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.
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 individuals ability to function as a member of the team; and the entire teams ability to function as an efficient collective entity. There are several factors that influence the teams 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."
And as infection preventionists ponder those new challenges, the guide reminds practitioners of the lessons learned:
- In todays surgical practice environment, challenged by newly recognized pathogens and well-known pathogens that have become resistant to current therapeutic modalities, all members of the healthcare team must remain aware of the impact of HAIs in orthopedic surgical patients and must implement evidence-based prevention strategies to reduce the incidence of HAIs.
- Given the associated unnecessary morbidity and mortality that could be prevented, the suffering that could be eliminated, and the money that could be saved, no healthcare organization can risk ignoring the benefits of effective strategies aimed at preventing HAIs.
- Effective teamwork and communication among all members of the surgical team is an important factor in improving patient outcomes.
- Various tools and checklists, which can be customized by the facility, have been developed to assist in preventing SSIs in orthopedic surgical patients.
- Perioperative personnel and IPs are in a unique position to provide leadership in improving the quality and safety of patient care; by forming an alliance, they can be they can be effective change agents in product evaluation and selection, thereby promoting positive patient outcomes.
Experts Weigh in on SSI Prevention
ICT asked clinical experts to share their thoughts and best practices for surgical site infection (SSI) prevention.
John S. Foor, MD: Proper skin antisepsis is an important component of the prevention of surgical site infections (SSIs). Based on my experience as a vascular surgeon, and my interpretation of the current guidelines and data, following are some key practices to consider.
Antiseptic showers: Patient skin preparation begins at home. Antiseptic showers have been shown to reduce the microorganism levels on patients skin. Due to its residual antimicrobial effect, I instruct patients to have two chlorhexidine gluconate (CHG) antiseptic showers the day before surgery once in the afternoon and then again in the evening before going to bed. I give the patient an antiseptic CHG scrub brush as well as detailed instructions on effective showering techniques.
Skin preparation: There are three common choices for skin preparation iodine-based products, alcohol products and products with a combination of CHG with alcohol. While all have benefits, my preferred antiseptic is a combination of 2 percent CHG in 70 percent isopropyl alcohol (ChloraPrep) due to the combined immediate (by alcohol) and persistent (by CHG) action against microorganisms that increase the risk for SSIs and bloodstream infections (BSIs). Further, studies have demonstrated that CHG in the solution provides continued activity even in the presence of protein-laden body fluids, specifically blood. Literature demonstrates that iodine-based antiseptic products can be neutralized in the presence of body fluids, meaning the patient would not realize the full potential benefits of antimicrobial activity. In addition, a recent study published in the New England Journal of Medicine demonstrated that preoperative use of 2 percent CHG/70 percent isopropyl alcohol reduced total SSIs by 41 percent compared to use of povidone-iodine solution.
Incise drapes: During operative procedures, utilization of skin barrier drapes has been shown to provide a sterile operative field, which does decrease the risk of potential microbial contamination of the surgical field. This can also extend to potentially reducing the risk of contamination of prosthetic devices, e.g., heart valves, vascular grafts, and joint prosthetics. Therefore, the use of antimicrobial incise drapes have significant potential to decrease the development of SSIs.
While your facility likely already has a robust set of measures in place to prevent infections, I encourage you to take stock of your current practices and systems and evaluate the data supporting various prevention protocols. This will contribute not only to improved patient care, but also to the financial health of your institution.
John S. Foor, MD, is a vascular surgeon and infection prevention specialist at Vascular surgeons of Ohio, Mount Carmel Medical Center in Columbus, Ohio.
1. Centers for Disease Control and Prevention. Guideline for Prevention of Surgical Site Infection, 1999. Infect Control Hosp Epidemiol 1999; 20:247-280.
2. Garcia R, Mulberry G, Brady A, Hibbard JS. Comparison of ChloraPrep and Betadine as preoperative skin preparation antiseptics. Poster presented at 40th annual meeting of the Infectious Disease Society of America. Oct. 25, 2002.
3. Data on file. Enturia, Inc.
4. Gottardi W. Iodine and Iodine Compounds. In: Block SS. Disinfection, Serilization, and Preservation. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:159-183.
5. Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010 Jan 7;362(1):18-26.
Michelle Hulse Stevens, MD: Perioperative preparation is a complex process. The time involved in preparing the operating room and patient are scrutinized because efficiency and optimal patient safety are paramount. Patient preoperative skin antisepsis is only one process that takes place.
The skin is the largest body organ and is important for infection prevention. Because the patients own skin is often the source of bacteria for surgical site infections, disinfecting the skin by reducing bacterial density to the lowest possible level prior to surgery is important since skin cannot be sterilized. Using showers/wipes prior to surgery cleanse the skin and if the product contains an antiseptic agent starts the process of skin disinfection. Once the patient is in the operating room the preoperative skin antiseptic (prep) must have immediate bacterial kill and persistent activity.
