Two great new resources on preventing surgical site infections (SSIís) became available last month. NICE (the UKís National Institute for Health and Clinical Excellence) released its guidance on surgical site infections. The guidance includes a summary guideline, a quick reference, and a much larger guideline, plus evidence tables and other resources.
The second resource is a supplement to the October issue of Infection Control & Hospital Epidemiology. The entire supplement consists of ďA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care HospitalsĒ and is available free online. This resource includes articles on strategies to prevent central line-associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, preventing MRSA and C. difficile infections, plus the article on preventing surgical site infections. All the recommendations were sponsored and authored by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA), partnering with Association for Professionals in Infection Control and Epidemiology (APIC), the Joint Commission, and the American Hospital Association (AHA). Youíll find each of the individual articles to be comprehensive and useful or you can read the summary article, which includes the key recommended practices for all of the HAIís.
The compendium article summarizes the statistics on SSIís. SSIís occur in 2-5% of surgical procedures and their occurrence greatly increases patient morbidity and mortality, length of stay, and resource consumption. The risk of death is 2-11 times higher in patients with SSIís and in about three-quarters of those who die, death is attributable to the SSI. SSIís add 7-10 days of hospital stay and $3000 to $29,000 additional cost.
The compendium article does a nice job of describing the methods for detection of SSIís, including use of automated data systems to expand surveillance. It also discusses the need for post-discharge surveillance.
The compendium article includes a table with risk factors for SSIís, both intrinsic and extrinsic, and their associated grades of evidence. Many of the interventions to prevent SSIís are familiar to most of you through the SCIP (Surgical Care Improvement Project).
Good surgical care begins well before the surgery. The patient (and family or caregivers where appropriate) should be informed about the risks of infection and what will be done to reduce those risks as part of the informed consent process. Good control of diabetes reduces the SSI risk. Smoking increases the SSI risk so smoking cessation should be encouraged well prior to surgery.
The NICE guideline notes the patient should bathe or shower with soap on the day of or day before the surgery. The usefulness of preoperative bathing with chlorhexidine-containing solutions remains an unresolved issue. Hair removal is no longer routinely recommended. For those operations where hair must be removed for surgical access, it should be removed with electric clippers on the day of the surgery, with clippers having a single-use removable head. Razors should not be used (they actually increase the risk of infection). The compendium guideline also allows use of depilatory preparations.
The full NICE guideline provides a summary of the procedures for which prophylactic antibiotics have been shown to be effective in reducing SSIís and the associated evidence base. The timing of antibiotic prophylaxis in those cases where antibiotics are indicated is crucial. The SCIP project uses the target within one hour prior to surgical incision, though the period is extended to 2 hours for antibiotics such as vancomycin and fluoroquinolones to allow for maximum tissue availability during surgery. Note that vancomycin is not an antibiotic routinely used in prophylaxis but may be used under special circumstances. The compendium recommendation also notes that the dosing of the prophylactic antibiotic may need to be increased in morbidly obese patients. Limiting duration of prophylactic antibiotics is important to reduce the emergence of antibiotic resistance and to prevent C. difficile infections. Prophylactic antibiotics should be discontinued within 24 hours of surgery (48 hours for cardiac surgery). The NICE guideline differs in that it recommends considering a single dose of† prophylactic antibiotic be given on starting anesthesia, with subsequent doses determined by the operating time and the pharmacokinetics of the antibiotic. While the single dose approach may be more cost-effective, it should be noted that the evidence for single-dose vs. 24 hour dosing is still limited.
Prophylactic antibiotics should be an item on your surgical safety cheklist (see our July 1, 2008 Patient Safety Tip of the Week ďWHOís New Surgical Safety ChecklistĒ).
Both guidelines discuss many of the procedures related to the immediate operative period, including surgical scrub (staff hand cleansing/decontamination), use of gowns and gloves and masks, antiseptic skin preparation, etc. The NICE guideline also addresses many postoperative procedures such as dressing changes and also provides many ďdo not doĒ things for wound care. The NICE guideline has one major difference from the US guidelines: hospital staff should remove hand jewelry, artificial nails, and nail polish before operations. The NICE guideline also cautions that there be sufficient time for evaporation of skin antiseptics and avoiding pooling of alcohol-based preparations (see our Patient Safety Tip of the Week for December 4, 2007 ďSurgical FiresĒ and April 29, 2008 ďASA Practice Advisory on Operating Room FiresĒ).
Neither the NICE nor the compendium guidelines have specific recommendations regarding duration of surgery. Work with the National Nosocomial Infections Surveillance system risk index had shown that the incidence of SSIís increases when the procedure duration exceeds the 75th percentile for the duration for that type of procedure. Though some of that may be simply explained by very complex procedures requiring more time, minimizing duration should be encouraged when possible. Yet we know of few hospitals that actually track procedure duration in real-time. And adding time pressure to a procedure might conceivably increase the likelihood of other intraoperative errors that might be detrimental to the patient. Nevertheless, since there are a limited number of operative risk factors that are amenable to change, tracking operative time might be useful in some circumstances (eg. in a teaching hospital where duration may be extended because of the educational aspects). A recent study of SSIís (Campbell 2008) did show that hospitals that were high outliers for SSIís had higher trainee-to-bed ratios and the operations took significantly longer.
The compendium article discusses the infrastructure needs and the importance of education (staff, patients, family) and especially a system for feedback about SSI rates to be used in quality improvement activities.
Both the NICE and the compendium guidelines also do a good job of discussing issues that are yet unresolved (eg. role of routine MRSA screening or decolonization, role of preoperative bathing with chlorhexidine-containing solutions, etc.) and those shown not to be helpful (eg. delaying surgery to give parenteral nutrition) and areas for further research (eg. role of tissue oxygenation).
Lastly, the compendium article discusses the performance measures that your facility should be using to monitor SSIís and your preventive measures.
Long gone are the days when we thought that SSIís were ďpart of doing businessĒ. It is clear that 40-60% of SSIís are preventable (IHI 5 Million Lives Campaign). Preventing them helps your patients, your staff morale, your standing in the community, and your bottom line.
Update: See our December 2008 Whatís New in the Patient Safety World column ďMore on Preventing Surgical Site Infections (SSIís)Ē
NICE guidance on surgical site infections
Hospital Acquired Infections Compendium. In supplement to October issue of Infection Control & Hospital Epidemiology 2008; 29: 901-994
Campbell DA, Henderson WG, Englesbe MJ, Hall BL, OíReilly M, Bratzler D, Dellinger EP, et al. Surgical Site Infection Prevention: The Importance of Operative Duration and Blood TransfusionóResults of the First American College of Surgeons/National Surgical Quality Improvement Program Best Practices Initiative. Journal of the American College of Surgeons 2008;† published online 10 October 2008.