Surgical Site Infections

Involved, informed people are the most effective weapon against infection

Editor’s note: Healthcare-acquired infections are among the leading causes of death in the United States, according to the U.S. Department of Health and Human Services. At any given time, about one in every 20 inpatients has an infection related to their hospital care. Healthcare-acquired infections alone are responsible for $28 billion to $33 billion in preventable healthcare expenditures annually. These infections are largely preventable and can be drastically reduced to save lives and avoid excess costs. This month, the Journal of Healthcare Contracting looks at surgical site infections – their causes, preventive measures and the role of the supply chain executive.

A surgical site infection is a post-surgical infection that occurs in the part of the body where the surgery took place. Most patients who have surgery do not develop an infection, according to the Centers for Disease Control and Prevention. However, infections develop in about one to three out of every 100 patients who have surgery.

Such infections are a frequent cause of morbidity following surgical procedures, says the Institute for Healthcare Improvement. They have also been shown to increase mortality, readmission rates, length of stay, and costs for patients who incur them. An estimated 40 to 60 percent of these infections are preventable.

Some of the common symptoms of a surgical site infection are:

  • Redness and pain around the surgical site.
  • Drainage of cloudy fluid from the surgical wound.
  • Fever.

Most surgical site infections can be treated with antibiotics, though sometimes patients with surgical site infections need another surgery to treat the infection, according to the CDC. But the emphasis today is on preventing infections.

Doctors, nurses, and other healthcare providers have many options to reduce the likelihood of surgical site infections among patients, including:

  • Cleaning their hands and arms up to their elbows with an antiseptic agent just before the surgery.
  • Cleaning the skin at the site of the surgery with a germicidal soap.
  • Cleaning their hands with soap and water or an alcohol-based hand rub before and after caring for each patient.
  • Removing some of the patient’s hair immediately before surgery using electric clippers (not a razor, which can compromise the skin integrity) if the hair is in the same area where the procedure will occur.
  • Wearing hair covers, masks, gowns, and gloves during surgery to keep the surgery area clean.
  • Giving the patient antibiotics before surgery starts (and then stopping them within 24 hours after surgery.)

Proper disinfection and sterilization of surgical instruments, and ensuring the operating suite is clean, are essential components of a program to reduce surgical site infections.

People are the most important factor in any surgical-site-infection program, says Michelle Hulse Stevens, M.D., medical director for the Infection Prevention Division, 3M Infection Prevention. “It’s important that you have multidisciplinary teams that work well together,” she says. “Pulling in the right stakeholders is important.”

In most facilities, those stakeholders include OR nursing, surgeons or medical staff, central sterile supply and environmental services. It’s important to have a physician champion as well as buy-in from senior management, she adds.

Technology is important, of course, says Stevens. But “it is important to address fundamental gaps in process first. [Healthcare organizations] need to have good patient-care processes in place, and then look at what technologies can help simplify, augment or mitigate risk in an already optimized program.”

All stakeholders need to maintain open and healthy communication with each other regarding the processes and programs that are being addressed, says Stevens. “The supply chain team is an important stakeholder in inventory management and materials decisions, so it is important to remember the contribution they can make.”

The goal of surgical-site program is simple – to reduce preventable surgical-site infections, says Stevens. “Surgical site infection prevention focuses on mitigation of risk factors that can be addressed, a multifactorial process that is complex and has its highest impact if optimized.”

As with any quality improvement program, though, the toughest part might be sustaining improvements over time, she adds. “It’s not a project. It’s a fundamental activity that needs to happen every day, with every surgery and every patient. It has to be top-of-mind for everybody.”

Preventing surgical site infections: Four components of care

The Institute for Healthcare Improvement has identified four components of care to reduce the incidence of surgical site infections.

1. Appropriate use of prophylactic antibiotics. Some strategies being employed are:

  • Use of preprinted or computerized standing orders specifying antibiotic, timing, dose, and discontinuation.
  • Development of pharmacist- and nurse-driven protocols that include preoperative antibiotic selection and dosing based on surgical type and patient-specific criteria (age, weight, allergies, renal clearance, etc.).
  • Change of OR drug stocks to include only standard doses and standard drugs, reflecting national guidelines.
  • Assignment of dosing responsibilities to anesthesia or designated nurse (e.g., pre-op holding or circulator) to improve timeliness.
  • Involvement of pharmacy, infection control, and infectious disease staff to ensure appropriate timing, selection, and duration.
  • Verification of administration time during time-out or pre-procedural briefing so action can be taken if not administered.

2. Appropriate hair removal. For many years, it has been known that the use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all. Razors can cause small cuts and nicks to skin, many of which may be microscopic and not visible to the human eye. Steps that hospitals are employing to improve performance on appropriate hair removal include:

  • Maintenance of an adequate supply of clippers, and training of staff on proper use.
  • Use of reminders (signs, posters).
  • Education of patients not to self-shave preoperatively.
  • Removal of all razors from the entire hospital.
  • Work with the purchasing department so that razors are no longer purchased by the hospital.

3. Controlled posteroperative serum glucose in cardiac surgery. Medical literature shows that the degree of hyperglycemia in the postoperative period has been correlated with the rate of surgical site infections in patients undergoing major cardiac surgery. Measures that hospitals are taking to improve performance on postoperative glucose control include:

  • Implementation of one standard glucose control protocol for cardiac surgery.
  • Regular checks of preoperative blood glucose levels on all patients to identify hyperglycemia. (This is best done early enough that assessment of risk can be completed and treatment initiated if appropriate.)
  • Assignment of responsibility and accountability for blood glucose monitoring and control.

4. Immediate postoperative normothermia in colorectal surgery. Medical literature indicates that patients undergoing colorectal surgery have a decreased risk of surgical site infection if they are not allowed to become hypothermic during the perioperative period. Measures that hospitals are taking include:

  • Prevention of hypothermia at all phases of the surgical process.
  • Use of warmed forced-air blankets preoperatively, during surgery, and in PACU.
  • Use of warmed fluids for IVs and flushes in surgical sites and openings.
  • Use of warming blankets under patients on the operating table.
  • Use of hats and booties on patients perioperatively.
  • Adjustment of engineering controls so that operating rooms and patient areas are not permitted to become excessively cold overnight, when many rooms are closed.
  • Measurement of temperature with a standard type of thermometer.
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