By Kelly M. Pyrek
Now that surgical site infections (SSIs) are being targeted for reduction by the U.S. Department of Health and Human Services (HHS) in its Action Plan to Prevent Healthcare-Associated Infections, hospitals have even greater incentive to address orthopedic-related SSIs which present immense costs and significant morbidity and mortality. According to the Guide to the Elimination of Orthopedic Surgical Site Infections, APIC's latest elimination guide released in January, it is estimated that between 6,000 and 20,000 orthopedic SSIs occur annually, increasing the average hospital stay by two weeks and increasing the costs of these procedures by as much as 300 percent.
This new guide is designed to provide practical tools, strategies and resources for infection preventionists, care providers, surgical staff and quality improvement teams to use in their efforts to eliminate orthopedic SSIs, says Linda Greene, RN, MPS, CIC, director of infection prevention and control at Rochester General Health System in Rochester, N.Y., lead author of the guide. The guide focuses on orthopedic surgeries in clean, primarily elective cases, with an emphasis on joint replacements but an applicability to other orthopedic surgeries. The guide emphasizes that, "Because orthopedic surgery is performed in a variety of inpatient and outpatient settings, the need for increased vigilance, strict adherence to aseptic technique, attention to adequacy of reprocessing, and management of intraoperative breaches of sterile technique are vitally important to ensure a safe and consistent standard of care. Breaches of sterile technique, inadequate sterilization of equipment and lack of adherence to aseptic technique have been associated with outbreaks of SSIs."
"One of the key things about these elimination guides is that they contain practical tools for infection preventionists," Greene says. Many scientific guidelines and practice recommendations already exist, but many operating room professionals and infection preventionists are looking for instruction on implementation of day-to-day practices. AORN shared its checklists with us, and together we provide the 'how' in these processes -- the nuts and bolts of how to conduct risk assessments, how to time the antibiotic prophylaxis and other practices that are extremely important to SSI prevention."
The guide notes that, "An effective facility-wide infection prevention and control program is composed of many components and interventions that can reduce the risk of infection in surgery patients. This includes an understanding of the surgical population and the associated risk factors, effective methods for case finding, expertise in the analysis of data, effective communication of outcomes, and implementation of evidenced-based strategies to improve outcomes. Central to this theme is collaboration. In order to ensure patient safety and optimum patient outcomes, IPs, surgeons, perioperative staff, nurses, and all members of the healthcare team must work together to implement evidence-based practices that minimize the risk of infection."
SSI prevention is a tall order, Greene admits, emphasizing that collaboration among stakeholders is essential. In fact, Greene acknowledges that the very publication of the new guide signals a greater need and opportunity for the infection prevention and surgical services departments to work together more than ever before.
"Getting out of one's comfort zone is important," Greene says. One of the things we talked about in the webinar was getting out of your comfort zone. I think some infection preventionists don't always understand the processes occurring in the OR, and I believe it is equally important for
the OR staff to understand what infection preventionists do. And both parties need to understand the outcome data. The current patient safety movement requires a lot of collaboration and connecting the dots, so that healthcare professionals understand that what they do for a patient today connects to an outcome down the line. Oftentimes healthcare professionals work in silos, especially in the OR because it is a restrictive area where you don't necessarily interact as often as or as much with other members of the healthcare team."
The guide advocates unity, and notes, "In the dynamic and often hectic surgical practice environment, the importance of teamwork as a factor in infection control and prevention must be recognized. There is increasing evidence that teamwork and collaboration are essential to improved patient outcomes … There are two important aspects of the nature of teamwork: the individual’s ability to function as a member of the team; and the entire team’s ability to function as an efficient collective entity. There are several factors that influence the team’s performance, such as task demands, team composition, and the organizational context. Teams must be able to accomplish tasks as a unit, although team members may have individual tasks that change from member to member and from day to day. Consequently, each team member must possess general team competencies and skills that can be transferred from task to task and from team to team. One primary objective in team training is encouraging participation from individual team members, while developing the knowledge and skills necessary to successfully perform as a group member. As a result, team training, involving perioperative staff, surgeons and other members of the surgical team, has become routine in many organizations throughout the country. In the surgical practice setting, the traditional hierarchical culture has been blamed for the failure of individuals to function as teams in this environment."
