Healthcare-Associated Infections _ ______________________________________________________________
PRACTICAL STEPS IN FOLLOWING GUIDELINES TO PREVENT SURGICAL SITE INFECTIONS Appropriate Use of Prophylactic Antibiotics Use preprinted or computerized standing orders specifying antibiotic, timing, dose, and discontinuation. Develop pharmacist- and nurse-driven protocols that include preoperative antibiotic selection and dosing based on surgical type and patient- specific criteria (e.g., age, weight, allergies, renal clearance). Change operating room drug stocks to include only standard doses and standard drugs, reflecting national guidelines. Reassign dosing responsibilities to anesthesia or holding area nurses to improve timeliness. Involve pharmacy, infection control, and infectious disease staff to ensure appropriate timing, selection, and duration. Verify administration time during “time-out” or preprocedural briefing so action can be taken if not administered. Appropriate Hair Removal Ensure adequate supply of clippers and train staff in proper use. Remove all razors throughout the hospital. Work with the purchasing department to ensure that razors are no longer purchased by the hospital. Use signs or posters as reminders. Educate patients about not shaving preoperatively. Maintaining Adequate Glycemic Control Implement one standard glucose control protocol (sliding scale or insulin drip). Regularly check preoperative blood glucose levels on all patients. Assign responsibility and accountability for blood glucose monitoring and control. Maintaining a Warm Body Temperature Use hats and booties on patients preoperatively. Use warmed forced-air blankets preoperatively, during surgery, and in the recovery room. Use warmed intravenous fluids. Use warming blankets under patients on the operating table. Maintaining a Warm Body Temperature Prevent hypothermia at all phases of the surgical process. Use hats and booties on patients perioperatively. Use warmed forced-air blankets preoperatively, during surgery, and in the recovery room. Use warmed intravenous fluids. Use warming blankets under patients on the operating table. Adjust engineering controls so that operating rooms and patient areas are not permitted to become excessively cold overnight, when many rooms are closed. Measure temperature with a standard type of thermometer. Source: [192] Table 11
Ventilator-Associated Pneumonia The risk of ventilator-associated pneumonia correlates with the duration of intubation; the risk has been estimated to be 3% per day during the five-day period after intubation, decreasing to 2% per day for days 5 through 10 and to 1% per day for longer durations [196]. Nearly half of all cases of ventilator-associated pneumonia develop within the first four days of mechanical ventilation [193]. In addition to duration of ventilation, several other risk factors among adults have been identified, including a supine head position; use of a naso- gastric tube, paralytic agents, or PPI or histamine-2 receptor antagonists; patient age; chronic lung disease; and head trauma [22; 144]. In one study, ventilator-associated pneumonia was most frequently associated with ICU admission diagnoses of postoperative care, neurologic conditions, sepsis, and cardiac complications [197]. Transmission and Common Pathogens Gram-negative enteric bacilli and Pseudomonas spp. rarely colonize the upper respiratory tract of healthy individuals, but often do so in persons with an underlying disease, such as alcohol use disorder, and in those who are hospitalized or reside in nursing homes. Most cases of pneumonia that develop in a healthcare facility are caused by aspiration of oropharyngeal or gastric secretions colonized with hospital bacterial flora. Consequently, the prevalent causation as well
An estimated 10% of patients requiring mechanical ventilation will develop pneumonia as a complication, and the mortality rate directly attributable to ventilator-associated pneumonia is estimated at 13% [20]. Excess cost of care resulting from prolongation of hospital stay is estimated to be range from $30,000 to $40,000 per patient [20].
Risk Factors Hospital-Acquired Pneumonia
In a systematic review, the American College of Physicians found several patient-related and surgery-related factors that increased the risk of postoperative pulmonary complications. The most common patient-related factors were the presence of COPD and an age older than 60 years [143]. Other significant factors were an American Society of Anesthesiologists (ASA) class 2 (defined as a patient with mild systemic disease) or higher, functional dependence, and congestive heart failure. Cigarette use was associated with a modest increase in risk, and obesity and mild or moderate asthma were not found to increase risk [143]. Use of a PPI or histamine-2 receptor antagonist is also thought to be a risk factor [144]. Surgery- related factors included prolonged duration of surgery (more than three to four hours), emergency surgery, and surgical site, with abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, and aortic aneurysm repair being associated with the greatest risks [143].
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