Join us for a unique opportunity to learn about strategies for reducing Surgical Site Infections (SSIs), complications, and cost. During this one-hour program, gain best practices for setting up your patient for successful discharge and view case studies with tips and pearls for applying advanced modalities of treatment in challenging clinical scenarios.
By the end of this webinar, attendees will be able to:
Describe the clinical and economic burden of surgical site complications and surgical site infections
Review the importance of pre-, intra-, and postoperative management strategies & best practices to reduce the risk of Surgical Site Infections.
Explain unintended perioperative hypothermia, and illustrate why prewarming is beneficial in helping to prevent unintended perioperative hypothermia
Examine the role of closed incision negative pressure therapy (ciNPT) for Incision Management to reduce the incidence of Surgical Site Infections, surgical site complications, hospital readmissions & post-op follow-up appointments
Demonstrate ciNPT efficacy via case & outcome reviews; share best practices & technique tips to manage the surgical site and enhance post-operative recovery
Good day to everyone and on behalf of three am I would like to welcome you to the strategies and best practices to enhance recovery, increase efficiency and decrease readmissions setting up your patient for successful discharge webinar. Yeah, thank you for making the time in your busy schedule to participate in this very important webinar. My name is vedra Augenstein and I'm an associate professor of surgery at the Carolinas Medical Center in charlotte north Carolina. Currently I'm on the board of the Americas hernia society and I co chaired the robotics committee of SAGES. Today, I'm partnering with barbara brady ph D R N C C R N. C N C C S. C. From Sentara Health Systems in Norfolk Virginia Dr brady graduated with her A. S. In 1981 Her Msn in 1999 and her PhD in 2000 and 13. Dr. Brady's career has focused on critically ill patients across several services including trauma critical care and cardiac surgery. Since 1981, Dr. Brady's clinical roles have examined the quality of care and improving patient outcomes. Over the next hour we will share strategies for reducing surgical site infections complications and costs and we will also discuss best practices for setting up your patient for a successful discharge. If you would like to ask a question, you can click on the Q. And a icon. Please know that there will be dedicated time for Q. And a session at the end of today's webinar at this time I'm going to start my presentation. These are some of my disclosures. I started out by being a general surgery resident at the University of Louisville and then came to Carolinas medical center to do a one year minimally invasive fellowship. I practice a lot of robotics currently in my practice. But also a majority of my patients are actually some of these patients pictured on the screen here as we are a tertiary referral center for some of these very complicated abdominal wall hernias. Uh and I practice a lot of abdominal wall reconstruction. So when we talk about hernias, uh and today I'm going to show you some data that has really been a practice changer. Uh So I will share some data and then I'll share some case examples. But a lot of times when people talk about hernias, uh they can say, well, you know, it's just a hernia of course. Uh you guys know very well that hernias come in very different shapes and sizes. Um so with all this knowledge that we have about optimizing patients, how can we predict complications, how do we talk to these patients about the impact of their comorbidities? And what can we actually do to encourage our patients to change their outcomes? Because we know that there are data right now that can really help and significantly affect how these patients do. I'm going to share a little bit of data like this paper here from Jammeh from 2015, almost half a million surgical patients now. These patients are from every practice from orthopedic spine, plastic surgery in general surgery, vascular surgery, looking at readmission rates. So these are the patients that for whatever reason don't do well at home and they have to be readmitted to the hospital. So not much to surprise to you in the audience that patients who undergo lower extremity bypasses are very high risk and they're one of the most common reasons for re admission to the hospital. One thing that's fairly surprising I think is that the second most common reason for re admission to the hospital is eventual hernia repair. So I want to share with you guys today this app, which is really downloadable. This is something if you go on itunes, you can type in cedar and hernia uh and you can find this app freely downloaded and you can use it with counseling some of your patients. I think it's very interesting uh if you look at the data that it shows you and I'm going to lead you through one of our patients. But the app is basically made out of 500 of our very own patients over a million data points and then basically uh coming up with odds ratios or predict predictive values for what is significant as far as related to one complication. So for example, if you see a patient Who had an and arata me that has very high risk ratio of developing a postoperative wound complication, also things such as obesity, diabetes smoking. Those are also very common predictors as you guys also know for developing wound complications. So for example, if you take this nice lady who is a patient of mine who is 49 Um has a bmi of 37 and she has a history of multiple ventral hernia repairs. She is currently a poorly controlled diabetic who's had a mess excision in the past and is currently a smoker. If you just think about what is the risk, you're going to quote this patient for a risk of wound infection and using our app this carolina's equation for determining associated risks. Uh this patient actually has a 65% risk of developing a postoperative wound complication. If we take her to the operating room as she is currently. The nice thing about this app is that you can interactively sit in the office or in the hospital with the patient and you can actually show them using this app how they can decrease the risk of having a one complication with just some lifestyle modifications. So for example is this if this patient were to quit smoking for four weeks pre operatively get her diabetes under control. So that hemoglobin a one c number is under 7.2. And then she also loses £25 while she's managing her diabetes. Her risk for developing a woman complication is significantly lower. She's now at a 20% risk of developing a one complication. Uh So as you can imagine, this is a much easier patient to take care of somebody that really will do very much do much better post operatively. Then if she is taken to the operating room when she first presents to the office, Of course, a lot of people would like to say that a wound complication is a never event after