Surgical site infections have been a long time threat to the health of Americas patients. Government agencies and infection control practitioners are fighting back and winning.
Two national initiatives that have made great strides in the care of surgical patients and helped to reduce the incidence of surgical site infections (SSIs) are the Surgical Infection Prevention Project (SIPP) and the Surgical Care Improvement Program (SCIP). Dale W. Bratzler, DO, MPH, QIOSC medical director for the Oklahoma Foundation for Medical Quality and a pioneer of the SIPP and SCIP initiatives, published two journal articles in 2006 offering an update and overview of the programs.
The SIPP is a national partnership project, Bratzler explains. We make that distinction because we have 10 organizations that came together to guide implementation of this national quality improvement project focusing on surgical care. We have a steering committee that has representatives from each of those 10 organizations and they meet on a monthly basis to make decisions about implementation about this national project.
Bratzler says that while the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (formally known as JCAHO), through their performance measurement systems, provide the infrastructure for data collection and analysis, the decisions about implementation are largely made by this national steering committee.
This is a project that grew out of the work we started in 2002 looking at use of antibiotics for surgical prophylaxis, he continues. It originally was a national program to focus on whether antibiotics were being delivered at the right time, if the right drugs were being used, and whether they were being stopped appropriately in patients that were undergoing surgery. We published that work in 2005. (See ICT editor Kelly Pyreks article on this topic at www.infectioncontroltoday.com/articles/406/406_551topics.html).
Most of the data that I have, looking at whether things are changing or not, comes from the original three measures that focused on antibiotics, because we have been capturing data on those basically since operations performed in 2001. What we have seen over time, is that there has been a progressive increase in the number of hospitals that have been capturing and collecting that data, and actually reporting it.
Bratzler says that in the third quarter of 2002, about 30 hospitals were capturing and reporting data. However, at the end of 2005, that number grew to nearly 1,700 hospitals.
Then, CMS, in its rules for implementation of the Deficit Reduction Act (DRA), basically tied reporting for some of those antibiotic measures to payment for reporting. So, in January of 2006, the number of hospital reporting jumped to 3,247, Bratzler explains. He adds that he expects the number of hospitals collecting and reporting data will meet or exceed the 4,000 mark by July 2007.
The implementation nationally of the SCIP project started in 2006 for hospitals. It expands the list of perioperative surgical care that the SIPP initiative began. SCIP still focuses on prophylactic antibiotics to prevent SSIs, but other processes of care including control of the patients blood sugar; avoiding the use of razors; and finally, keeping patients warm in the operating room (OR) also are included in the initiative.
We are also now focusing on deep vein thrombosis (DVT) and pulmonary embolism, Bratzler adds. We look at whether patients having surgery are receiving appropriate forms of prophylaxis to prevent deep vein thrombosis. Those measures now are endorsed by the National Quality Forum and were effective January 2007. They have been added to the list of measures that hospitals can report if they want to get their full Medicare payment update.
Other new measures are on the horizon. The last measure that hospitals can start capturing the data on is the use of beta blockers. We have hospitals looking at the use of beta blockers in those patients that come into the hospital who are chronically taking beta blockers. That measure is not publicly reported yet because it hasnt gone through the National Quality Forum process yet, but we think it will be.
Bratzler adds that the use of Foley catheters may be another focus in the near future to reduce urinary tract infections.
Right now, SCIP is an expanded set of nine measures that are captured around perioperative surgical care. We know that large numbers of hospitals now are routinely looking at their medical records and capturing this data and submitting it. And hopefully, were seeing lots of hospitals improve what they are actually doing rather than just capturing the data. Hopefully they are actually improving the quality of care.
Bratzler points out that is exactly what has been proven with the antibiotic measures. When we first started the project, only about 56 percent of patients got their antibiotic started within the hour before the surgical incision was made; that number is now approaching 80 percent, Bratzler adds.
In terms of stopping antibiotics, in 2001, it was found that only about 41 percent of the patients had their antibiotics stopped within 24 hours of the end of surgery. The most recent numbers are up around 72 percent. So care practices have clearly changed over time, Bratzler adds.
He also admits the initiatives arent free of challenges. For instance the data collection can be a very challenging task for the participating facilities, and it can be expected to become more challenging as the SCIP initiative evolves.
The other thing is that with all of our performance measures for hospitals it is very challenging keeping them up-to-date. Just because of the infrastructure to capture that data, it takes us anywhere from six to 11 months typically to actually incorporate new science into these performance measurement tools.
Bratzler says what has proven most successful, and where the most activity is currently focused, is streamlining the use of prophylactic antibiotics and the DVT measure. He adds that the assigning of the delivery of the antibiotics is what is grabbing the most attention currently. In most cases the duty is assigned to when the patient enters the OR and is more commonly being tasked to the anesthesiologist, he concludes.
One Such Case Study
Jan Fitzgerald, RN, MS, director of quality and medical management at Baystate Medical Center in Springfield, Mass., has been participating in SIPP and now SCIP since its inception. Baystates improved methods have made such an impact that the hospital graces the Institute of Healthcare Improvement (IHI)s Web page on SSIs.
