Best practices nel controllo delle infezioni
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Best practices nel controllo
delle infezioni
Francesco Di Marzo
Consultant Gen Surgeon,
Versilia - ASL Nordovest
Consulting/Speaker for: Nestlè Healthscience
KCI/Acelity J&J Covidien/Medtronic
Editorial board member "IOZ" @ARS Toscana
Council and Educational Committee member
@Surgical Infection Society Europe
Abdominal wall hernia in Tuscany
• 14.346 patients in 2013
• Regional most performed surgery 5,6%
• Laparoscopic procedure 3,6%
• Setting and Charlson Comorbidity Index significantly correlate (p
Concerns
• Lack of conformity
• Coding errors
• No interactions between clinical database and HDD
• Error-prone system
• No SSI surveillance program
World conf on Abd Wall
Hernia surgery, Milan 2015
EHS, Rotterdam 2016
F. Di Marzo, MD
SSI - starting line: 2013-2014 case by case
clinical records review
# clinical records 644
(jan 2013 – dec 2014)
2013 324
2104 320
F. Di Marzo, MD
Finish line: 2013-2014 SSI ratio
# SSI 26 (4,03%)
2013 14 (4,32%)
2104 12 (3,75%)
F. Di Marzo, MD
Hospital report
NNIS Risk Index
3,00
0(N/%) 6 (23) 2,25
#SSI
1,50
9 (34.6) 0,75
1(N/%)
0,00
1 2 3
4 5 6
7 8 9
10 11
2(N/%) 10(38.4) 12 13 14
15 16
17 18
19 20
21 22
January 2013 to december 2014 23 24
3(N/%) 1(3.84)
F. Di Marzo, MDConcerns
• Data collection
• 44 items Patient?
• Time consuming activity
• indirect method
surveillance
• no high-tech tools
8
F. Di Marzo, MDPatient-centered clinical practice • What about our advisory sistem? • Is time to change our alert level? • How to perform at the highest level of excellence? • Is the excellence-zone the same for any institution/hospital/department/ward/team/ surgeon? • Are we missing the point?
PREOPERATIVE
HOME
Patient and care givers’ education
stop smoking 30 days before surgery
weight loss (BMI >30 kg/mt2)
preoperative nutritional supplementation (benefits for both well and malnourished
patients, starting 5 days before surgery)
preoperative shower with clorexidine (night before admission)
VTE prophylaxis
Preop evaluation form
F. Di Marzo, MDPREOPERATIVE
WARD
preoperative shower with clorexidine (day of surgery);
antimicrobial prophylaxis (selection and prescription);
CHO prepor load (evening before + DOS)
checklist
PREAN / Oper Room
hair removal (only if necessary and only with hair clippers immediately
before surgery, outside the operating room);
prevention of hypothermia (not < 36° C )
preoperative skin preparation (with a clorexidine/alcohol solution);
antimicrobial prophylaxis (30-60 min before incision).
F. Di Marzo, MDINTRAOPERATIVE
use of HEPA filters
clothing/covering restriction
use a double pair of gloves
limiting traffic and idle conversations in the operating room (main door closed);
prevention of hypothermia (not < 36° C );
hyperoxia (FiO2 = 80 %)
antimicrobial prophylaxis (Re-dose during prolonged procedures: 1-2 times the half-life)
use of appropriate wound closure technique and materials (continuous sutures are
better than interrupted ones, slowly absorbable monofilament sutures or
absorbable synthetic PGA are better than multifilament sutures or catgut);
sutures coated with antimicrobial agents
do not use electrocautery for opening wounds
do not use conduit drains or drainage through a working incision
restrictive fluid administration during and after surgery
delayed primary closure for highly contaminated wounds
wound protectors (both open and lap)
negative pressure devices for closed wounds in selected high-risk patients
F. Di Marzo, MDPOSTOPERATIVE
WARD
postoperative glucose control (to< 150-180 mg/dl)
postoperative hyperoxia (FiO2 = 80 % for at least 2 – 6 h)
early enteral feeding
early rehabilitation
antimicrobial discontinuation
foley and drain early removal
WARD/HOME
post-op surveillance (wound assessment form - ASEPSIS );
wound care Team (nurse)
GP cooperation
HOSP/HOME
patient and care givers’ information about woundcare
monthly report
F. Di Marzo, MDStrategies
4 phases program • Engage • support by senior leadership • enganged physicians as champions • multidisciplinary team • guideline / safety culture • Educate • team, patients, caregivers • Execute • reduce barriers • improve adherence • Evaluate • measure tool • outcomes
A virtuous circle
Transmural
GP Transmural
cooperation cooperation
Home
Outpatient Outpatient
Clinic Clinic
Nurse PATIENT Nurse
Ward Ward
Psych
ICU OR
Anesth Surg
F. Di Marzo, MDPatient profile
Age/Gender
BMI
Smoking
Ph act
Nutrit Status
Diabetes
Cancer/CHRT
#meds
Pulm/Heart dz
Per Vasc dz
Genetics
F. Di Marzo, MDTheatre profile
Surg Team
Anest/ICU/PACU
Procedures
Operative events
Soft Skills
Hard Skills
Team perfor
Operative envir
Human factors
Positive organizational
behavior
F. Di Marzo, MDInstitution profile
Med Service
Nurs Serv
Rad Serv
Path Serv
IT
Microbiol Serv
Hosp Infrastr
Human factors
Positive organizational
behavior
F. Di Marzo, MDOperative envir
Inductive approach to SSI: data analysis
and pilot-project
2015
Microbio serv
Human Factors
5 surgical team project: SSI prevention (FMECA)
2015-16
Procedures
ABDOMINAL WALL HERNIA SURGERY IN TUSCANY: annual
data and final crosslinked analysis between Clinical and
Hospital Discharge Record Databases. EHS 2016
IT
Human Factors
Surgical site infection surveillance and reduction
in spoke hospital March-16
Positive Org BehaviorEuropean Abdominal Wall
Reconstruction Network and SSO
F. Di Marzo, MDEuropean AWaReNeSS
M. Boermeester (NL)
L. Jorgensen (DK)
H. Pokorny (A)
D. Leaper (GB)
O. Mestak (CZ)
T. Gaarder (N)
C. Moench (D)
T. Pinkney (GB)
K Rasa (TR)
I.Rubio (E)
Y.A. Martinez (E)
T. Sautner (A)
F. de Vries (NL)
23
F. Di Marzo, MDApproach
• Collect data • Develop
• Standardize • risk assess tools
• definitions • performance index
• procedures • quality
• outcomes • quantity
24Objectives
• Improve patient’s QOL
• Reduce economic burden
• Train a NEW generation of
health professionals
25Future perspectives
SSI control/surveillance & Positive
Organizational Behavior
Study design
26
F. Di Marzo, MDt0 SSO & POB evaluation 1st paper
prof. N. A. De Carlo
SSO training Ext Obs prof. L. Dal Corso
event 1 prof. D. Leaper
event 2 Interviewer L. Gigliodoro
event 3
12 months Trainers F. Di Marzo
POB training
event 1 Trainees
event 2
event 3 SSOTeam
t1 Outcome analysis 2nd paper
27
F. Di Marzo, MD4 phases program • Engage • support by senior leadership • enganged physicians as champions • multidisciplinary team • guideline / safety culture • Educate • team, patients, caregivers • Execute • reduce barriers • improve adherence • Evaluate • measure tool & methodology • outcomes
High Tech FollowApp
Thank you, keep in touch fdimarzo@yahoo.com
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