undergoing surgery, but we know that that's not the case. What we also know is that if you look at most of the hernia literature, looking specifically at open ventral hernia repairs anywhere from 29 to 60s, 6% of these patients develop some kind of a wound complication in complex repairs. Um what's also interesting to note is uh, you know, this is kind of like what comes first uh and uh what if you have what happens first is that the wound, that's in fact that and then after that, that is the most uh important risk factor for developing a hernia recurrence. So one thing after another and our patients enter this vicious cycle of hernia repairs hernia recurrences. What's also important to note is that these patients really significantly suffer complications related to their quality of life. We tracked our patients in the office who had complications post operatively, such as one complications. And when you compare them to those who do not have complications, you can see there's a statistically significant increase towards a poorer quality of life, such as pain activity limitation and next sensation patients who have a wound complications. The other thing that was interesting from the study is that we tracked exactly how many times a patient would come and see us in the office if they had a wound complication in a year versus those patients who did not. And then we also attract the duration of their office visit. And then how many times they call the office? So poor patient who had no wound complications. This is One of those uh, well visits patient will come to the office about three times a year, 13 minute visit and about one uh, on average, one phone call per year. Now, if a patient had a one complication, almost nine visits 42 minutes where more than likely you're opening up the wound, you're popping staples out. You're packing the wound, Not a very comfortable 42 minutes. And then lots of phone calls to the office as well. So just 11 complication. Well, actually back us up about six hours a year. So just imagining how many more cases we could do a surgeon's or how many more patients we could see in the office Instead of having to take care of just that one wound complications. It's certainly something significant. And certainly something we need to pay attention to. Um, what are our current options in high risk patients. As far as wound closure. I think some of the important things we already mentioned as far as optimizing pre operatively delayed skin closure and I'll discuss that a little bit later. Uh Antibiotic patterns, strips, irrigation is there are many of these on the market uh and with varying success. We've all used them at some point packing with gauze, covering with something some kind of addressing. And then what I'm going to talk about more is the use of negative institutional therapy. Uh So uh for the last several years I've become a huge fan of using the pra vina for incision management And when trying to describe to people as far as what the Praveen A does. I think it's really important to know that it delivers continuous negative pressure for somewhere up to seven days. It holds the incision alleges together uh removes the fluids and infectious materials as its suctioning. It also acts as a barrier to external infectious sources and it reduces the edema at the wound edge. All of these worked very nicely together to prevent one complications and and problems as I'll demonstrate in some of this literature. Um So I'm just going to look at a few studies here. This first one is actually an abdominal wall reconstruction very clearly demonstrating. You can see the patients who had incision all negative pressure therapy in the blue bar and then conventional dressings in the red bar. You can see that looking across the whole spectrum from moon complications in the essence, skin fat necrosis, Ciroma, hernia recurrence and infection that you really have a significant decrease in uh these problems in the incision along negative pressure wound therapy. Um So certainly favorable data. This is a study uh prospective randomized trial which is a little bit older from 2012. Looking at fractures and really looking at infectious complications in the distance, a significant decrease when using negative pressure wound therapy. Um What I'd like to present here for the next minute or so is this really nice trial? This is a multi center randomized control trial which is one of the most recent trials which was done using the pro vina. Uh This was done on revision me arthur apostasy patients. A randomized trial when patients who are very difficult to heal. These patients have a lot of complications usually as far as healing. So this trial is very nice demonstration of how negative incision therapy may be helpful. Uh So they essentially had two groups. The patients were randomized into these two equal groups. One had the clothes decisional negative pressure therapy uh and the other one had a silver impregnated dressing. Um And what was interesting is any of these randomized controlled trials is that we perform interim analysis and for this trial particularly they terminated the study because when they did their interim analysis there was actually such a significant difference that uh that there was a clear benefits of the study at this time was terminated. Looking deeper into the study and looking at some of the other results you can see here comparing the red bar versus the gray box uh with the clothes decisional negative therapy with the red bar. You can see that percentage of patients with surgical site complications significantly lower at 30, and 90 days. Uh and then you can see some kind of the complication of types of complications. Uh also readmission re operation length of state. All of these were significantly, you can see Much lower, you know well, but as far as the statistically significant, the 90 day readmission in the length of state. But you can just by looking at the bars, you can see there's definitely a reduction using the clothes decisional negative therapy and then also uh taking this a little bit further and looking at activity of daily living, sports and recreation, which obviously is very important for patients who underwent these knee surgeries. You can see that the patients with the clothes decisional negative therapy had much, much better results than those with the conventional silver dressing. Uh so in conclusion, uh this is the results of one of the most current trials using the Privy to really supporting its use and acceptance. Um so looking through some of the other literature, I think this is really important to know that the thoracic surgeons have used Praveen a products for a while for their external infections. Uh this is actually how I was even able to introduce the Praveen a to our hospital because we used to not have it and it was only approved for our thoracic surgeons. And then I started essentially kind of uh stealing it from their core and using it in my hernia patients until it was actually approved for everybody