Wiping out surgical site infections

Protocols and preparation are key.

Hospitalists can help reduce surgical site infections (SSIs) by being aware of an item that could have disastrous results for surgery patients: razors.

“Hospitalists should look out for them and not use them for anything,” said Fran Griffin, project director at the Institute for Healthcare Improvement (IHI). “Do not [use them] to shave a patient before an IV or [central line] or prior to an EKG. Do not even have disposable ones available.”

Appropriate hair removal with clippers rather than razors, which have been shown to cause more infections, is one of four components of care that the IHI included in an SSI prevention initiative, part of its 100,000 Lives Campaign (). That campaign ran from December 2004 to June 2006, and the SSI initiative is now part of the IHI's 5 Million Lives Campaign, which was announced in December 2006.

Hospitalists can help reduce surgical site infections by being aware of an item that could have disastrous results for surgery patients razors Photo by Comstock Complete
Hospitalists can help reduce surgical site infections by being aware of an item that could have disastrous results for surgery patients: razors. Photo by Comstock Complete.

The other three SSI prevention components are appropriate use of antibiotics (giving the right one according to national guidelines, giving it within one hour before surgical incision and discontinuing it within 24 hours after surgery), maintenance of postoperative glucose control for major cardiac surgery patients and maintenance of postoperative normothermia for colorectal surgery patients.

Although these items are not new and have been supported by other organizations such as the Joint Commission and CMS, SSIs still account for 14% to 16% of all hospital-acquired infections and 40% of all hospital-acquired infections among surgical patients, according to the American College of Surgeons (ACS).

Of postoperative infections, an estimated 40% to 60% can be prevented just by appropriate use of antibiotics, Ms. Griffin noted. Part of the problem, she said, is that a number of hospitals still don't have greater than 90% compliance with accepted protocols. “In any other industry that wouldn't be considered good enough. Why do we consider 90% good enough in health care?” she asked.

ACS and the IHI agree that SSIs are still all too common and costly: They increase mortality and readmission rates, and each one increases length of stay by seven days at a cost of $3,152.

So what's the holdup? While some hospitals had already begun addressing SSIs before IHI launched its campaigns, hurdles still include designing a good process, making changes that physicians can accept and addressing debate over the evidence. For those who have been able to meet the challenges, the results have been impressive, drastically if not completely reducing the incidence of preventable SSIs.

Making it work

Having a standard process in place and a person assigned to oversee it is especially critical to meeting the antibiotic goals. At OSF St. Joseph Medical Center, a 157-bed hospital in Bloomington, Ill., that person is Kathy Haig, RN, director of quality, patient safety officer and risk manager. She has plenty of company on her SSI team: an infection control nurse; representatives from patient services, pharmacy, education and the operating room; an anesthesiologist; and medical and surgical champions.

When it began in 2004, the team's goals were to reduce its SSI rate (which ranged from 2.8% to 3.35%) by half, double the days between SSIs and have 95% compliance with the processes included in the IHI campaigns. Its efforts have paid off: SSI rates are now less than 1% on average with some months at zero, and 93% to 100% of patients are on an antibiotic within one hour of surgery.

It hasn't been easy, especially for physicians who fear that standardized processes will lead to “cookbook medicine.” However, OSF made the effort to meet specific needs. For example, its prophylactic antibiotic protocol has different default order sets for different areas such as ob/gyn and cardiac care. To keep everyone on the same page, the syringe used to deliver the antibiotic goes with the patient to the OR, Ms. Haig said.

Elsewhere, hospitals have found it best to have anesthesiology own the process. “If you don't hardwire it, it's not likely to be done consistently or reliably,” explained Spike Lipschutz, MD, senior vice president of clinical affairs at South Shore Hospital in South Weymouth, Mass. Once that happened, the hospital modified the surgical antibiotic grid to account for allergies, established redosing guidelines for long surgeries and changed from guidelines to standing orders. As a result, the 284-bed hospital's overall compliance rate jumped from 86% in 2006 to 92% in 2007 and antibiotic selection is correct almost 100% of the time in most areas.

Preparation is key, Ms. Griffin emphasized. That's why IHI suggests starting with a pilot population of at least 100 cases per month of, for example, hip and knee replacement patients.

Countering resistance

Some doctors cling to what they're used to and question whether there's enough evidence to change. “We anticipated it being difficult,” Ms. Haig said. Showing the literature helped, she said.

