Surgical site infection rate drops to zero in months

Antibiotics and no razors contribute

(Editor's note: This is the first of a two-part series that looks at effective strategies to reduce surgical site infection rates. This month, we look at the importance of reducing the use of razors, using prophylactic antibiotics, and keeping the patient warm. Next month, experts talk about glucose management, environmental control, and new products.)

Between 2% and 5% of patients undergoing surgical procedures will develop a surgical site infection that results in additional costs that range from $2,734 to $26,019 for each infection, according to the Centers for Disease Control's National Nosocomial Infections Surveillance system.

The surgical site infection rate at Porter Hospital in Middlebury, VT, was 2.6% when the ambulatory surgery staff initiated a program to address infection in October 2004. "Today, our surgical site infection rate is zero," says Ann Beauregard, RN, RN, performance improvement manager. Most of the hospital's surgical procedures are outpatient, with orthopedics, general surgery, and gynecological surgery representing the greatest volume, she says.

The performance improvement team started the project with reports from infection control nurses that tracked the type of surgical wound, timing of prophylactic antibiotic if used, surgeon, type of prep for surgery, start time for procedure, and length of procedure, she says. "We gathered our data and information from a wide range of literature to develop recommendations for change," she says.

Cynthia Spry, RN, MA, MSN, CNOR, clinical consultant at Advance Sterilization Products in Irvine, CA, says, "The good news for surgery managers is that we have a lot more information about prevention of surgical site infections, and we have more emphasis on the importance of reducing these infections."

With regulatory agencies such as the Centers for Medicare & Medicaid Services and accreditation agencies such as the Joint Commission on the Accreditation of Healthcare Organizations focusing on patient safety and prevention of infection, outpatient surgery managers have a lot more clout when they approach administration and physicians about the need to address infection rates, she says.

"We've known since the 1960s that shaving patients prior to surgery increased the risk of infection, but there are still people reluctant to change," points out Spry. As more surgical programs focus on infection prevention, practices are changing to only shave the patient if necessary and, when necessary, shave immediately before the procedure and never use a dry razor, she says.

One of the first changes at Porter Hospital was the elimination of razors in the operating room, says Beauregard. "We use clippers if we need to remove hair from the incision site," she says.

Antibiotics effective when used correctly

The use of prophylactic antibiotics is also very important to reducing surgical site infections, says Spry. "It is important to use the right antibiotic at the right time and to realize that not all procedures require a prophylactic antibiotic," she says.

"Procedures such laparoscopic cholecystectomies, laparoscopic hysterectomies, and urinary procedures all require prophylactic antibiotics," says Beauregard. Procedures that are not abdominal such as knee arthroscopies generally don't require antibiotics, she points out.

Melinda Rogers, RN, CNOR, clinical development specialist for surgical services at Northside Hospital in Atlanta, says, "We have used prophylactic antibiotics for all recommended procedures for over two years."

Because her hospital participates in the Surgical Care Improvement Project (SCIP), and reduction of surgical site infections is one focus of the project, Rogers uses SCIP resources for guidance on use of prophylactic antibiotics. "The tools available on the SCIP web site are helpful as you identify which procedures are appropriate for prophylactic antibiotics and which antibiotics are best for each situation," she says.

Broad-spectrum antibiotics should not be used because they are less effective against specific bacteria present in different procedures, and all prophylactic antibiotics should be discontinued within 24 hours of initial use because it should not be necessary at that point, Spry says.

One of the keys to proper antibiotic administration is allowing enough time for the antibiotic to get to the cell level, says Beauregard. "You need to administer the antibiotic 30-60 minutes prior to the first cut," she says.

Studies of their procedures showed that hysterectomy patients who were scheduled as the first procedure in the morning were often receiving the antibiotic fewer than 30 minutes prior to the incision, Beauregard notes. "We found that nurses were taking vital signs, checking patient history, and handling their other responsibilities prior to administering the antibiotic."