to use it. But this is a nice study basically demonstrating what was previously already shown that there is a significant decrease uh infection, infectious complications when using the patina therapy and external wounds. Um so now I'm going to switch gears a little bit. I'm going to go to my patients. Um and I have the privilege of taking a lot of uh a lot of care of a lot of post transplant patients in my office. Uh Obviously these patients are complicated in nature, not only because all of these patients here have liver transplant, but there are also co morbid in the way that either they have morbid obesity, diabetes and they're all an immuno suppression and immuno suppression as you know, can be very difficult to deal with some of these patients pre operatively. I will have extensive discussions with their hepatology ist trying to basically optimized and for surgery. Trying to see if there's something else we can put them on uh because there are a lot of different medications that can be used just in that period operative period and can really cause a significant decrease in postoperative complications. It managed appropriately when we look at data on hernia repairs in post transplant patients. Uh This is the first paper that comes up from 2000 and 1913 month follow at 25% recurrence. But that's pretty high recurrence with a 13 month follow up. Um If you look at this paper from and also plastic surgery from DR Singh actually looks a little bit better, especially if you're looking at biological measures versus the synthetic measures that have a much higher recurrence and mesh X. Plantation infection. Uh This paper from DR Evans now shows a three year follow up with a 6% recurrence rate. Uh So this is actually much much better and I'll show you a patient of mine. So this gentleman actually this is a picture his wife shared with me. This was a cell phone picture after his transplant. He developed this problem right in the center of his incision. And at that time he was seen by his transplant surgeon and underwent a hernia repair small open hernia repair. Uh He did okay for some time and then presented to my office when he actually had a hernia recurrence. Uh So at that time also the patient had lost a lot of weight. So when so many in office he looked like this, you can see that he really has a lot of skin irregularity. He's very thin right here. Um But he was optimized by his liver surgeons. And at this time they thought that he was in appropriate shape to undergo recurrent hernia repair. So I took him to the operating room. A lot of these patients. If you are not careful about where you make your incisions, you can really d vascular rise the whole skin flap especially since these hernias go all the way out to the right flank very often. And you have to do a lot of skin undermining in order to get to a good lateral edge of the muscle. So when the skin has been cut several different ways here, if you undermine and you can really get into a lot of complications. So what I like to do is essentially do it um upside down boomerang clinical ectomy uh and exercise that whole area of skin where the incision is. Get into the abdomen. Take out the old mesh patch. Uh And then what I will do is I'll actually take down the peritoneum, going all the way around the abdominal wall cavity and then close the peritoneum. So all the intestine, all the viscera is essentially separated by this very thin layer of the peritoneum. Uh At this point I can play submission on the abdomen. I usually transplant patients or any kind of high risk patients. I use a biological mesh. Uh And then you can close the fascia there. The nice thing about closing the perineum before you actually place the mesh in there is that you don't have to place a lot of futures to hold the mesh in place. It really only requires a few futures just to make sure that the mesh doesn't wrinkle. But it's a nice plane where the mesh can incorporate very nicely into the abdominal wall. This is the fashion clothes. I placed a little edge of the mesh that I had left over over his eye for it because I was afraid with him being so thin that he may actually ulcer it right in the area of his incision. Uh and then close his incision. Um I know that there are a lot of different ways that people like to use the Praveen A. So I'll just take a second to let you know my biases. Um And in my practice what I'll do on these patients. So they will have one drain which is right on top of the mesh. Taking the perineum down and everything is pretty traumatic. And they will accumulate some fluid here. I don't want that fluid to be in between the mesh and the abdominal wall. So these drains usually stay until the patient goes home, Then the flash is closed. Then replace another drain into the subcutaneous tissue. What I'll do is I'll actually close the subcutaneous tissue using like a tool monocle and observable future. And then I will play some staples. And I'll usually space these about one centimeter in part. Um My bias behind this is that the Praveen a works so well. First having. And the silver dressing underneath. But the other nice thing about it is that the section that it provides, I feel like it really helps uh section in between these staples and take any of the Adina out and helps also with preventing Ciroma information from at least what I have seen. Um And uh and then uh this is just a little bit of uh data on our post transplant patients. So about 17 patients so far not taken care of. You can see that these are big defects, 300 centimeters squared. Mesh is also huge. All of them had a Praveen A therapy. We had zero surgical site infections. And these are very core morbid patients. As you've seen the pictures all on immune suppression. Uh and we've also not had any hernia occurrences at 22 months. I think the reason we don't see so many hernia occurrences anymore is that we've really significantly decreased one complications with the privy to. So certainly something that to be very happy about this is yet another patient, this very nice lady had an emergent laparotomy. She had a colostomy and also developed a hernia. So when she came to see me, she wanted to both have her colostomy reversed and have her hernia effects on cat scan. You can see here there's sort of liver, you can see the rectus muscles are pretty separate, about a 15 centimeter defect. And then also a little bit of a defect where her stoma is. Uh So when I saw her pre operatively, I told her, you know, you're going to have to lose a little bit away. Pre operatively she was also smoker. I made her quit smoking check her urine cotinine level before she undergoes surgery. And uh and then this is her in the operating room. I also excised her environment line scar. Just made my incision right over top of her hernia. Took down the stone to that wei really no contamination whatsoever. Put her bowel together. Also when prepared meal as you can see, the perineum is completely closed here and this is a 15 centimeter ruler. But what's really nice is her weight