In the case of using clippers instead of razors, decades-old evidence shows that shaving leads to more infections than using clippers or not removing hair at all. Yet stories still circulate of disgruntled staff hiding razors or bringing them in from home. To get everyone on board, Porter Hospital, a 45-bed facility in Middlebury, Vt., let staff try out several types of clippers and pick their favorite.

Some also question whether there's enough evidence for the normothermia recommendation. However, the IHI and the Surgical Care Improvement Project (SCIP), a partnership of organizations to improve patient care, maintain that the literature—and “theoretical rationale and experimental data”—indicates that colorectal surgery patients are less likely to get an SSI if they do not become hypothermic perioperatively and that patients become hypothermic during surgery because of anesthesia, anxiety, wet skin preparations and skin exposure in cold ORs.

The key is to have the resources in place, including warming blankets, head covers and IV fluids at room temperature. Reliable thermometers are critical, said Patricia Jannene, RN, vice president of patient care services at Porter Hospital. The hospital had previously used warming blankets only when the patients said they were cold. “But the reality was they were cold and not feeling it,” she said. Now staff uses temporal artery thermometers to get an objective reading.

It's also important to be sure that the OR isn't too cold. When OSF increased the temperature from 65 to 67 degrees Fahrenheit, it prepared for a negative staff reaction by offering to provide cooling vests, but never needed them. At Porter Hospital, the culprit behind the 60-degree OR in the morning was a cost-conscious housekeeper who turned down the thermostat at night even when it was 15 degrees below zero outside.

Protocol changes in glucose control, by contrast, are usually accepted because they're limited to cardiac surgery, backed by several studies showing that glucose control improves surgical outcomes and easy to implement in post-op cardiac settings, Ms. Griffin said.

Keeping watch

Because SSIs can occur after discharge, many facilities measure SSIs within 30 days, the IHI's recommended time frame. Still, hospitalists may be involved with discontinuation of antibiotics or other elements of SSI prevention.

Hospitals keep on top of their performance by measuring criteria monthly and getting the word out to staff. Porter, for example, posts its performance on the break room's bulletin board. Hospital staff are proud of their results—reducing SSI rates from almost 3% in 2004 to zero for 18 months running. “If you give information and empower staff, they'll stand on their hands to make it work,” Ms. Jannene said.

Still, getting to zero may be hard because of factors beyond the hospital's control, such as a patient's condition before surgery. That means that even doing everything right may not be enough. “It doesn't mean [SSIs] won't happen, but that we did what we could do,” Dr. Lipschutz said.

One way to keep on top of best practices is to see what others are doing. Ms. Haig talked about a recent visit from a doctor and nurse from Florida who were looking at how OSF dealt with SSIs. In turn, she said she doesn't hesitate to pick up hints from others, especially as she gears up for further improvements. “When it comes to safety, there's no competition or boundaries,” she said. “I think we've got a very good start, but there's a long road ahead of us.”

Paula S. Katz is a freelance writer in Vernon Hills, Ill.

The 100,000 Lives Campaign

The Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign ran from June 2004 to December 2006. This article is the fifth in a retrospective series examining the campaign's initiatives:

  • Deploy rapid response teams
  • Deliver reliable, evidence-based care for acute myocardial infarction
  • Prevent adverse drug events
  • Prevent central line infections
  • Prevent surgical site infections
  • Prevent ventilator-associated pneumonia

For information on IHI and links to tools and case studies on surgical site infections, go to ihi.org.

Tips for success

Here are some tips for improving the way your hospital handles prevention of surgical site infection from those who spoke with ACP Hospitalist:

Have leadership support. At Fairview Hospital in Great Barrington, Mass., the key to ensuring that antibiotics were given within one hour prior to incision was to have an anesthesia champion, said Pavani Rangachari, administrative director of quality and patient safety.

Use preprinted or computerized standing orders. This helps with antibiotic use by specifying the antibiotic, timing, dose and discontinuation. Have a physician or individual departments develop a protocol for the first antibiotic dose.

Use a team approach. Give dosing responsibilities for antibiotics to anesthesiologists or holding area nurses. Involve pharmacy, infection control and infectious disease staff to ensure appropriate timing, selection and duration.

Be tenacious. Some of the changes can be challenging and, occasionally, surprising. For example, OSF St. Joseph Medical Center in Bloomington, Ill., determined a key problem was having only one room for preadmission testing and ended up renovating part of the hospital for surgical staging. Although that took a while because of budgetary constraints and the time needed for new construction, all scheduled surgical patients are now readied by the “experts”—those staff who routinely prepare patients for surgery, said Kathy Haig, RN, director of quality, patient safety officer and risk manager.