Greene says it is imperative for all members of the OR team, surgeons included, to be held accountable. "I think it starts with leadership," she says. "As an institution becomes a very high-quality organization, there is greater leadership accountability and part of what happens is that administration holds the chief of surgery accountable, who in turn holds his surgeons accountable." Greene points to another mechanism for accountability based on current pay-for-performance policies: "Central-line infection rates will be posted on the Hospital Compare website and then eventually there will be surgical site infection rates posted -- my gut feeling is that orthopedic infections relating to joint replacement in hips and knees might be one area where the rates would be posted on the Hospital Compare website. We also know that the CDC will be working on not just the surgical site guidelines, but on guidelines for hip and knee replacements, and the Institute for Healthcare Improvement (IHI) is focusing on orthopedic infections. So it seems like many things are aligning in terms of a focus on orthopedics. What will happen as a result is administrators will see the value in holding surgeons, along with the entire OR team, accountable. It's a long, slow process; in my own organization I have seen vast improvement and a number of my colleagues have said things are changing and people want to do the right thing -- but we must make it easier for them to do the right thing."
Doing the right thing often depends on good communication and ensuring that information is not hoarded. Greene says that the prevention of SSIs in general and orthopedic SSIs in specific requires infection preventionists and OR nurses to "know what their surgical site infection rates are, what it means for that patient across the continuum of care, and that what they are doing for the patient now impacts outcomes down the road. They must find out what those outcomes are so they can improve their care delivery." Greene adds, "The level of information-sharing varies among hospitals and health systems across the country; in some areas, it may be very, very limited, and OR professionals may only receive an annual in-service on infection prevention. In other institutions there may be a truly collaborative approach. One of the things that we have done in order to be collaborative is ensuring appropriate feedback as well as infection rate information reaches the OR team and its managers, not just the chief of surgery. We want to make certain that this data is shared with everyone in the OR so that there is real-time feedback and people can begin to look at their processes. The other key element is risk assessment, and making sure that everyone is at the table when this is conducted -- so that when I look at the surgical procedures I am going to target this year, I can draw in the OR staff in terms of that communication."
Putting one's epidemiology-related skills to work in the aforementioned risk assessment process is necessary, Greene says, which can lead to a better understanding of the pathogenesis of infection, and ultimately to improved and evidence-based prevention and control strategies. According to the guide, "The rates of SSI following various orthopedic procedures appear to be increased when certain risk factors are present. Risk factors can be either patient- or procedure-specific, and may be modifiable or non-modifiable. With regard to clean spinal procedures, risk factors that have been associated with increased SSI include estimated blood loss of greater than one liter, previous SSI at the operative site, diabetes, obesity, longer procedure times (more than five hours), current smoking, ASA score of three or more, weight loss, dependent functional status, preoperative hematocrit of less than 36, disseminated cancer, elevated preoperative or postoperative serum glucose level, suboptimal timing of antibiotic prophylaxis, and two or more surgical residents participating in the operative procedure. Additionally, posterior approach or combined anterior/posterior approach was associated with higher rates of infection."
With so many "moving parts" associated with orthopedic surgery, the risk of complications and infection skyrockets and it can be challenging, if not impossible, to pinpoint the one contributing factor that tips the balance toward an adverse outcome. As the guide notes, "An SSI is similar to all infections, in that it is typically multi-factorial in origin. The occurrence of a postoperative infection is dependent upon the interaction of patient- or host-related factors, such as host immunity, nutritional status, co-morbid conditions; procedure-related factors, including the presence of foreign bodies and tissue trauma associated with the procedure; microbial properties, such as ability to adhere to tissue or foreign bodies and innate virulence, and appropriate and timely antimicrobial prophylaxis."