loss. Uh The fascia came together very nicely and we didn't have to do any kind of uh cutting of uh the fashion, no component separation of any kind place. The mesh closed her fashion. Here's a drain uh In her surprise vina in place. And she healed very nicely. Um As far as looking at our data on using the pra vina. Um I have been, as I told you, I've used this for several years now, but I became so convinced that it's working really well. And I was telling everybody in the hospital about it. And I didn't even know how well it was working until we actually looked at our data. So as I told you were a very big center for referrals for complex hernia repairs. And uh what we did as a study. The propensity matched the patients who had the Trevena versus those patients who had a credential addressing. Uh You can see this is 692 patients. Uh 67 of the patients had the pro vina. Uh BMS are 36 on average, which is about normal in our practice. Um And uh you can see that um are hernia recurrence in the Praveen a group with zero versus 8% in the other group. And then when we propensity matched it for one complications, uh We went down from 47 a half percent to 15%. Which is very interesting because if you use the cedar app on these same group of patients, the cedar app almost accurately predicted. Uh These complications predicted the surgical occurrence rate at 49.8%. Where it really would have been 47.5%. Except we did not use the provisional when the app was created. So I can tell you now that using that app. It does. I think for my practice and I use the Praveen a. It actually overestimate some of these wound complications. Um So we need to definitely update that data. So as far as looking more into analysis, I think what's really important and prevents a lot of people from using the pra vina is that uh in general, I think surgeons like to be cost conscious into operating. And we're using lots of different things in the operating room. Lots of different glues, lots of different meshes. And all of these can really make these repairs be very expensive. So I think when thinking about closing the skin, I guess not realizing the data about how costly wound complications are, can kind of deter some of the surgeons from using uh negative institutional therapy. This is a paper that one of my fellows dr Katie Schlosser who is a resident now at uh University of Ohio. Um And uh and she actually looked at a cost analysis and uh looking at patients who uh so basically uh Trevena was cost effective if the decrease of surgical site infection was by 30%, which was very cost effective in our patient population. But I think anytime we're using any kind of an implant Such as a piece of mesh, you know, which these implants can be anywhere from 1000 to $10,000 when you're using these kind of implants or any time if you're using an orthopedic implant, you're using a graft. Uh these are patients that you really do not want to have an infection. And because then potentially your graft, your mash etcetera can become ineffective. So I think preventing those infections is going to be extremely cost effective. I'm going to share with you this patient here. This is a very nice lady who actually had this hernia out for about 10 years. Uh and she kept presenting to our hospital over and over with bowel obstructions except this very scary panis. Nobody wanted to do anything on her and she would come in place. So they would place an energy tube. Uh and then she would somehow result for a bowel obstruction. People would tell her to lose weight, should go home, wouldn't lose weight and then we'll come back to the hospital again. Uh And I'll just show you after uh you know, I saw her in the hospital, I was consulted for the first time, took a look at this panis and then decided that we needed to go and take her to the operating room, take care of her. Uh I'll show you here a video of her operation. Um What we had to do is we had to suspend her panis upon essentially ivy pulse uh to keep the sterile. So you can see my fellow and are never used this. I've seen this used at a hernia meeting. So hopefully I can give you guys some ideas here, but you can see that the whole O. R. Team is essentially in this operating room trying to figure out how we're gonna do this. People are coming in from the hallway. Uh And what we start by doing is suspending this panis and then we're using the liga shirt. Um What's nice about suspending this really large panis. We don't do this all the time. Obviously just for once like this. But what's nice about suspending is that you're actually auto transfusing the patient because all that blood is essentially going back into the patient. Uh So now we're getting all the way down to um The area where she's obstructed. You can see here this panis even though it looks huge, only ways that I think about £25. So skin and fat doesn't weigh that much. But certainly to her, it's a love. So this is how obstructed her bow was. You know, she had a real true bowel obstruction. She had been living with this for a long time. The hernia was nothing. It was teeny tiny. It was this pan is that was the biggest problem. We actually had to make this bigger in order to do a formal hernia repair because I was afraid that more stuff would come out of this. If we just placed a small little mesh, you can see here, we're just kind of measuring how the skin is going to come together. Did we taken up skin uh and then deciding to do a very similar repair to what I've showed you before doing this prepared near release. The peritoneum is kind of an ideal structure that everybody has in their abdomen, varying thickness depending on where you are and from person to person. But it's very thin and uh you can see here, you can see the glove through it. But you can make a very nice flap that's going to completely isolate the intestine from where you're going to place the mesh. And this this really helps as far as Segregating the mesh from the intestines. So you're not having a lot of inter abdominal adhesions. So for example this lady needs to have a laproscopic called suspecting me 10 years from now may not be the easiest case, but at least she doesn't have mesh that could be stuck to her intestine. More than likely she'll have this protective perineum which will help us prevent her intestine if we have to go in there and do anything laparoscopically. So this part of the case, as you can see, can be a little bit tedious as we're kind of getting through, mobilizing the perineum all the way around the abdominal cavity. Uh And you know, this is something that we teach our residents in the operating room. Um I do this particular type of operation on my robotic cases as well because you can really see these layers very nicely and do a nice dissection, you can use these kid miners and get really far laterally. You can see the perineum so thin that you can see the intestine underneath there. Once you get this perineum completely taken back. Now this is not any type of a component separation. This doesn't do anything