Isopropyl alcohol provides immediate bacterial kill and when combined with chlorhexidine gluconate or iodophor there is persistent broad spectrum antisepsis. Generally speaking, using one of these combinations is widely supported by evidence based guideline generating organizations including CDC, SHEA, IDSA, AORN, and most recently, NQF. Currently no one prepping agent has been found to be superior.
It is important to apply the antiseptic skin prep solution following manufacturers directions for use to achieve the expected level of bacterial kill. Not all preps have the same application instructions. For example, iodine povacrylex/alcohol directions state: paint a single uniform coat, allow to dry, while chlorhexidine/alcohol preps have two sets of directions: scrub for 30 seconds on a dry site and 2 minutes on a moist site, allow to dry. These directions are required to meet the FDA efficacy criteria.
Until further evidence is available, where applicable, choose a surgical prep that contains isopropyl alcohol, apply the product correctly and consider the health economics of all preps used in the operating room.
Michelle Hulse Stevens, MD, is medical director of the Infection Prevention Division of 3M Healthcare.
Caroline Ginn, RN, BSN, CNOR: Surgical drapes are among the most critical barrier protection products in the operating room. Selecting drape products that help prevent the spread of infectious agents involves an in-depth understanding of how well different fabrics prevent fluids from striking through. The Association for the Advancement of Medical Instrumentation (AAMI) ratings for drapes serves as an effective guideline; however, it is necessary to understand the ratings in order to make the most informed decision.
To be rated at a particular AAMI level, with one being the lowest protection and four being the highest, a drape or gown must pass fluid resistance and viral penetration tests in the "critical zone" of the product at increasing thresholds. The critical zone has been defined by AAMI to represent the area most likely to come in contact with surgical fluids. For drapes, the critical zone is defined as "the area surrounding the fenestration" and on most drapes is defined by the drapes reinforcement. However, it is also important to understand not only how the reinforcement fabric performs, but also how the entire drape will respond to surgical fluids.
Why consider the entire drape? Fluid can contact the drape outside of the reinforced area surrounding the critical zone. For some drapes, the area outside the critical zone is constructed of non-impervious fabrics. During more fluid-intense procedures, it is important to choose a drape that provides the largest critical zone to minimize the possibility of fluid striking through the fabric. For less fluid-intensive procedures or for procedures where the fluid can be more easily directed to fluid collection pouches, clinicians may choose a product that offers drape-ability with the amount of protection they need.
To summarize, selecting barrier products requires an understanding of not only the AAMI ratings, but the advantages the barriers provide outside of the critical zone. The right products can affect the ability to help prevent the spread of infectious agents which can lead to lower infections, better outcomes and lower costs.
Caroline Ginn, RN, BSN, CNOR, is a clinical consultant with Cardinal Health.
J. Hudson Garrett Jr., PhD: One of the most critical interventions in the operating room that can be routinely performed to decrease the risk for cross transmission and development of surgical site infections (SSIs) is routine cleaning and disinfection of the healthcare environment. This includes both medical equipment and environmental surfaces. To maximize the efficacy of the chosen disinfectant product, thorough cleaning must be performed prior to disinfectant use.
Cleaning, as defined by the latest CDC Guideline for Disinfection and Sterilization in Healthcare Facilities released in 2008, is "the removal of foreign material (e.g. soil, and organic matter) from objects, and is normally accomplished using water with detergents or enzymatic products. Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic materials that remain on the surfaces of instruments interfere with the effectiveness of these processes." Cleaning removes bioburden from the affected surface by reducing the number of microorganisms that must be inactivated. Removing bioburden from the surface prior to application of the disinfectant solution will result in increased disinfectant efficacy. It is also important to also apply friction to the area being cleaning and disinfected in order to remove more resistant forms of microorganisms such as spores (i.e., Clostridium difficile) from the surfaces that may not be readily inactivated by the disinfectant. This will decrease the risk for development of multidrug-resistant organisms (MDROs).
The use of an EPA-accepted product with proven efficacy claims is also crucial to selection of the appropriate product. In addition, the infection preventionist should refer to the facilitys risk assessment and ensure that the disinfectant selected has efficacy claims for microorganisms that are routinely found within the facility. Efficacy claims are readily available through the products manufacturer, and should be carefully reviewed prior to introduction of the product into the facility.
A thorough cleaning and disinfection program combined with careful selection of the most appropriate hospital-grade disinfectant will dramatically improve the healthcare professionals daily fight against healthcare-associated infections.
J. Hudson Garrett Jr., PhD, is director of clinical affairs for PDI Healthcare.