In 2002, Fitzgerald and her colleagues at Baystate started with SIPP. Baystate was the Mass. representative on the SIPP steering committee. The representatives of Baystate attended training sessions that featured leading experts in not only the science behind reducing surgical infections, but the experts in the improvement methodologies.
They gave us the science to make the changes and they gave us the models to make changes as well, Fitzgerald shares. I think hospitals should be thinking about doing everything they can to ensure patients get everything to prevent them from having a hospital acquired infection or event. Our hospital participating in the SIPP collaborative and then the SCIP collaborative has been a really good thing because it really validated to us that our hospital is on the right track when it comes to caring for patients. When the calls for participation came out we were happy to join.
In August of 2002, Fitzgerald says the team at Baystate began by initiating the prophylactic antibiotic measure. After some tweaking here and some changes there, the hospital decidedly ended up with the anesthesiologist administering the antibiotic in the OR prior to the first surgical incision. We took off when we started doing that. They were tremendous at it, Fitzgerald asserts.
We have extremely high levels of antibiotic administration since we adopted that model, she continues. It wasnt perfect all the way and it took us a little bit of measuring and talking and measuring and talking, and showing the anesthesiologists how well they were doing, but now it is actually embedded right into their practice and their culture and they do it all the time now.
In the model that we have for anesthesiology, our anesthesiologists go to different sites across the hospital so they take that practice with them. When we started, it was just in one of the ORs, but because the anesthesiology team goes from one OR to all the different ORs, they actually spread that change of them administering the antibiotic within 60 minutes prior to incision as they move from location to location.
Our rates now across all of our operating areas is actually very high (for antibiotic prophylaxis).
Fitzgerald says they also spent countless hours educating not only the staff, but the surgeons as well. In our institution, our surgeons are responsible for picking the drug, so we made sure they had the information for picking the right drug for the procedure as well as the patient, she explains.
Changes were made to the hospitals forms that are used when booking cases to aid in the surgeons picking the right antibiotic. In addition, Baystate shaped a computerized order entry system that enabled them to lock down and ensure that the antibiotic chosen by the surgeon was in fact the correct one to use based upon the procedure being performed.
We took all the razors out of the hospital and we had clippers in all the rooms so patients were clipped instead of shaved. The other thing was heightened awareness about temperature; making sure patients were kept warm throughout their case, Fitzgerald adds.
Last was the antibiotic duration. The prophylactic regimen is to be discontinued within 24 hours of the surgery end time. That has been the toughest thing to move forward because we had a lot of surgeons who had no infections in their patients so its hard to move somebody if nothing is wrong. We actually have gotten everybody now to stop at 24 hours using the science that continuing antibiotics beyond the incision being closed doesnt impact the rate of infection.
Fitzgerald explains that when they began participating in SIPP in 2002, the measures were identified as interventions that hospitals could choose to put in place to reduce infection. We chose to put them all in place, she emphasizes. Some of them have stronger evidence and more studies and more observational randomized trials than others, and others were just kind of like If this works in pig studies
As time passed, and the changes became increasingly beneficial to both the hospital and the patients, Baystate became more involved. Then, SIPP evolved into SCIP and since, Fitzgeralds facility has taken on the additional measures for reducing postoperative cardiac events in patients at risk and reducing postoperative DVT.
Since we started, we actually are experiencing the lowest rates of surgical infections that we ever have had since we began tracking. During the last two to three years we have had infection rates of between 1 percent and 1.5 percent. We do quite a bit of surgery here so thats pretty remarkable, Fitzgerald asserts.
She says their success is a direct relation to the proactive nature of the Baystate team, and that they all are committed to focusing on the next steps of SIPP into SCIP. The challenges going forward are real, Fitzgerald warns, but she explains that part of the challenge is simply sustaining the high levels of performance. Once you get going and you have done it for a long time and you are doing very well. Youre at 99.9 and you drop to 98.9 and youre kind of like Oh drats, what happened? Sustaining the energy is always kind of tough going forward. Anytime we have any kind of a dip, we always do an investigation to see what happened. Constant communication and interaction with all members of the hospital team must remain constant, she adds.
Bratzler explains that the other big challenge in the initiatives pertains to outcomes measures. If I were to ask the steering committee what they would like to see most as we move forward, it would be outcome measures, he says. The steering committee from the outset has said we need to be looking at outcomes; the things that patients care about. Its very challenging to do that, but we think it is a very important place to go.
He continues, The SIPP and the subsequent SCIP represent a new frontier for the Medicare program as far as measuring hospital quality. There is now a real commitment at looking at surgical care, surgical processes of care, surgical outcomes, and eventually surgical efficiency measures (i.e. whether patients being cared for appropriately, and are being cared for in such a way that doesnt require them to be re-hospitalized). I think there is a real commitment now to focus on improving the quality of surgical care.
The SCIP goal is to reduce the incidence of surgical complications nationally by 25 percent by the year 2010.