as far as releasing the muscle but it essentially just segregates the intestine from where the mesh is going to be. Uh Then you can basically just reconstructed with some stitches. These are just absorb all stitches. And uh we will usually close this perineum just as you can see right there. Very very thin. If you make any holes in it, I will place like this one right here, we'll just close these holes because if you let that whole potentially intestine could come through the perineum and then become incarcerated underneath your mesh. So on her we're using a big synthetic mesh. Um So she really had that very protruding abdomen. And this was a completely clean case. So I decided that I wanted to put in something that's um that's pretty sturdy and uh we can see here we placed a few stitches superior early a few stitches of services to stitches in fairly a few stitches severely. Uh And then also laterally just the security smash. So it doesn't go anywhere. Um And this really also kind of helps take some of the pressure off your anterior midline closure. Um And you can see we're taking turns my fellow and are closing this, making sure that the mesh is nice and flattened out. I think a lot of hernia recurrence is not only depend on infection and all that but it's also the techniques are extremely important. Um And then we also for pain control. Most of our patients we do a transverse abdominals. Mountain National block and I use license license on mobile pivoting mixture. Uh and then you can see that we place the drain underneath the fascia. We close the fascia in her didn't really have any trouble closing it because this was a fairly small hernia. Uh and then she had a little bit of bulging here and fairly. So I just wanted to kind of pretend that I'm a plastic surgeon and do a little bit of a die stasis repair just to make things look even a little bit better. We place usually wondering in our pinnacle ectomy subcutaneous place. But for her we actually did too because this was such a large flop. We wash and irrigate everything routinely with best trace and irrigation. Use some kind of a hemostat IQ product. And then as you can see this is a very long incision um close this uh first with the moniker ALs as I explained earlier and then closed with um close with stapler in place. The privy to as you can tell, we use the entire Praveen a uh in her uh the entire customizable Trevena for this patient. And then this is her standing up in the hospital. Uh and you can see she looks really good. Now this patient does not look so good. This patient had a really nice hernia repair however post operatively and you can see she had a big panis if you look underneath her incision, there's this redness. I think a lot of times when people do pinnacle academies. One common mistake is that they make their decisions really low right in the area where the skin is broken down. And I think that really contributes to how uh patients heal poorly with pinnacle ectomy. So I usually go above that. This patient had a previous uh midline incision and then also this inferior incision. And what often when you have these inverted T incisions which you will see is that there's some blood supply issues. And what she developed is this necrosis right at the edge of one of her flops. Uh So often what you may see is that surgeons will apply uh some type of creams um that are hopefully going to help vascular rise the skin maybe just cover it, add some antibiotics. Is uh the problem though is that we're just seeing the tip of the iceberg here. And these kind of patients, especially if they have a $10,000 mesh underneath their fashion. They need to be taken to the operating room essentially that very same day or the next day. Uh and this is what she looks like an operating room. So you can see that it's not just that ugly ulcer. You know? The story is much worse underneath. You really are going to see a lot of uh the vascular rise subcutaneous tissue, uh fat and you really need to take all that off and completely wash everything out and then re close the good uh good healing skin and subcutaneous tissue. And this is what she looks like post operative in our office after that re excision. So I think it's important to be proactive a lot of times after we've done a really big repair, we kind of just want to bury our head in the sand and not have to go back to the operating room. But I think these types of patients really uh they not only deserve but they also need a lot of careful attention and being able to troubleshoot even small problems such as these type of wound complications. I think part of our success at our hospital really depends on the people we work with. Uh So julie K. Laws is one of our uh wound nurse is one of the she's a division manager for uh K. Ci at our hospital. And she's a previous school nurse and she has done just an amazing job uh taking care of our patients. We not only have these very nice Praveen a uh inserts that you can see that can help. So all of your partners know what to do when they get a call in the middle of the night by one of the patients. But she's also help us create this very nice leaflet a flyer that we send all of our patients home with. And it can really help figure out what the patient needs to do and troubleshoot if anything happens with the privy to um as far as um looking at which patients are appropriate for using the pra vina. Uh There's a recent indication by the F. D. A. In 2000 and 19 which basically using the Trevena therapy units. They're intended to aid in reducing the incidence of Ciroma and in patients at high risk of postoperative infections. It also in reducing the incidents superficial surgical site infection in Class one and two wounds. Uh And this is just the indication statement for europe and also latin America. Uh conclusion. I think there are a lot of things that uh surgical complications can occur often and trying to avoid them. Uh We need to be proactive so I think optimizing patients preoperative is extremely important. Also considering therapies such as per vina, which can make a huge difference, is also very very important. Uh And then considering a delayed closure and some of the patients who have heavily contaminated wounds. Thank you very much for your attention at this time. I would like to invite dr brady and look forward to her presentation. I'd like to say thank you to dr Augustine for that very informative presentation as well as your kind introduction um for this. Um Next question of the panel discussion. I also like to thank for him um for the opportunity to speak to all of you and most importantly, um I'd like to thank the participants for joining in this really very important discussion, which is focused on the importance of a standardized process for surgical site infection prevention and really reaching every patient every time. This is um some important information um that we have to include in itself. Moving forward. Um I had mentioned that I am a speaker and a consultant for a three M. Um and um this