"I think there are a number of factors relating to orthopedic SSIs and I don't think you can always detect where or when an adverse outcome develops," Greene says. "What we're seeing is that resistant organisms are much more prevalent in the community, so people often enter hospitals colonized with MRSA or some other pathogen. That organism may be living on the person's skin and not causing them any trouble, but now when you make a surgical incision, you give that organism an opportunity to invade. So the question becomes, are we taking great care with our pre-, peri- and post-op infection prevention practices? Have we applied the skin prep correctly and allowed it to dry? In the pre-op period have we looked for any risk factors the patient may have? Are we looking at the OR environment carefully? There are so many things to look at, so I think SSI prevention requires a multi-factorial approach. In the OR, a perfect storm is brewing -- you have a colonized patient, you are hurrying to turn over rooms, maybe the prep doesn't dry adequately, maybe there is something to do with surgical technique or a lack of timely antibiotic prophylaxis. I'm not sure if we could say just one thing contributes to SSIs, as these factors are all things we must think about. And the more we standardize our processes the more we make sure we can close the gap on any deficiencies in practice. "
As the guide explains, "An effective infection prevention program for orthopedic surgery has many components. Implementation of, and consistent adherence to, evidence-based practices to reduce the risk of SSI is key to success. However, it is important to conduct a thorough risk assessment and to collect and analyze surveillance data to drive improvements. Surveillance data can provide measurable results to evaluate the effectiveness of infection prevention interventions." The guide defines a risk assessment as "a systematic evaluation for identifying risks in the healthcare setting. Infection control assessment identifies risks for acquiring or transmitting infections, and includes strategies for prioritizing and mitigating those risks. A risk assessment can be either quantitative or qualitative, and can include both process and outcome measures."
Risk assessment is just part of the strategy; surveillance must be conducted to produce objective data that is in turn used to improve patient outcomes. According to the guide, surveillance helps to determine baseline rates of adverse events (including HAIs); detect changes in the rates or distribution of these events; facilitate investigation of significantly increased rates of infection; determine the effectiveness of infection prevention and control measures; monitor compliance with established hospital practices; evaluate changes in practice; and identify areas where research would be beneficial. The guide explains, further, "There are many factors to consider when designing an orthopedic surgery surveillance program. The first steps are defining the population at risk and determining the resources available. For example, based upon the risk assessment, consider whether all orthopedic surgeries will be monitored or if just selected procedures such as total hip surgeries or total knee surgeries will be followed. Often, if opportunities for improvement are identified in one procedure, such as total hip replacements, then process improvement activities that are identified can be applied to the service as a whole. Criteria used to conduct surveillance must remain consistent."
In addition to addressing these infection prevention program-related tasks, the guide reviews key strategies for the pre-operative preparation, underscoring practices such as patient preoperative skin preparation and nasal decolonization, plus reviews of issues in the perioperative setting, including skin antisepsis, antibiotic prophylaxis, and other intraoperative factors, and the post-surgical period. One risk factor that is popping up on infection preventionists' radars is environmental hygiene in the OR and the impact that it can have on a surgical case. "I think that historically, ORs have had pretty good guidelines regarding the cleaning and disinfection of the surgical suite, but now we must think of the future OR environment. For example, we are moving toward an increasing number of electronics in the OR, and people are also bringing computers on wheels into the OR and mobile devices, objects that historically have not been in the OR. We have to think about the level of contamination present and whether or not these computers and devices have been wiped between cases. We must broaden that focus and say 'OK, what's our patient population and in terms of environment, what has changed?' It's those kinds of things we didn't give a thought to 10 years ago."
Greene continues, "There are many interventions out there now; people are looking into germicidal UV light to decontaminate surfaces, for example. In many cases we don't measure how well we are cleaning -- are we getting all of the organisms, especially after a very contaminated case? A method such as bioluminescence technology, where one swipes the surface to see what organic count is after cleaning, has been used in our facility on computer keyboards. It's not something you use all of the time but it's a wonderful tool. Part of what we need to do is engage every team member to understand that awareness about cleaning can be everyone's responsibility. One thing we have done that I think has worked well is getting our environmental services personnel actively involved -- they sit in on discussions, and it's amazing what can happen when you begin to engage all kinds of stakeholders; you start thinking about things you hadn't thought about before."