Prophylactic Nasal Decolonization
Infection control practitioners (ICPs) and epidemiologists across the nation and across the globe are arming themselves in their fight against SSIs. It is well known that Staphylococcus aureus (S. aureus) is a common cause of postoperative SSIs. Nasal colonization by this organism has been found to increase a patients chances for developing such infections. So, it only makes sense to investigate what can help reduce this likelihood. Researchers are quickly figuring out that a simple prophylactic treatment with nasal mupirocin for S. aureus-colonized patients prevents such postoperative infections from occurring.¹ This hypothesis has been studied heavily over the past few years.
The application of intranasal mupirocin calcium ointment 2 percent has been shown effective for the eradication of nasal colonization of most strains of methicillin-resistant Staphylococcus aureus (MRSA) both in vitro and in clinical studies, according to GlaxoSmithKlines product leaflet for its Bactroban Nasal® product. The products indications specifically state it is for use in adult patients and healthcare workers (HCWs) to aid in the reduction of outbreaks of MRSA.
Mary Nicholson, RN, BSN, CIC, an infection control practitioner at the Christ Hospital in Cincinnati, set out to determine whether the practice really works to reduce actual SSI rates. At the Christ Hospital, Nicholson notes that S. aureus accounted for more than 80 percent of sternal wound infections in cardiac surgery patients prior to the inception of this study.² Approximately 700 cardiac surgeries are performed each year at the Christ facility, with an associated infection rate of 1.8 percent per 100 procedures performed.
In an attempt to reduce this rate of S. aureus sternal wound infections, Nicholson investigated the use of prophylactic intranasal mupirocin. Each cardiac surgery patient was nasally cultured before entering the OR, and then intranasal mupirocin was applied and continued every 12 hours. The mupirocin was discontinued if the culture returned negative, but was continued for seven days when the culture returned positive. Interestingly, the cultures showed a 21 percent carrier rate.
Nicholson noted a decrease in S aureus-associated SSIs after implementation of the prophylactic treatment program. Impressively, the case rate dropped to 0.37 percent per 100 procedures over a 17-month period.
In a study conducted at the University of California, San Francisco, the cost effectiveness of the use of mupirocin in reducing S. aureus-related SSIs was investigated as was the cost effectiveness of varying levels of screening prior to administration of the treatment.³ Using a cost-effectiveness analysis, the researchers compared the following three strategies:
1. Screen with nasal culture and give treatment to carriers
2. Give treatment to all patients without screening
3. Neither screen nor treat
Lisa Young, MD, an infectious disease specialist with Greater Denver Infectious Disease Specialists, was the leading researcher of the study. Essentially the study is a computerized model, she explains. We didnt actually go through and screen these patients. We looked at all the costs associated with screening patients and administering mupirocin and then all of the costs associated with outcomes of whether they had SSIs or whether they didnt.
The study looked at the perspective of society so it took into account what the patient had to go through to get screened; what the cost associated with the patients outcomes would be if they required home health care for a SSI. We tried to take into account all the different factors both for the hospital and for the patients and included taking into account the amount of time it takes to screen people or to apply the mupirocin.
Both the screen and treat strategies were found to be cost effective. It was actually cost saving; which is relatively unique because a lot of interventions we look at will actually cost a certain amount of money, Young explains. This actually saved regardless of whether you did a screen and treat or whether you just treated everybody with mupirocin.
Young explains that the program is cost saving due to SSIs being a very expensive complication to treat.
The University of Leeds used mupirocin as part of their battle against MRSA SSIs. Patients there received perioperative prophylaxis with nasal mupirocin for five days, and a shower or bath with 2 percent triclosan before surgery.
After introduction of this treatment plan, the researchers noted a marked decrease in the incidence of MRSA SSIs from 23 SSIs per 1,000 operations in the six months prior to 3.3 and 4, respectively, in subsequent consecutive six-month periods.4 The same researchers later set out to ensure their successful prophylactic treatment with mupirocin was not causing an increase in resistance.5
They found that in the four year study period, there were no trends toward increased prevalence of mupirocin resistance. The results of phage typing did not support the clonal spread of resistant strains, the researchers wrote, leaving them to conclude, Despite four years of use, there was no evidence of sustained emergence or spread of mupirocin resistance.
Young agrees that the rate of resistance is very low. Its only when people are chronically placed on mupirocin that we see a lot of resistance, she asserts.
It is also interesting to note that one French hospital found the incidence of S. aureus nasal carriage among its hospital personnel to be 20 percent. After obtaining swabs from personnel, researchers found a higher percent of carriage among doctors (5 tested positive out of 16 tested; for an average of 31 percent) than among nurses (3 tested positive out of 24 swabbed; for 12.5 percent).6
Young says a treatment program for HCWs with mupirocin would not be nearly as feasible as the prophylactic treatment regimens for the patients because as she explains, mupirocin only temporarily eradicates colonization. For a patient who is going in for major surgery, they have this sort of defined risk period where they are going to get an SSI, so if you can eradicate the colonization just during that time period, then you may prevent the infection. Its really hard to eradicate staph carriage on a long term basis. After about three weeks or so people become recolonized.