relationship, this um uh working working relationship really kind of developed um from the work that I had done at um the organization I am with. We're going to discuss some of the organizational specific interventions that we use to reduce surgical site um and hospital acquired infection rates. And um in particular we looked at our cardiac surgery. The surgical site infections are amazing and a major concern. Um There are over eight million people at risk for health care associated infections and post surgical complications can lead to significant costs. And that can be up to 20, almost 22% of all healthcare associated infections. Additionally, these infections really increase the average length of stay and that is almost 10 days, With an additional cost of almost $39,000. And in particular um centers from Medicare and Medicaid emphasized the need to decrease costs and improved care by identifying hospital acquired conditions that will not be reimbursed. And this includes three surgical site infections. You just sign it has fallen coronary artery bypass grafting surgical sites following um surgical site infections following um orthopedic procedures and then surgical site infections following bariatric procedures. And I'm, as I had mentioned, we started our focus on media sinusitis based on our organization data. So how do patients um uh get a surgical site infection? Up to 60% maybe preventable by using evidence-based guidelines. And um uh we have to think about a consistent approach the same way every day. Um used to be our favorite saying in our cardiac surgery world for preparing patients for surgery um and aligned to guidelines as well as best practice. And that includes temperature monitoring. And I like the schematic because it does really provide a very nice very quick overview and that includes temperature monitoring, nasal decolonization, um uh patient bathing um surgical prep again, temperature management through out um not just the monitoring but the management hand hygiene is always important both for the patients as well as for the health care providers and close decision negative um pressure therapy and also had some amazing results. So um so this p I process understanding our problem again. This is the case study and the results in the outcomes should not be interpreted as a guarantee. However, this is what we really found in our institutions with the way that we approach our opportunity which was identified as the highest procedures based on organizational data. So what we noticed is that we were having a spike in our cardiac surgery infection right now. Late in the superior made intervention, um evaluation and assessment a bit more difficult. So we had to be very comprehensive. So um we we started our goal was to reduce hospital acquired surgical citing sections through risk reduction. We want to reduce the my um microbial exposures. We started with two phases. Phase one was changing practicing protocols took a real big focus of the pre op in drop post up and post discharge as well. And we were able to include um uh clinical providers from each of these um phases of care. We had a very interactive group. Phase two was developing a universal skin and nasal decolonization approach and really we're into a stage three as well. Um because as you know uh it is best to have sustainability as well as um look for continuous improvement to reduce our surgical site infections as well as all hospital acquired infections. So um and again this is just um one organizations um this reduction experience. What we did is we focus on very specific surgical service lines. We did a we developed a multidisciplinary team approach and that was in conjunction with Sage and three a.m. We examined pre operative preoperative and postoperative processes. We looked at expert recommendations and interventions and as I mentioned, um the spike was quite relevant. So our phase one really focused on inter operative procedures um in that again you were entering a sterile um robotic cavities. So the idea is to maintain that sterility going in during the procedure and then post procedure. So we looked at skin preparation. We also looked at temperature management and the goal of norma ther mia that included pre intra in the immediate postoperative period. We could identify some time frames that we were very good at maintaining normal hermia in particular. Um Are inter operative in our immediate postoperative staff were hyper vigilant on it. We also looked at our closure devices um closure methods um as well. And that included surgical as well as dressing Phase two. As I had mentioned, looked at post skin closure, sternal stabilization methods. We also really embrace skin and naval decolonization during all phases of in patient care. Um and expanded our education provided by clinical by the clinics were discharged here. So Faith one, we're going to talk about the intra operative procedures. Again we want full transparency and accountability. So we developed a committee work group um that that included committee's work groups and practitioners. Health care workers need to understand changes both intellectually the why and the emotional component. What is the patient impact? We also wanted to really have meaningful changes. What is it, what's the gold standard? What are evidence based or community best practices and in particular? Um What is now um We wanted to be very very um Finally and as I mentioned time timing is critical um and about the time that we were starting this um to get all of the phases. We we weren't aware of the blooming uh pandemic um the covid pandemic that was coming. So um that is some of the reasons that we had kind of um that are processed may not have been as smooth as it could have been in different time frames because overwhelmed healthcare systems cannot accommodate new project we really need in support. Um when we were in the crux of our a covid pandemic but having said that are elective surgeries were also cancelled. However, we were still doing um emergent cases. So um and obviously the other thing that I want to identify is that there's on back from literature to practice implementation and this is just throughout the healthcare healthcare systems overall and really with our technology and the availability of knowledge, we're trying to shorten that time frame um from literature to practice implementation. So the face on, as I had mentioned was an immediate start and that was back in March of 2019 and we focused on inter operative methods um and that was because we had a very very very dedicated um consistent um uh group or staff. We followed up with onboard data collection and review. We reviewed inter operative processes as well as their sterility and this included birth, um personal and um practice interpretive practices and surgical techniques that included skin preparation and line insertion as well as skin opening and vein harvesting in particular looking at their cabbages as well as our inter operative monitoring and then we've also focused