A hospital saved a tidy sum and left 10 patients much happier those who did not have surgical site infections (SSIs), as predicted by the SSI rate prior to an intervention that revamped the patient preparation protocol.

“Considering that the average cost to treat one SSI is $90,000, the reduction of 10 SSIs in the post-implementation period represents potential savings of $900,000 in SSI treatment costs,” said Patti Steger, CLS, MT(ASCP), CIC, infection prevention manager at Hoag Orthopedic Institute in Orange, CA. “More than anything, we achieved better outcomes for our patients, and that is ultimately what we are here for.”

Recently, Steger detailed her program success at the 2021 virtual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

“The pre-operative prep went from two to five days, and the scope was expanded to include nasal decolonization,” she said. “By giving patient kits with SSI prevention education, we believe we achieved high rates of patient compliance. We did not have any increase of pre-operative skin issues reported, and we did see a decrease in the incidence of complex SSIs.”

SSIs are costly and may require surgery and prolonged antibiotic treatment.

“At our facility, these treatment costs can range between $30,000 and $175,000,” Steger said. “The readmission also results in prolonged lengths of stay, and the SSI increases the patients’ morbidity and mortality risk. The more intangible impacts on the patient’s life include longer recovery time, increased pain, prolonged antibiotic exposure, and delayed return to work, which may have substantial social and financial impacts on the patient and their family.”

To address an increased incidence of SSIs, a multidisciplinary workgroup was formed that included infection prevention, surgeons, anesthesiologists, hospitalists, pre-operative leaders and nurses, and staff and patient educators.

“Patient factors, such as nasal and body colonization, were identified as possible contributors to the increase in our SSIs, and due to the prevalence of SSIs caused by skin organisms, the decision was made to revamp the presurgical patient preparation process,” she said.

For example, patients complained about a chlorhexidine gluconate (CHG) skin preparation product that caused stickiness on application.

“Not only was this a patient dissatisfier, but during the pre-operative skin check, we discovered that the patient would have skin tears in their skin folds, presumably from the tackiness of this product prior to drying,” she said. “Lastly, nasal decolonization was only addressed on the day of surgery. Patients reported that the product had an unpleasant odor and feel. The nurses reported that they would have to stop patients who would instinctively try to blow their nose because of the feeling of nasal congestion.”

The New Protocol

In 2019, a new presurgical universal decolonization protocol was implemented that included bathing with a chlorhexidine gluconate (CHG) foam product once a day and twice-a-day application of an alcohol-based nasal antiseptic product. A “universal decolonization kit” was created that included the CHG foam product, alcohol-based nasal swabs, a shower mitt, a timer, and instructions on how to use each product. These kits were distributed to the surgeons’ offices to be given to patients during their preoperative appointment. The patient then receives a preadmission phone call a week before surgery to confirm they have received the kit and then given verbal instructions on its use. Prior to implementation, all staff were educated on the new universal decolonization protocol and a frequently asked questions document was posted to address issues as they came up, she explained.

“Preoperative nurses continue to use the 2% CHG wipes on the surgical site as before; however, we have changed the nasal decolonization product to the alcohol-based agent,” Steger said. “After surgery, the alcohol-based agent is also used twice a day until the patient is discharged. The patient is advised [to] continue to use any remaining product at their surgeon’s discretion until consumed.”

On the day of surgery, the pre-operative nurse confirms that the patient has completed the universal decolonization protocol. This is documented in the medical chart.

“Once the new universal decolonization protocol process was stable, an audit of a random sample of patient charts was conducted,” she said. “This showed that our patient-reported compliance with our protocol was greater than 93%. In informal interviews, our patients reported that the CHG foam product was easy to apply with the provided shower mitt, and they did not report any issues with stickiness after application. The nasal product was also reported to be simple to use.”

An 18-month pre- and post-analysis was completed, showing that during the pre-implementation period, from March 2018 to August 2019, there were about 6,800 procedures and 22 complex SSIs. This resulted in a standardized infection ratio (SIR) of 1.2 and a rate of SSI per 100 procedures of 0.3.

Post-implementation period results, including about 6,300 procedures from September 2019 to February 2021, were impressive. SSIs dropped 55% to 12, and the SIR was halved to 0.6. The rate of SSIs per 100 procedures also fell to 0.1.

“Prior to the change, the total cost for presurgical patient preparation was approximately $22 per patient,” Steger said. “This translates to just under $150,000 for the 18-month pre-implementation period. Post-implementation, the cost per patient was approximately $38.50 and the total for the 18-month post-implementation period was almost $245,000.”

The new protocol raised costs $95,000 but prevented 10 surgical infections for a net gain of about $805,000.

“We learned several lessons during this process,” she concluded. “It’s critical to have all members of the healthcare team represented so you can gather all their viewpoints and achieve a comprehensive examination of the entire process. We also considered what our patients’ feedback was to staff and physicians. Finally, it was important to involve our clinical informaticist to make the necessary changes in the electronic health record order sets and documentation so that it would match our new process.”