Physician's Weekly Article - Preventing Surgical Site Infections

       Surgical site infections are significant problems associated with major operations, but practical tools are being developed to reduce the impact of these complications.

      The Surgical Care Improvement Project —Series #1

      This Physician’s Weekly feature story is the first of a three-part series on the Surgical Care Improvement Project. The second part of this series will describe tools to manage adverse cardiac events in surgery. The series will conclude with a feature that evaluates tools to help surgeons prevent and treat deep vein thrombosis in surgical patients.

      Initiated in 2003, the Surgical Care Improvement Project (SCIP) partnership is a multi-year national campaign designed to substantially reduce surgical mortality and morbidity through collaborative efforts. Ultimately, the goal of SCIP is to reduce the incidence of preventable surgical complications by 25% throughout the United States by the year 2010. The national partnership comprises 10 different organizations which are committed to improving the safety of surgical care through the reduction of several types of postoperative complications, including—among other complications—surgical site infections (SSIs).

      SSIs Continue to Plague Hospitals

      The CDC estimates that approximately 500,000 SSIs occur each year in the U.S. “Approximately 30 million major operations are performed annually,” explains Dale W. Bratzler, DO, MPH, “and it’s estimated that between 3% and 5% of all patients will develop an SSI. These complications have a tremendous impact, not only on patients but also on healthcare systems. Most studies have suggested that patient mortality rates double when patients develop an SSI. They also substantially increase length of stay, cost of care, and patient morbidity. Furthermore, SSIs increase the need for hospital readmissions and admissions to the ICU.”

      Despite advances in infection control practices, SSIs remain a substantial cause of morbidity and mortality among hospitalized patients. According to Dr. Bratzler, systemic and process changes that promote compliance with established guidelines and standards may help decrease infectious morbidity. “For example,” he says, “appropriate preoperative administration of antibiotics is effective in preventing infection and reducing morbidity and mortality. However, many physicians and hospitals have inconsistent methods of administering these agents.”

      Appropriate Antibiotic Administration is Critical

      Improving the timing, selection, and duration of prophylactic antibiotic administration are among the key quality measures that are essential factors in SCIP to effectively prevent SSIs (Table 1). “Three of the six SSI performance measures that have been rolled out in SCIP relate to antibiotic administration,” says Dr. Bratzler. “The first measure involves initiating the antibiotic dose within 60 minutes before the incision. Study after study has demonstrated that the timeframe before the incision is critical, and administering the appropriate antibiotic can reduce infection rates.”

      It is also important to use prophylactic antibiotics that are consistent with published guidelines from nationally recognized medical groups and professional societies, says Dr. Bratzler (Table 2). “SCIP recognizes that a number of different guidelines have been published with specific recommendations for antibiotics in patients having elective surgery. The key is to ensure that physicians order an antibiotic that is consistent with recommendations in evidence-based guidelines. It’s critical that antibiotics which cover the most common organisms encountered at the time of surgery are used so that SSIs can be prevented.”

      Another key SCIP performance measure regarding antibiotic use in SSIs is to discontinue these drugs within 24 hours of elective surgery and within 48 hours for cardiac surgery. “Numerous studies have demonstrated that giving antibiotics for longer durations does not help lower infection rates,” Dr. Bratzler says. “Data have demonstrated that continuing patients on antibiotics for long durations after surgery can increase the likelihood of antibiotic resistance, further complicating treatment for these patients. This has been consistently demonstrated in studies that have compared a single preoperative dose of an antibiotic with multiple doses after surgery. It should be noted that this SCIP performance measure on antibiotic duration is not trying to change the infection rate. Instead, the purpose here is to reduce the likelihood of resistant infections when one does occur, and to reduce the burden of antibiotic use so that clustering or colonization of pathogens doesn’t occur.”

      Glucose Control, Hair Removal, & Normothermia

      Controlling glucose levels in patients undergoing cardiac surgery, properly removing hair in all surgeries, and keeping body temperatures stable when undergoing colorectal surgery are among the other key SCIP performance measures for SSIs. “We now have strong evidence demonstrating that hyperglycemia in patients having cardiac surgery is associated with higher SSI rates. Keeping glucose under control for 48 hours after cardiac surgery is important because 50% of these patients will develop hyperglycemia. The literature demonstrating the importance of glucose control in surgery is still emerging, but the currently available evidence is strong. Setting up systems for controlling glucose in surgery patients is critical because many practitioners—surgeons, physicians, hospitalists, ICU staff, and other providers—will be involved in and responsible for the management of these individuals during their course of care.”

      Preoperative hair removal has been a customary practice for surgical patients, but studies have since revealed that hair removal may be a contributing risk factor for infections. In fact, CDC guidelines released in 1999 indicated that preoperative shaving of the surgical site the night before an operation was associated with a significantly higher risk for surgical site infections than either use of depilatory agents or no hair removal. “If hair removal is required,” Dr. Bratzler says, “then patients should not be shaved the night before surgery and hair should preferably be removed with electric clippers or use of a depilatory. In fact, it behooves hospitals to remove razors from stock carts and surgical prep kits and to stock operative holding areas with clippers instead.”

      Unplanned perioperative hypothermia during surgery has been linked to significant adverse consequences, including bleeding, adverse cardiac events, altered drug metabolism, and other problems. Hypothermia remains troublesome during the perioperative period despite the availability of technology to prevent it, especially in colorectal surgery. As a key measure in SCIP, Dr. Bratzler says it is important that patients undergoing colorectal procedures experience postoperative normothermia because it can reduce the rate of SSIs. “Standardizing the operative suite ambient temperature, placing warm blankets or forced-air warming blankets on patients upon transfers to operative beds, limiting body exposures, and using only warmed IV, irrigation fluids and inhalation gases can help.”

      Significant Progress Expected

      According to Dr. Bratzler, the SCIP performance measures established for SSIs have important implications and should help reduce the incidence of postoperative infections. “The measures on appropriate antibiotic use as well as glucose control, hair removal, and body temperature are all controllable risk factors that relate to SSIs. All healthcare team members and hospital administration should become familiar with these indicators and use them to improve their practices. Early data collected from SCIP has demonstrated that participating institutions are steadily improving their practices, and more progress is anticipated in the future.”

      Dr. Bratzler has indicated to Physician’s Weekly that he has or has had no financial interests to report.