PAPS - Optimizing skin antisepsis for neonatal surgery - Sophie Carr

So, next, we have Sophie Carr from British Columbia, presenting on optimizing skin antisepsis for neonatal surgery, and afterwards, we'll hear some commentary from Dr. Rebecca Rentia from Mercy Children's Hospital in Kansas City. Hi everyone. Thank you for this opportunity to present our work on optimizing skin antisepsis for neonatal surgery. My name is Sophie Carr and I'm a fourth year medical student at the University of British Columbia. I will be discussing off label use of a topical antiseptic in this presentation, but have no other relevant disclosures. Surgical site infections are a costly, yet modifiable source morbidity, particularly within the neonatal population. Pre-operative skin antisepsis is one of the primary prevention strategies routinely performed to reduce the risk of SSIs. A growing body of evidence in adults suggests that chlorhexidine gluconate and isopropyl alcohol provide superior protection against SSIs than povidone iodine. Equivalent data does not yet exist for the neonatal surgical population, but CHG antisepsis is commonly used for invasive non-surgical procedures in NICUs and for prevention of newborn nosocomial infections in developing countries. Although commonly used within the neonatal population, current product labeling discourages CHG IPA antisepsis in infants under two months of age, as there is limited safety data and concerns around adverse effects, particularly skin injuries. As part of a multi-pronged strategy targeting SSI reduction at BC Children's Hospital, we undertook a quality improvement project with the following aims. Number one, establish an evidence basis for safe surgical skin antisepsis in neonates. Number two, implement a neonatal CHG IPA skin antisepsis protocol. and three, evaluate the safety and effectiveness of this protocol. Through much collaboration with our team, engagement of stakeholders, surveying of other institutions and literature reviews, we developed the neonatal skin antisepsis protocol. Inclusion was limited to general surgery patients only with 34 weeks post conceptual age and 1500 grams as the lower age and weight limits. The yellow table outlines which solution was used based on age cutoffs, either 2% or 0.5% CHG. Skin integrity was assessed using a validated tool called the neonatal skin condition score. And an analysis comparing pre- and post-implementation data was subsequently performed to assess protocol effectiveness. This is our data collection sheet, front and back, which followed patients on the protocol from the operating room to the NICU. Implementation of the protocol occurred in February 2020 and was preceded by education of both OR and NICU staff. A total of 50 patients were included, none of which experienced adverse skin prep outcomes. 8% developed SSIs within the 30-day post-op period compared to 14% in the matched retrospective providone cohort. A comparison of SSI rates between the CHG versus PI cohort revealed no significant difference. Zooming back out a bit, this project has engaged stakeholders in neonatal surgical quality improvement work. It has informed the development and implementation of a neonatal CHG IPA surgical skin prep protocol and it has led to collaboration with other Canadian Nisqued pediatric sites who are looking to implement a similar protocol. These project outcomes all play into our end goal of improving patient care through ensuring safety and improving clinical outcomes. Thank you very much for your time and with that, I will conclude my presentation. Dr. Carr, what a fantastic presentation. I think this really speaks to every pediatric surgeon and anybody taking care of neonatal children. There's really a wide range of topical anesthetic preparations that are um antiseptic preparations that are used in neonatal surgery. And the formulations are really variable and um there's even between the different types of formulations, there's many variations. I wonder, um, what the level of contamination was between some of the different neonatal cases and then how did you determine your weight cutoffs? And were there any other parts of a bundle? Because usually when stakeholders become involved, the entire process of surgical site infections is evaluated in great detail. Um, also the the cutoffs, I'm really curious about how you determined the formulation because there's many different formulations of chlorhexidine. Uh, how you determine those. Great presentation and thanks again. Thanks very much for the questions, Dr. and the commentary. Um, in response to your first question, uh with regards to contamination of cases. majority of them were class two, so clean contaminated cases, which is um really more in keeping with the literature in terms of adult um SSI reduction in use of CHG antisepsis. Um, there were a few uh contaminated cases, but the majority of were clean contaminated. Um, and in terms of our uh lower uh age and weight cutoffs, that was something we spent a great deal of time kind of discussing and and and trying to figure out where was the best place to start. Um, our priority was really to insurance ensure safety as this was a quality improvement project and so, uh, wanting to uh, take fairly conservative lower age and weight cutoffs uh for our first kind of go around of this initiative. Um, our protocol was largely modeled um, off of well a number of different sources, but the primary source was the McGill uh protocol used in Quebec, Canada. And they used a lower age uh cutoff of 28 weeks gestational age um with a a lower weight cutoff of a 100 grand or sorry, a thousand grams. Um, so we decided to start at a more conservative place, recognizing that we were excluding a a large portion of our neonatal surgery patients. Um, and then uh hopefully in future um projects kind of expand that pool and and do so in a very cautious careful way. Um, as the primary advert or concern is really the adverse skin reactions uh with less than 28 weeks gestational age being the primary population affected by those in the literature. Um, and yes, this was this project really stemmed from our wider quality improvement initiatives, um, tackling our SSI rates within neonatal surgery at BC Children's Hospital. So, um, this was conducted in conjunction with a number of different initiatives, um, uh including evidently our antibiotic prophylaxis and so optimizing that, um, using adhere adherrent uh draping to ensure we weren't contaminating the field and then um, for our class two clean contaminated cases, uh using a um, a clean closure bundle. Um, so changing our gloves uh prior to closure, um, and really taking a multi-pronged uh approach to targeting our SSI rates. I might have missed it, but what was your SSI rate before you performed the study and was the um, uh the bundle where you changed your gloves or had a closing protocol, um, was that also part of the pre protocol? Like the control before you started the study. Right. So, um, I I don't want to have that data off the top of my head um as this was um uh we we didn't have it as a perfect control as it was really just one of the additional initiatives that we added in. Um, uh so we didn't do a direct comparison. This was more of uh trying to ensure safety within in using that antiseptic solution. Um, However, we did do look at um uh a retrospective cohort when we were using povione iodine in the same population and um, the SSI rate, though there was no statistical difference was 14% as compared to eight in a very small group. This was only just 50 50 patients. So it's hard to really show any significant difference. Sophie, we have we have 30 seconds left and I want you to do a rapid fire answer here. Rapid fire answer from the audience. First of all, was your decrease in SSI statistically significant? Yes or no? No. Okay. And the other question was, which procedures did you use prep and which did you not? Um, so all general general surgery cases that um didn't have uh any open exposed mucosa or in which the patient evidently was allergic to CG or IPA. Okay. Phenomenal, great discussion. Got it right under the bell sort of a little over the bell. Sorry. Blows after the bell. Uh, so back to your corners.