By Susan Cantrell, ELS

You may have heard "The operation was a success, but the patient died" as the punch line of an old joke, but, sadly, it is too often true. Surgical-site infection (SSI) can be a life-threatening complication following a successful operation.

Consequences of SSI

In a study by Leape et al, it was reported that 14% of all adverse events in hospitalized patients were due to SSIs.1 The Centers for Disease Control and Prevention (CDC)’s "Guideline for Prevention of Surgical Site Infection, 1999," noted that SSIs were the "third most frequently reported nosocomial infection, representing 14% to 16% of all nosocomial infections among hospitalized patients."2 The guideline also stated that hospitals in the CDC’s National Nosocomial Infection Surveillance System who conducted SSI surveillance from 1986 to 1996 reported 15,523 SSIs resulting from 593,344 operations. SSIs were the most common nosocomial infection among surgery patients, accounting for 38% of infections. Of these, two thirds of the infections were confined to the incision, with one third affecting organs or spaces accessed during the operation. The deaths of 77% of the patients with SSI were reportedly related to the infection.

Patients experiencing SSI have their hospital stay prolonged by 7.3 days on average, to the tune of $3,152 in extra charges.2,3 Studies by Boyce et al4 and Poulsen et al5 also associate increased length of hospital stay and cost with SSIs. Patients who develop an SSI need, on average, 4.6 more ambulatory-care visits than do patients who escape SSI.6,7 Clearly, SSIs cause substantial morbidity and mortality and create a financial burden on already stressed budgets of healthcare systems.

Interventions to Reduce Rates of SSI

Certain interventions can reduce SSI rates. Method of hair removal, use of appropriate antiseptics to prepare the operative site and for surgical hand scrubs, and the timing of antibiotic prophylaxis should be reviewed to ensure that practices deviating from standard guidelines are not contributing to elevated rates.7

Vicki Brinsko, Infection Control Coordinator, Vanderbilt University Medical Center, Nashville, Tennessee, related how their department made a matrix, basically a check list, comprised of the CDC’s recommendations outlined in the SSI guideline.2 Brinsko explained, "When there is a rise in SSIs, a meeting is called, and we go over the matrix to make sure we are in compliance with the guidelines." Vanderbilt has the necessary steps in place to prevent SSIs, as much as it is within their power. Even religiously using the guidelines will not completely stop SSIs because the infections are transmitted by colonized healthcare workers, and the colonizing germs are endemic to hospitals and other healthcare facilities. The most that can be hoped for is to hold them down. The CDC SSI guidelines are very specific about measures to take to reduce the incidence of SSI.

Timing of Administration of Antibiotics

Often," Brinsko said, "it’s a matter of the timing of administration of antibiotics being off. The CDC recommends antibiotics be given to patients 30 minutes before ‘cut time,’ so that the antibiotic has time to work. Delaying administration of antibiotics can easily become a problem. Sometimes nurses are assigned the task of administering antibiotics, sometimes anesthetists are assigned to do it, and no matter who delivers the antibiotics, there can be reasons it’s delayed. If a previous operation has run longer than expected, for example, that can delay the patient in getting to the operating room, so antibiotics may not be given within the recommended time period." Brinsko also pointed out that "If cutting corners has been a problem, it will be revealed during the investigation of an outbreak."

Limiting Room Traffic

Another area that Brinsko and her team track is traffic in a room. Each time a door is opened, a way is provided for organisms to enter. "You’d be surprised how many times a door is opened as healthcare personnel gather items, such as intravenous fluid solutions, when preparing for surgery; so, we put counters on the door."

Skin Preparation and Hand Cleansing

"Artificial nails are a hot issue. The Association of periOperative Registered Nurses (AORN) says not even to use nail polish, but everybody loves artificial nails. They look great, but if you are in health care and touch patients, especially in the operating room or intensive care unit, do not wear them. Bacteria and fungi, particularly, can grow in the spaces between the nail and the tip of the finger, and scrubbing can’t get rid of these organisms. Operating nurses have to be very cognizant of nail cleansing."

"Skin preparation also is very important, explained Brinsko. "The CDC recommends clipping rather than shaving hair to cut down on infection." Shaving can cut the skin, giving bacteria an opportunity to infect. "Surgical skin prep solutions should be applied in an aseptic fashion, as recommended by AORN."

The CDC also has published a hand-hygiene guideline for healthcare settings.8 Traditionally, a 10-minute hand scrub has been required preoperatively of surgical staff, but the advent of waterless hand solutions has brought about dramatic changes. Carolyn Twomey, clinical nurse consultant for Regent Medical, Norcross, GA, said, "The whole scrub issue has changed so much, the horizon is very different from what it was even a year ago. When the new hand-hygiene guidelines came out in October 2002, it forever changed the way scrub is handled in the operating room for most people. There is a move afoot to use a detergent-based solution for the first scrub of the day and for each case thereafter rubbing hands with an alcohol-based product, as recommended in the [CDC’s] ‘Guideline for Hand Hygiene in Healthcare Settings.’8 Quite a bit of variation is occurring in different operating rooms. There are some who are using the new alcohol-based products on the market without a detergent-based scrub for the first case of the day. There are still a lot of people who scrub, but the trend is moving toward a hand scrub once with a detergent-based cleansing solution, such as Regent’s Hibiclens, followed by a hand rub with an alcohol-based cleanser, such as Hibistat, for each subsequent procedure."