on closure devices and methods For this initial phase. Um one again we found that some of our opportunities were targeted temperature management and that included pre to post um postoperative period tended to be hyper vigilance in the inter operative, in the postoperative period. We also in our skin preparation looking at community best practices, add an additional cleansing step um as well our team interactions. Um I think that this is very very important actually. Um We empowered all of the staff to do peer to peer coaching. Um And this actually became really really important. We increased our use of figure eights um with the thought that the sternal wires um figure eight configuration for sternal wires and high risk patients. This very theory driven and was to decrease the local inflammatory process and therefore reduce infectious risk. We no longer use Alpha gaza tape on the chest area. Um We only use silver coda dressings on low risk patients. And um and we use three um um Praveen a incision dressing on hired uh The essence risk patients. Um We also made quite a few um postoperative clinical practice changes. We reinforced enforced um post op rewarming protocols. Um The staff were very very very well educated and done that and it just kind of brought a renewed um I really knew the awareness the silver impregnated dressing. Um Actually the postoperative stuff really supported that quite a while. We did have some provider variance um to the length of time that we left the dressing on and this this is um little bit of a step off or a learning curve that we had to have with our providers. Um As as you are aware the silver impregnated dressings really the best um to remain intact for seven days. So we had a lot of work that we needed to do and that was kind of our learning and their trust curves and again we kind of reinforced that warmer patients are much more stable. Additionally, this improved our early excavation rates. Um I did a couple of words about pre warming. We had um not been this aggressive with that um as we could have been and the healthcare organizations around the world and there's been several um have have public several recommendations or guidelines emphasizing the importance of the preoperative temperature management and as I mentioned we were hypervigilant inter operative hyper vigilant on postoperative. However that pretty pre operative was a real um gap for us. The mechanism that we used is of course the three and their hunger. Um We use that both intra operatively as well as in our postoperative period. Um And then we had started a project um and it was using the three and Bair hugger temperature monitoring system. This is a non invasive way um for that continuous um temperature monitoring and it depended on the phase of tear um How are temperature, how we were doing an accurate consistent temperature monitoring. This actually was really well received by our preoperative staff to continue on with what our lessons learned for and um our pilots because of the covid and interrupt interruption. We had a lot of success is we had a lot of team transition. We also found that we got better peer to peer coaching. Um And we had a lot a much better patient outcome ownership and overall um really significant decrease in our hospital acquired infections as well as our surgical site rates uh and an incredible different sections. However um are continuing ongoing process was interrupted by covid. Um So we were very limited um in particular about the preoperative temperature management. Um And then that was probably one of our bigger impact phase two we're gonna talk about nasal skin to colonization. Um So our phase two was um what looked at the nasal and scandic organization. Well there was a real um overall the literature lacked a consensus um on approach. You know are you going to use antibiotics? Are you going to use antiseptic? Who has um ownership of the process because it was very comprehensive. Um How and and our improvement in our phase one outcomes with the things that we had discussed made face to kind of less imperative. The other thing is given latency period. These two interventions evaluations are a little bit more difficult days one interventions um that that exposure that risk could be seen quite quickly. So whereas face to tend to be a slower so our C. D. C. D. C. Did make some recommendations back in october 2019. And that really gave us renewed impetus. Um And this expanded from surgical site infections to a more inclusive hospital acquired infection uh approach. We also had considerable administrative support as well. And the timing was yes january 2020. Yeah before just before the brink of the combat pandemics. These are the CDC recommendations um that are available on site. And um we ended up going with a nasal antiseptic and what we chose was nasal Cavity 99 may be considered as an ultimate to um uh back back to band and a multifaceted approach to reduce surgical citing factions. And these were the data that supported um this um our mitigation. Mhm. So we looked at the CDC recommendations and we really decided to be very comprehensive. We included all our patients in our iCU. We included I. M. C. And acute care patients um that had um vascular access devices. And we expanded this to include our central lines ticks and midline as well as for we catheter. We included all surgical in patient but then um skin and nasal decolonization. We also had the mother baby strategies for a few section patients in skins PhD application and that was a real um uh work across the two. Additionally. Um we included our emergency room and all patients going to the O. R. Including trauma um that we're going to be a minute post up and patients um coming into the air going directly to the O. R. R. The men to post up at this organization. So even giving our preoperative benefits that way. As I mentioned we really looked at the difference in the nasal decolonization methods, antibiotics versus the antiseptics and this is partly what we came up with the antibiotic use extended time to efficacy. We were also very concerned as an organization and our workgroup about antibiotic stewardship. Um We also there was substantial the development of resistant strains of staph warriors. It was also the problem with patient non adherence because of the eid dozing. There were problems with limited patient populations. He had to be very very specific as well as the need for pre assessment including M. R. S. A. Swab. And the workflow could be very confusing to start start start and stop time in particular. Well we found with the antiseptic there were really two based approaches the alcalde um solutions as well as the iodine based solutions. And what we found with the alcohol was it was a nearer or anti microbial coverage. And again it was that B. I. D. Dozing. So the iodine um scene of iodine based strategies seemed to be um meet our needs better because they had broader anti microbial coverage. They had wrapped onset reductions in microbial organism burdens