstandardmaskremovaltimeat2hourspostarrivaltopatientroomNon-rebreathermaskapplicationtopatientwithinitiationofoxygenflowUtilizationoftimerabandoned27SupplementalOxygenPerioperatively28PatientSatisfaction

Non-RebreatherMaskIntervieweachpatientpostdiscontinuation246outof255patientsweresatisfiedwiththeuseofthenon-rebreathermask(96.5%)29Chlorhexadine4%/AlcoholPrep

March19,2003–February29,2004RecommendationNumber%CasesReviewed258Chlorhexadine4%/alcoholprep23591.1%BetadineScrub+alcoholprep166.8%TotalKnee/TotalJointRecommendations303131OtherInpatientOrthoStartedJuly200332NeuroSurgeryStartedNovember200333March2003OrthoHipsandKneesJuly2003OtherOrthoNovember2003NeuroJanuary2004C-SectionsMay2004OB/GYNNovember2004ColonFebruary2005GeneralSurgeryandUrologySeptember2005WoundCare,Podiatry,andPlasticsSSICollaborative3YearPlan34AppropriateProphylacticAntibioticSelectedSurgeryType#Successes#CasesPercentOverallRate90692198%HipandKneeArthroplasty(2ndQtr2003–2ndQtr2005)65065599%Hysterectomy(3rdQtr2004–2ndQtr2005)24925996%ColonSurgery(May,2005–July,2005)77100%35PercentofAbxGivenWithin1HourofIncisionSurgeryType#Successes#CasesPercentOverallRate91292199%HipandKneeArthroplasty(2ndQtr2003–2ndQtr2005)65265599.5%Hysterectomy(3rdQtr2004–2ndQtr2005)25425998%ColonSurgery(May,2005–July,2005)6