Hospital Infection Prevention-Tracking infections after outpatient surgery

Form streamlines process, improves communication

Surgical outpatients are frequently lost to follow-up, and hospitals without post-discharge surveillance programs may not be aware of subsequent infections. To address this problem, infection control professionals and surgeons at Peninsula Regional Medical Center in Salisbury, MD, designed a form to help track and record outpatient infections that might otherwise be missed. (See form, p. 4.)

They designed a focused surveillance program for surgical breast procedures, which include lumpectomy, simple mastectomy, radical mastectomy, and post-op reconstruction, explains Jo-Ann Lewis, RN, BSN, infection control nurse, who presented the findings recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology.¹

"We know that [the patients] are getting good follow-up with their surgeons," she told Hospital Infection Control. "But our criterion is if the infection occurred within 30 days of the procedure. If we don't use a postdischarge surveillance form, we don't know if they developed an infection, and there is no way that we can find that out."

An immediate key was the involvement of the 17 surgeons who performed the procedures. "The majority of [these] patients — probably 85% to 90% — are outpatients and never came back [to the hospital] again," she says. "If we wanted to find out about their infections, we knew we would have to depend on our surgeons. The success that we have had has a lot to do with having a couple of surgeons who have been very supportive."

The form was designed so that either the surgeon or office staff could review the records and fill it out. Education was given to general and plastic surgeons and their office staffs, and one contact person from each of six offices was identified. "Every quarter, I ask them to fill out this form, letting me know whether or not the patient has developed an infection," Lewis says. "Giving them constant feedback has really helped. We have gone to their meetings and discussed the results with them."

Forms were sent out to 342 patients, and 278 (81.3%) were returned. Of those, 64 (18.7%) required follow-up phone calls to obtain infection information. Of the 22 patients with infections, 15 (68%) would have been identified via usual surveillance methods (culture review, review of admission diagnoses, and review of suspected infection reports from home health). However, 32% would have been missed. Also, five (23%) of the infections would have been missed if follow-up phone calls for non-returned forms were not performed.

Most of the infections were incisional, but some were deeper, including post-op reconstructions that require removal of implants. A concern was that the infection rates appeared high when compared to benchmark data in the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance (NNIS) system. "We are definitely getting really accurate data," she said. "But when we compared our rates to the NNIS data, our rates were very high. But when I contacted the CDC and talked to them, the consensus was that we were not comparing apples to apples because NNIS looks only at inpatients. If we only looked at our inpatients in this category, we wouldn't have [many] infections either."

Instead, the rates will be compared to those in the literature in the ongoing project, which included a thorough review and reinforcement of aseptic technique during surgery. A possible significant finding was that patients who received antibiotics prior to surgery had lower infection rates. Overall, 65% of the surgeons have adopted that practice in light of the findings. In addition, an emphasis has been added on patient education regarding wound care and aseptic technique in the home. A similar surveillance approach could be taken for a hospital-affiliated clinic, she notes.

"It's painless," Lewis says. "It doesn't take very long to call the office, and it actually helps keeps me in touch with the office staff. If the patient had an infection, they can just check off what the symptoms are. I will look at that and determine if it meets the criteria for a true infection. If I have questions, I can call and ask the [staff] or the surgeon himself to make the determination of infection."

Reference

1. Lewis J. Use of post-discharge surveillance forms for outpatient surgical breast procedures. Presented at the Association for Professionals in Infection Control and Epidemiology. Minneapolis; June 18-22, 2000.