National Initiative Strives to Reduce Surgical Site Infections

September 1, 2004

National Initiative Strives to Reduce Surgical Site Infections

National Initiative Strives to Reduce Surgical Site Infections

By Kelly M. Pyrek

Perioperative infections complicate anestimated 2.6 percent of nearly 30 million operations annually, resulting inapproximately 780,000 surgical site infections (SSIs).

Tried-and-true methods of preventing these SSIs with aparticular emphasis on the administration of antimicrobial surgical prophylaxis are being supported by the work of a number of physicians, nurses andinfectious-disease experts from the entire healthcare continuum. Their effortsto reduce the 40 percent to 60 percent of preventable SSIs have culminated inthe Surgical Infection Prevention project (SIP), a national quality improvementinitiative launched two years ago and co-sponsored by the Centers for Medicare& Medicaid Services (CMS) and the Centers for Disease Control and Prevention(CDC). SIP is conducted through the CMS Health Care Quality Improvement Program,and its goal is to reduce the occurrence of post-operative infection byimproving the selection and timing of preventive antibiotic administration.

In June, the authors of all current U.S. surgical infectionprevention guidelines, along with professional organizations that are involvedin surgical care, released a joint advisory statement on infection prevention,Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical InfectionPrevention Project.

This advisory statement is the result of a year-long effortby leading national medical organizations to identify best practices forpreventing surgical site infections, says Peter Houck, MD, leader of MedicaresNational Surgical Infection Prevention Project. We are pleased that thisstatement has been accepted by more than 20 medical societies and nationalhealthcare organizations.

Participating organizations were American Academy ofOrthopaedic Surgeons, American College of Obstetricians and Gynecologists,American College of Surgeons, American Geriatrics Society, American Society ofHealth-System Pharmacists, Infectious Diseases Society of America, The MedicalLetter, Society of Thoracic Surgeons, Surgical Infection Society, Society forHealthcare Epidemiology of America, and VHA, Inc.

Representatives of these and other organizations serve on theprojects expert panel. The expert panel meets monthly to provide clinicalexpertise and support to the CMS/CDC steering committee on project features,such as operations/procedures, quality indicators, support and collaboration.The expert panel is comprised of leading infectious disease and surgical expertsrepresenting more than 16 national organizations.

When SIP was launched in 2002, clinical experts identifiedareas of inconsistency among the existing surgical infection prevention practiceguidelines, as well as issues that were not addressed in any of the guidelines.Areas of focus included selection of antibiotics for patients with certainantibiotic allergies, and the duration of antibiotic therapy after completion ofthe operation.

Project leaders hosted a forum of national medicalorganizations in January 2003 which led to initial consensus regardingantibiotic selection, timing, and duration for certain surgeries. The resultingadvisory statement was accepted by all of the participating organizations, aswell as additional national medical organizations. The principle concepts comingout of this forum were recommendations that antibiotics used to prevent surgicalinfection should be given during the hour before surgery and that they shouldnot be used for more than 24 hours after the end of the operation. Timelyadministration results in more effective infection prevention, while shortduration is less likely to produce antibiotic-resistant bacteria, expertsconcurred.

Optimal prophylaxis ensures that adequate concentration ofan appropriate antimicrobial are present in the serum, tissue, and wound duringthee entire time that the incision is open and at risk for bacterialcontamination, Bratzler and Houck1 write. The antimicrobial should be active against bacteria that are likely to be encountered during the particular type of operation being performed and should be safe for the patient and economical for the hospital. The selection and duration of antimicrobial prophylaxis should have the smallest impact possible on the normal bacterial flora of the patient and the microbiologic ecology of the hospital.

One of the things we identified very early in the process ofdeveloping the SIPP was the fact there were quite a few different guidelines forantimicrobial prophylaxis, and we wanted to achieve consistency, says DaleBratzler, DO, of the Oklahoma Foundation for Medical Quality. To some extent,our goal was to simplify the guidelines, get the authors of the guidelinestogether, and in the process of reviewing the literature and talking about theguidelines, we might develop some consensus and consistency in the guidelines asthey were updated. That has definitely happened.

Most importantly, SIP addresses the need to translate clinicalresearch into real-world practice.

I think translating research into practice is a key issue,Bratzler says. As I travel the U.S. speaking about SIP, I frequently point out that the original data (suggesting administering the first antimicrobial dose within the hour before surgical incision) was first published in 1957; it hastaken 40 years to get that evidence into practice. And were still not there.Its critical to take evidence from clinical trials and then get hospitals andoperative teams to apply it to practice. He continues, Its not easywork. In our audit, more than 99 percent of the patients got anantibiotic dose; the doctors almost never forgot to give one, but the timingwas not good. Only about 60 percent of patients got their .rst dose withinan hour before the incision. Its all about empowering someone to make surethe antibiotic is turned on within that hour before incision. Its not thatpeople dont understand and recognize theres real benefit from antimicrobialprophylaxis, but the challenge is putting the system in place to make sure ithappens with every patient.