and you could be very very much more inclusive and patient population and the workflow could be very consistent with daily um skin CHD decolonization or decontamination. Um We looked also across product solutions and when we were assessing this we looked at efficacy killed times nuclear membrane adherence, nursing workflow as well as patient compliance, organization, accessibility and costs and unit level accessibility and storage to choose our final product. And this is just an additional data that support uh support those findings. Both surgical site infections um as well as staffers and M. R. S. A. Um surgical site infections. We had most pretty extensively what are type of organisms were um and and um our staff aureus um was one of our bigger um high risk um the nasal skin decolonization workgroup. We looked at a single kit with both skin and nasal decolonization. We monitor our outcomes. And as I mentioned we brought it we included Cody's collapses, surgical site infections as well as M. R. S. A transmission right. The implementation plan was to pilot high risk units cardiac surgery and then to brought into all I see us and our faith one was high risk units, cardiac surgery division line. We did pre operative inter operative post operative to discharge. Um So I was quite expensive. We also really looked at um and then we followed up Phase two was with all of our see us and then um pastries um was all units are workflow, the storage and location of supplies. Again, we wanted to make it incredibly easy for nurses to be able to um He mailed it to deliver the treatment and again, um Why did we choose the nose toes? Kids? Historically we had success with our H. I. A. Hospital acquired infection rates across surgical services as well as our organizations. Across multiple organizations. The workflow, we were known excessive um daily treatment and this kind of really facilitated practice changed pretty easily and we anticipated that it would increase compliance. The warm solutions also increased our patient adherence additionally, um we really preferred the provident iodine solution because of what's called the four ps the pollen eric film and the anti microbial action persistency, the ph balance and additionally less important to us was a pediatric indication. Um We also have Brighton partnerships with industry reps for education support and compliance monitoring and the costs were quite favorable. The pilot, we start in the high risk units um we used workflow um quality um data to identify gaps and opportunities and then we rolled out a somewhat modified plan to the entire organization um and we created, you know, distribution list for clear consistent guidance as well as a portfolio documents so that everyone could forget the information that they needed quite quickly. Our evaluation techniques, we looked at both qualitative and quantitative data. We evaluated the work processes and our sustainability. We've had multiple types of practice reinforcement accountability. This includes daily line calls, Claudia's classes as well as reported. Um And the data overview of product use and infection rates. And that includes quality. Classy M. R. S. A transmission. What worked really well, increasing workflow compliance, skin and nasal treatment done simultaneously. Um additional warmers, um increased treatment adherence by the patients um And the timing based on 24 hour time frame. So we left us to the unit. This discretion, we didn't say that by nine a.m. Every patient, every surgical patient, every patient was a central line vascular access device or full. We had to be done. That's just not. Um That was not feasible for our unit. The the electronic health recommend record documentation still is a little bit difficult for us and that will be faced three um components. We met with providers um Again we we developed a portfolio that was stored on the share site for all staff to access and we did a lot of education um and how are we doing? Um So so this graph um it actually goes to november. Um We have data that are very consistent with this actually. We just got a congratulatory email from our ceo about the length of time in Afghanistan since our last club see um for the organization. So this organization will roll out of um Paula Deen iodine solution and skin decontamination has worked incredibly successful. Um Leave for our organization in um surgical site infections. Classy rates. Mrf transmissions um and has been very successful, very, very, very successful for cardiac surgery. So some of the bumps in our comes and not do their change in our practice, but due to other circumstances in particular the covid patient population. And what's interesting is these patients were in the EU and many organizations had a 300 fold increase in their H. I. A. Um rates H AI rates with the congress population population. We we did see small bumps, we didn't see that kind of impact. Um and we really had a very blended covid collapsing boat in some in summary. We really had the right products, the right messaging and the right implementation strategies. Our organization lessons learned think tanks really were very helpful. Um This was global for cardiac surgery division and what could be and what should be. We also really encourage multidisciplinary representation and partnership or incredibly important. The model that we use was called the pies and its assessment plan, intervention evaluation and sustainability. This really didn't help guide our process. Um Towns in the project organization and this really was a grassroots translation of science into practice. Um and then um we used a very broad and inclusive approach for no supposed. Um and again, as I mentioned, it was very effective. Um working with working relationships are incredibly important, peer to peer coaching is very important, time spent on the y set the stage for rollout accountability and sustainability across all of our phases, portfolio portfolio information provided easy access. It made the process very transparent. Um cost savings are extensive actually, but more importantly, um the patient impact, what was the covid impact? Did speed up the skin and nasal decolonization implementation luckily, um the non covid focus efforts in the global infection prevention project was placed on hold so I say three has been placed on hold and limits in our non employee presence in the organization would sometimes made education a little bit more difficult. However, um it is never too late to make process improvements, identified the gaps and keep working kobane and not. Um and as we all know it will be back. Pastry is gonna be consistent, preoperative warning, warming, enhanced postoperative turtle stabilization and reinforce faith women face to. Um Thank you very much. Are there any questions? Um comments, thank you dr brady for the excellent talk. We would now like to dedicate this time to take questions from our audience is please ask your question by clicking on the Q. And a icon located at the bottom of your screen.