SSI rates low, but call for safer surgery remains
Although the rates of serious surgical site infections (SSIs) following outpatient surgery are low, the number of patients who develop these serious infections is substantial and warrants continued quality improvement efforts because outpatient surgery is so common, according to a new study.
The study, "Surgical site infections following ambulatory procedures," was published in the Feb. 19 issue of the Journal of the American Medical Association and funded by the Agency for Healthcare Research and Quality (AHRQ).
Nearly two-thirds of all surgeries in the United States are performed in ambulatory settings. Researchers used AHRQ’s Healthcare Cost and Utilization Project databases to analyze SSI rates following surgery in hospital-owned ambulatory settings in eight states. Freestanding ambulatory surgery centers with no hospital affiliation were not included.
The authors found that 877 patients in the states, or a rate of 3.09 of every 1,000 patients, who had ambulatory surgery were treated within 14 days for a SSI that required hospitalization. At 30 days, the rate increased to 4.84 of every 1,000 patients. These data did not include procedures performed in physicians’ offices or freestanding facilities not owned by hospitals.
"Healthcare-associated infections remain a common complication of care following ambulatory surgery," said AHRQ Director Richard Kronick, PhD. "The number of patients experiencing these serious infections is an important consideration, and work should continue to make outpatient surgery safer."
AHRQ has undertaken a Safety Program for Ambulatory Surgery, which is promoting the use of the Comprehensive Unit-based Safety Program (CUSP), a proven method for preventing HAIs, to reduce SSIs and other complications from surgery in ambulatory surgery centers and hospital outpatient departments. (For more on CUSP, see, "Pilot program slashes colorectal SSIs by 33% — Hospital saves $168,000-$280,000 in one year," Same-Day Surgery, October 2012.)
About 3% of hospitalized patients who contract an SSI die from it. Having an SSI can add 7 to 10 days to a hospital stay and add up to $27,600 to the cost of hospital care. Yet, relatively little is known about SSIs in relation to ambulatory surgery.
285,000 SSIs were examined
To address this gap in knowledge, researchers led by Pamela L. Owens, PhD, and Claudia A. Steiner, MD, MPH, both of AHRQ, analyzed records of nearly 285,000 ambulatory surgeries (general surgery, orthopedic, neurosurgical, gynecologic, and urologic) that were followed by a serious SSI requiring a hospital stay or an ambulatory surgery visit in adult, low surgical risk patients. The records were from outpatient surgeries performed in 2010 in California, Florida, Georgia, Hawaii, Missouri, Nebraska, New York, and Tennessee.
Because the study found that most of the serious SSIs occur within 14 days, the study’s authors recommended that more attention be paid to preventing and reducing infections in the early window following an ambulatory surgery. For example, routine clinical follow-up within 14 days following an ambulatory surgery might help detect infections earlier before they become serious and require hospitalization. "Earlier access to a clinician or member of the surgical team ... may help identify and treat these infections early and reduce overall morbidity," the authors wrote.
The study’s authors said that the findings from this research reaffirm that quality improvement programs also should be targeted to prevent infections following ambulatory surgery. (To review draft SSI guidelines from the Centers for Disease Control and Prevention, see story below.)
CDC draft SSI guidelines find evidence elusive
(Editor’s note: The following story was excerpted from the HICprevent blog, also published by AHC Media, and written by Gary Evans. To access the blog, go to http://hicprevent.blogs.reliasmedia.com.)
The Centers for Disease Control and Prevention (CDC) has posted draft updated guidelines for preventing surgical site infections (SSIs), and it focuses on some difficult issues in an exhaustive and largely futile attempt to find conclusive data on various practices.
As a result, "no recommendation" is a recurrent theme in the document, though no page apparently was left unturned in the 261 references.
Here is the section on the question of wearing "orthopaedic space suits" for joint replacement procedures. The references are available in the CDC guideline, but were not reprinted for this excerpt.
How safe and effective are orthopaedic space suits in reducing the risk of SSI in prosthetic joint arthroplasty patients, and which healthcare personnel should wear them?
"The available data evaluated the use of a space suit as compared to no space suit.
For this comparison we considered deep SSI requiring reoperation, deep SSI requiring revision, and deep SSI as the critical outcomes. Superficial SSI outcome was also evaluated. The evidence for this question consists of 3 OBS studies at low risk of bias.
Very-low quality evidence suggested no benefit to using an orthopaedic space suit to reduce the risk of SSI. This was based on no difference in deep SSI requiring reoperation, deep SSI requiring revision surgery, or deep or superficial SSI in 3 OBS studies. The number of events for each of these studies was low. The largest national joint registry study with multiple subgroup analyses suggested that use of a space suit was associated with an increased number of deep SSIs requiring revision surgery within 6 months of THA or TKA, but this evidence was limited in size. Results did not differ based on the presence or absence of laminar flow. A large multicenter study using administrative data from patients undergoing TKA suggested no difference in deep SSIs requiring reoperation within 90 days. Reoperations included incision and drainage and implant removal. The definition of deep SSI in this study may have included PJI. Space suit and laminar flow use varied between groups. A third small study in THA and hip hemiarthroplasties reported only 1 deep SSI in the space suit group and 1 superficial SSI in each group at 24 months of follow up. High-efficiency particulate air (HEPA)/mixed turbulent filtration was used in both groups.
Our search did not identify data that quantified potential complications associated with the use of space suits. In one large national joint registry study (N=88,311) comments by surgeons completing a questionnaire (n=35) included "limited spatial awareness and ease of contamination due to an apparent false sense of security" with the use of a space suit. We did not evaluate the efficacy of the space suit as personal protective equipment.
Also, our search did not identify data that evaluated the association between specific health care personnel wearing a space suit and SSI. One retrospective controlled study included a surgeon questionnaire reporting that the surgeon, assistant, and scrub nurse were the team members wearing a full space suit. One prospective controlled study reported those same team members wearing the space suit in the intervention group."
Recommendation: No recommendation can be made regarding the safety and effectiveness of orthopaedic space suits or the health care personnel who should wear them for the prevention of surgical site infection in prosthetic joint arthroplasty. (No recommendation/unresolved issue) (Editor’s note: To access the full guidelines, go to http://bit.ly/1apEdtM.)
