By Kelly M. Pyrek
A hospital's surgical services department represents one of the most sizable challenges to infection prevention and control. Surgery also presents a significant risk to patients, and together, the operating room should be on the infection preventionist's radar for healthcare-associated infection (HAI) mitigation and elimination.
Research indicates that SSIs are the most common type of hospital-acquired infection. SSIs account for 20 percent of all infections that occur in the hospital setting. Although most patients recover from an SSI without any long-term consequences, they are at a two- to 11-fold increased risk of mortality. Furthermore, SSIs are the most costly of all hospital-acquired infections. With an annual estimated overall cost of $3 to $5 billion in the U.S., SSIs are associated with a nearly 10-day increased length of stay and an increase of $20,000 in the cost of hospitalization per admission. As many as 60 percent of SSIs are considered to be preventable. Now that the Centers for Medicare and Medicaid Services no longer pays additional amounts for the cost of treating conditions acquired in a hospital, SSIs have been targeted not only to improve clinical quality, but also to protect hospital reimbursement.
As the time of writing, the Centers for Disease Control and Prevention (CDC)'s HICPAC has not released its long-awaited update of its 1999 surgical site infection (SSI) prevention guidelines. In the meantime, newly released guidelines for the prevention, detection and management of SSIs issued by the American College of Surgeons (ACS) and the Surgical Infection Society (SIS) provide a comprehensive set of recommendations clinicians can use to optimize surgical care and educate patients about ways to contribute to their own well-being. The guidelines, titled "American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update," are based on a review of the best available research and clinical practice experience and update previous sets of recommendations on detecting and preventing SSIs from professional clinical and hospital societies.
The new guidelines were developed by investigators from the ACS and SIS, who reviewed evidence from the clinical literature as well as consulted outside content experts to reach consensus across the full course of treatment of surgical patients, including prehospital preparation, hospital interventions, and post-discharge care.
"The guidelines give clinicians step-by-step ways to address SSIs, because there is no single specific fix to the problem and there are many factors in the processes of care," says principal author Therese M. Duane, MD, MBA FACS, FCCM, vice-chair of quality and safety of the department of surgery and medical director of acute-care surgical research, Texas Health Care, at John Peter Smith Health Network, Fort Worth.
There are numerous challenges to ensuring compliance with any guidelines, and Duane offers some advice for boosting implementation of best practices for SSI prevention: "Focus on the team approach," she says. "This means having surgeons active and invested in infection prevention and control. Find the champion in your institution who is passionate about it so that he/she may be your liaison to the surgeons."
No guidelines are perfect, and there exist SSI prevention-related challenges in the real world of the operating suite that reflect both knowledge gaps and implementation gaps. "There is a little of both," Duane acknowledges. "We are finding that operationalizing guidelines that require coordination between surgeons and anesthesiology to be very difficult. It is two-fold -- making sure everyone understands the science behind the guideline and then secondly- folks taking ownership for the steps even when that means there will be overlap. An example, if the surgeons fail to get the antibiotic ordered – we need our anesthesiology colleagues to dose it anyway with a standardized protocol. There is some resistance to do this but it is necessary to have checks and balances in place."
It remains to be seen if HICPAC’s long-awaited update to its 1999 SSI prevention guideline could conflict with those from the ACS/SIS, especially in terms of unresolved issues. "There will always be conflict as evidence changes and it is often up to the mind of the interpreter," Duane says. "Ultimately if we are all just trying to do the next right thing for the patient then we should see improvement overall."
Let's take a look at the various recommendations of the updated ACS/SIS guidelines.
Hair in the surgical site should be removed only if it would interfere with surgery. Shaving causes microscopic cuts and abrasions, resulting in disruption of the skin's barrier defense against microorganisms. Clippers generally should be used instead of razors to remove hair.
Historically, guidelines have not recommended using antibiotic sutures to decrease SSIs, but there now is considerable evidence to support their use.
Surgical gloves can contain or develop defects. Double gloving decreases the risk of holes to the inner glove, so routine double gloving is recommended to protect the surgeon.
No studies have shown a difference in SSIs between patients who shower as early as 12 hours after surgery and patients who delay showering for more than 48 hours. Early showering does not increase the risk of SSIs and can be encouraged at the surgeon's discretion.
Topical and local antibiotics
Studies of individual procedures have shown promising results when using topical and local antibiotics to reduce infections, but large, randomized clinical trials of a wider range of procedures would be needed before supporting more widespread use or formal recommendations.
Some of the new guidelines call for a change in hospital management to reduce the risk of SSIs. While the presence of diabetes and use of diabetic medications are considered to be risk factors for SSIs, studies show that control of high blood sugar is more important immediately before an operation than over the long term. Research indicates that high blood sugar levels during an operation increase the risk of an SSI; excessively low blood sugar levels increase the risk of adverse outcomes and the frequency of hypoglycemic episodes, but they do not reduce the risk of an SSI. The consensus guidelines therefore set target blood glucose levels at 110-150 mg/dL for all patients regardless of their diabetic status in the immediate preoperative period.
A change in lifestyle habits can help patients reduce their risk of SSI. Recent research corroborates that smokers have the highest risk of SSIs and former smokers are at greater risk of infection than nonsmokers. A consensus guideline therefore encourages surgeons to advise their patients to stop smoking four to six weeks before an operation.
"An important message coming out of these guidelines is that patients have a major role in their own outcomes. That message cannot be underscored enough. Smoking cessation, blood glucose control for diabetic patients, and weight loss are some of the things patients can do to prevent an SSI," Duane says.
Some aspects of surgical management still do not have enough robust, high-quality data to warrant clear recommendations, such as optimal wound care after discharge. "These days, you can do all the right things preoperatively and in the hospital, but if clinicians do not give patients sufficient guidance about wound care and follow-up once they leave the hospital, patients can set themselves up for infections down the line," Duane says. "Trying to make sure patients and their families optimize wound care after they go home is integral to the success of their treatment."
The recommendations on reducing SSIs serve as starting points. These points provide benchmarks against which clinicians can track and trend their outcomes, and they identify for researchers the areas of surgical care that require more study.
"The guidelines show how we in the surgical community can make an impact from a practice and research standpoint," Duane says.