To that end, a number of hospitals have created regional SIPcollaboratives. One of the most successful has been the Surgical InfectionPrevention Collaborative Northwest (SIP NW) in which 11 Washington statehospitals have worked for the past year to reduce their SSI rates. The major goals of the SIP NW have been the properadministration of antibiotics, along with clipping not shaving thesurgical site, and maintenance of proper body temperature before and aftersurgery.

At the 240-bed Overlake Hospital Medical Center in Bellevue,Wash.:

  • 100 percent of all surgical cases received an appropriate selection of antibiotic prophylaxis

  • 75 percent of patients received antibiotics within an hour before surgical incision

  • 97 percent of patients who received antibiotics had those medicines discontinued within the appropriate 24-hour period after surgery

  • 72 percent of surgical patients had a temperature greater than 36 degrees Celsius

  • 88 percent of surgical patients had their hair removed at the surgical site without shaving

According to thesummary report for the SIP NW Outcomes Congress, in 2002, Overlake had 12 SSIs, and in 2003, that number was reduced to five, equating to a cost savings of$39,000.

At the 142-bed St. Marys Medical Center in Walla Walla,Wash.:

  • Appropriate antibiotic prophylaxis was administered to 100 percent of eligible patients in the pilot group

  • The proportion of patients receiving antibiotic prophylaxis within one hour before surgical incision was increased from 74 percent to 100 percent

  • The percentage of surgical patients with antibiotics discontinued within 24 hours after surgery went from 70 percent to 92 percent

  • The proportion of patients demonstrating minimal heat loss went from 25 percent to 92 percent

  • The proportion of patients undergoing appropriate hair removal at the surgical site changed from 10 percent to 80 percent

St. Marys summary report said, Changes in the perception of acceptable rates of infection have shifted to zero. There are no acceptable rates of healthcare-associated infections.

As Ive traveled across the country, Ive seen a widemix of hospitals participating in these local and regional collaboratives,Bratzler says.

There is a lot of excitement around the collaborative process, bringing people together for the common cause of fighting SSIs. InOklahoma, we started our collaborative on surgical infection prevention andmarketed it to infection control practitioners (ICPs) and operative teams, notnecessarily the same audience we usually would use for most of our qualityimprovement projects. We targeted ICPs because we thought they were veryimportant in terms of helping the hospitals take action on some of theseperformance measures. I think getting ICPs involved is the way its beenacross most of the country.

Houck says ICPs passion about the project is contagious.I spoke at the annual APIC meeting again this year and I was very impressedwith their enthusiasm. A lot of them were already working on SSI-preventionprojects, and many of them were participating in a SIPP collaborative. I thoughtthere was a terrific amount of energy there. The infection control communityreally sees SIP as a way to prevent infections as well as a way to get into thehealthcare quality-improvement world. Its no surprise, since often times,ICPs are the ones who actually are effecting change at their facilities.Physicians will be involved, but it seems to me, the nurses are actuallyspearheading the projects.

Bratzler concurs. The vast majority of surgeons areordering antibiotics, but we know they are not being given at the appropriatetime; weve seen operative teams take ownership of the fact they need to putthe systems into place, he says. Whether its the surgeon, or someoneelse from the OR staff, somebody has to take the responsibility of ensuring thatthe antibiotics get administered. In the infection control community, mostalready have an ongoing program for surveillance for SSIs, and many of them aredoing things beyond what were looking at in the national project, otherthings that reduce infection rates. ICPs have a key role in terms of theirongoing surveillance.

The next phase of the national initiative, called the SurgicalCare Improvement Project (SCIP), is under development, according to Bratzler andHouck. SCIP is a broad coalition of partners focused on improving surgical carein the U.S. through the prevention of complications associated withsurgery.

SCIP will take the measures we have been using for SIP,which are entirely for antimicrobial prophylaxis, and expand them to address anumber of post-operative complications such as acute myocardial infarction orpost-op pneumonia, Houck says. Through SCIP, we will continue to work onSSIs, but the scope of what were going to address will expand considerably.

Houck estimates that SCIP will be ready by the fall of 2005,and currently, the group is working on establishing performance measures,collecting data, and coordinating activities of all of the partners.

Whats so exciting about SCIP is the intense and intimateparticipation by all the organizations, as well as the spread of the workoutside the Medicare population, Houck adds.

Formore information about the National Surgical Infection Prevention Project, go towww.medqic.org/sip.