CDR Matt Armentano, PT, DPT, OCS FMC Lexington

CDR Matt Armentano, PT, DPT, OCS FMC Lexington

Define standard acceptable rates of surgical site infections in lower extremity total joint procedures Describe risk factors for surgical site infections following total joint surgical procedures Identify modifiable infection risks in incarcerated populations.

U.S. Narcotics Farm Opened in 1935 and named a USPHS Hospital in 1936 Staffed by U.S. Public Health Service Consisted of two divisions Clinical Research Center on Drug Addiction Addiction Research Center

Functioned as hospital & working farm.

1974 Facility was transferred to the Bureau of Prisons Low security correctional facility 1994 was designated as Medical Referral Center (MRC) for male inmates Currently serves as 1 of 6 MRCs for male inmates with more intensive medical/surgical needs

Population is approximately 1700 +/- inmates 32 medical inpatient beds Medical missions for the BOP include: Ambulatory care Bone marrow transplant Orthopedics Wound care Long Term care

Development of mission at FMC Lexintgon FMC Lexington Rehabilitation Dept (2011) 3 PTs Primary role was local rehabilitation 2012 - University of Kentucky orthopedic contract begins Rehabilitation department takes responsibility for orthopedic services

Rehabilitation and Orthopedics Department 9 Staff members 4 Physical Therapists 1 Occupational Therapist 1 Orthopedic Nurse Practitioner 2 PTAs 1 Medical Support Assistant My role Orthopedic specialist & liaison to UK Orthopedics and Sports medicine Responsible for coordination of all orthopedic care through UK Communicate/Coordinate with 15 different orthopedic surgeons & their staff Identified by BOP as an orthopedic referral center

Inmates throughout BOP identified as needing specialty orthopedic care and/or rehabilitation care Sent to MRCs as length of stay (LOS) for orthopedic care if care cannot be provided locally FMC Lexington currently has > 80 orthopedic LOS patients Variety of orthopedic problems Largest volume are total knee and hip patients Many very complex patients

Total Joint Arthroplasty Mostly total hip (THA) and total knee arthroplasty (TKA) TKA/THA - 44 % of LOS cases at FMC Lexington Total joint arthroplasty s have known complications Infection, Hardware Failure, Blood clots, Etc. Focus today is Deep Surgical Site Infection

Rate prior to 2012 information not available Our Rate from February 2012 Dec 2013 # surgeries = 34 # infections = 3 Rate = 9% Intervention needed?

APIC Association for Professionals in Infection Control and Epidemiology Guide to Elimination of Orthopedic Surgical Site Infections (2010) * Green LR, Mills R, Moss R, Sposato K, Vignari M. Guide to the Elimination of Orthopedic Surgical Site Infections: An APIC Guide, 2010. Available at: http://apic.org/professional-practice/implementation-guides.

Infection within 1 year post-op diagnosed by operative surgeon & requiring additional operative intervention (I&D and/or hardware exchange). Reported orthopedic surgical site infection rates (no differentiation between deep or superficial) Hip replacement: 0.67 2.4% * Knee replacement: 0.85-1.6% * * Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009; 37:783-805.

Two general risk factor categories * Host/Procedure Specific Modifiable/Non-modifiable * Green LR, Mills R, Moss R, Sposato K, Vignari M. Guide to the Elimination of Orthopedic Surgical Site Infections: An APIC Guide, 2010. Available at: http://apic.org/professional-practice/implementation-guides.

Host-Specific Procedure-Specific Modifiable - Obesity - Current Smoking - Hematocrit <36 - Elevated Pre or postoperative serum glucose - Nasal Carriage of Staph Aureus - Blood loss of > 1 liter - Longer procedure time - Suboptimal timing of prophylactic antibiotic - Two or more surgical residents participating in procedure - Prolonged wound drainage - Spinal procedure via anterior or posterior approach Non-Modifiable - Diabetes - Male - Rheumatoid Arthritis - ASA Score of 3 or More - Recent Weight loss - Dependent Functional Status - Disseminated Cancer - Admission from Health Care Facility - Blood loss of > 1 liter - Longer procedure time - Previous infection at site - Prolonged wound drainage - Low volume or procedures: - at hospital - by surgeon

Review of each case found no common consistent pattern of risk factors to explain infection 1 of 3 was obese (>35 BMI) 1 of 3 was diabetic None had previous infection 2 of 3 did not follow proper nasal or skin prep instructions

APIC Guide referenced 1999 CDC Guideline for Prevention of Surgical Site infection * Source of Most surgical site infections is endogenous flora of patients : skin mucous membrane hollow viscera (GI tract) * Green LR, Mills R, Moss R, Sposato K, Vignari M. Guide to the Elimination of Orthopedic Surgical Site Infections: An APIC Guide, 2010. Available at: http://apic.org/professional-practice/implementation-guides.

Identified areas at FMC that needed correction Pre-operative skin care & Nasal Decolonization Both being performed at FMC Prior to surgery Survey of post-op total joint patients Identified issues with consistent pre-operative antimicrobial shower/skin cleansing Identified issues with consistent nasal decolonization for appropriate duration

Met with UK Orthopedic Joint Replacement Service staff December 2013 Reviewed risk factors for this population per APIC Guideline Surgical procedures reviewed by UK Staff - found identical for BOP patients & UK Civilian patients Pre-operative and post-operative procedures were discussed Identified modifiable risk factors which could be manipulated to reduce infection rates

Bactroban nasal ointment x 7 days changed from 3 days which was protocol prior to UK contract education and tracking by physical therapy added BMI < 35 current BOP policy Vigorously enforced Admit day before surgery ensure consistent preoperative skin preparation Duration of inpatient stay to 6 days from 3 days

Since Intervention # of surgeries = 47 # of infections = 1 Rate = 2.1% This includes patients sent to us with Infection needing revision due to infection.