While this process did not affect patients scheduled later in the day, the patients who were scheduled first often went into the operating room more quickly because there were no cases before them that went a little longer than planned or necessitated cleaning of the room, Beauregard points out. "The first patients were moved into the operating room before the antibiotic got into their system," she explains. To address this issue, nurses began administering the antibiotic before they finished their other tasks, says Beauregard. "This gives the medication the extra time needed to get into the patient's system," she says.

Avoid hypothermia

Controlling the temperature of the room and the patient is also important to prevent infection, says Spry. Keep patients warm to prevent hypothermia, she says.

"Hypothermia reduces oxygen to the wound site and increases the buildup of collagen," she says. "Both of these conditions delay the wound healing process."

While patients have always appreciated warm blankets, studies have shown that keeping the patient's core temperature and the surgical site warm not only make the patient more comfortable, but also keep infection rates down, says Spry.1 "Pre-warm the patient in holding areas with warm blankets and make sure your operating rooms are not cold," she says. The rooms should be kept at a temperature that makes it possible to maintain the patient's normal core temperature, she adds.

At Porter Hospital, anesthesiologists warm fluids, and the patient's temperature in the operating room and in the recovery area are monitored, says Beauregard. After evaluating different methods of monitoring a patient's temperature, Beauregard's staff has chosen to use a temporal scanner thermometer because they found it to be easier to use and more accurate than other types of thermometers. "We chose the Exergen TA [McKesson Medical-Surgical, Richmond, VA] and we use it exclusively in the PACU and will be phasing out use of other thermometers throughout the entire hospital," she adds.

Other tips to keep patients warm include keeping them covered until you have to expose the surgical site, says Spry. "Also, when you are prepping the surgical area, expose only as much area as necessary," she adds.

Because you know that any amount of cold will reduce oxygen to the wound site, be sure to keep the patient well oxygenated during the procedure, suggests Spry. "Oxygen will speed healing and reduce the risk of infection," she says.

This is a good time for outpatient surgery managers to focus upon reduction of surgical site infection, points out Spry. "There is more research available on tactics that work, and there are protocols available for everyone's use," she says. "There are many different ways that surgery managers can approach this issue, and none of them require a lot of money — just attention to processes."

Reference

  1. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of wound infection and temperature group. N Engl J Med 1996; 334:1,209-1,215.

Sources/Resources

For more information about surgical site infection control, contact:

  • Ann Beauregard, RN, Performance Improvement Manager, Porter Hospital, 115 Porter Drive, Middlebury, VT 05753. Telephone: (802) 388-5645. E-mail: abeauregard@portermedical.org.
  • Melinda Rogers, RN, CNOR, Clinical Development Specialist, Northside Hospital, 1000 Johnson Ferry Road, Atlanta, GA 30342. Telephone: (404) 851-6065. E-mail: melinda.rogers@northside.com.
  • Cynthia Spry, RN, MSN, CNOR, Clinical Consultant, Advanced Sterilization Products. Telephone: (212) 627-4787. E-mail: cspry@aspus.jnj.com.

For tools, research, and recommendation for surgical site infection control, contact:

  • Institute for Health Improvement (IHI), 20 University Road, Seventh Floor, Cambridge, MA 02138. Telephone: (866) 787-0831 or (617) 301-4800. Fax: (617) 301-4848. Web: www.ihi.org. The IHI web site has a variety of tools to use in monitoring infections, developing surgical site infection control programs, and implementing programs. Click on "topics" on the left navigational bar. Choose "patient safety" then choose "surgical site infections."
  • The Surgical Care Improvement Project (SCIP) is a national collaborative effort between the Centers for Medicare and Medicaid Services, hospitals, and quality improvement organizations. At this time, the project is collecting data only from hospital-based inpatient programs but the tools, research, and recommendations are available to all surgery managers at www.medqic.org. Click on the SCIP logo on the right-hand side of the home page, then choose "infections" on the left navigational bar. A list of resources, tools, strategies, and other information related to surgical site infection prevention will be displayed.