The CDC hand-hygiene guideline highlights the need for persistent and cumulative activity in antiseptic preparations used for surgical hand scrubs.8 Persistent activity is defined as "prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product"; cumulative activity is defined as "a progressive decrease in the numbers of microorganisms recovered after repeated applications."

"Hibiclens has the ability to continue working after the scrub is finished," explained Twomey, "because chlorhexidine gluconate (CHG) bonds to the outermost layer of the skin. Its persistence means that there is a continued log reduction for up to 6 hours after a hand scrub; therefore, if there is a glove-barrier breach during a procedure, both the patient and the practitioner are protected by the lingering scrub product under the glove."

Twomey added, "Hibiclens has a New Drug Application (NDA) registration with the Food and Drug Administration (FDA), because its active ingredient, CHG, is a drug regulated by the FDA. All hand-hygiene products do not have an NDA from the FDA; some hand-hygiene products on the market just meet the requirements of the tentative final monograph."

Managing Hypothermia

Patient warmers* have become a part of the operating room, since, as Brinsko explained, "Lowering body temperature prior to and during surgery is known to increase risk of SSI." Even mild hypothermia can suppress the immune response, increasing incidence of infection.9 Hypothermia has been associated with increased length of hospital stay, increased use of blood products, increased need for mechanical ventilation, increased adverse cardiac events, altered drug metabolism, coagulopathies, and impaired wound healing with increased susceptibility to infection, all of which increase costs.9,10

The American Society of Peri-Anesthesia Nurses’ guidelines10 state that hypothermia averaging only 1.5°C below normal can cause cumulative adverse out-comes, adding as much as $2,500 to $7,000 per surgical patient to hospitalization costs."9 In a study on the costs of maintaining intraoperative normothermia, Mahoney and Odom9 came to the same conclusions and said that "Minimizing adverse outcomes is critical to cost-effective patient care in today’s competitive healthcare environment. The cost of preventing intraoperative hypothermia is much less than the cost of treating the adverse outcomes that affect patients experiencing intraoperative hypothermia. . . . Maintaining normothermia decreases the risk of adverse outcomes and saves time and money for patients, providers, and payers." AORN’s newly released guidelines also note that hypothermia can affect patients’ ability to recover from anesthesia, possibly increasing negative postoperative sequelae.11

Again on the KC product

Most patient warmers use forced-air (convective) heat, but the Kimberly Clark Patient Warming System, formerly the Arctic Sun Temperature Management System, uses conductive heat, said Jay Sommers, PhD, Director, Clinical and Scientific Documentation, Health Care, Kimberly-Clark Corp, Roswell, GA. Gel pads are put on the patient’s back. The pads are pre-warmed and cover about 20% of the patient’s total body surface. Water is pulled through the pads under negative pressure, minimizing the chance of leakage in the event that the pads are punctured or disconnected. Throughout surgery, the temperature of the water is constantly and automatically adjusted in response to the patient’s current temperature and the pre-set target. Just before surgery is finished, warm water is brought into the pads, bringing the patient’s body temperature up to normal. "Patients require less time in the intensive-care unit, experience fewer surgical-site infections, use less blood products, and it costs less money for each patient after using this procedure," said Sommers. A study by Stanley et al12 evaluating the Arctic Sun Temperature-Controlling system during off-pump coro-nary artery bypass (OPCAB) surgery found that "The Arctic Sun temperature-controlling system is more effective than conventional warming methods in preventing hypothermia during OPCAB surgery."

Conclusion

It isn’t reasonable to expect that we’ll never hear that not-so-funny joke that "the operation was a success, but the patient died" ever again, but fortunately there are a number of options, some mentioned here, that can be used by healthcare workers to reduce the incidence. Interventions used to prevent SSIs are employed with patient safety in mind, and of course that is always the most important concern. An enormous bonus is that protecting patients from SSIs clearly translates to substantial savings by healthcare facilities.

REFERENCES

1. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients: results of the Harvard medical practice study II. N Engl J Med 1991;324-377-384.

2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, the Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guideline for the prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20:247-280.

3. Martone WJ, Jarvis WR, Culver DH, Haley RW. Incidence and nature of endemic and epidemic nosocomial infections. In: Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston, MA: Little, Brown & Co; 1992:577-596.

4. Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1990;11:89-93.

5. Poulsen KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. Estimated costs of postoperative wound infections. A case-control study of marginal hospital and social security costs. Epidemiol Infect 1994;113:283-295.

6. Sands K, Vineyard G, Platt R. Surgical site infections occurring after hospital discharge. J Infect Dis 1996;173:963-970.

7. Roy M-C, Perl TM. Basics of surgical site infection surveillance. In: Herwaldt LA, Decker MD, eds. A Practical Handbook for Hospital Epidemiologists. Thorofare, NJ: SLACK Inc; 1998:99-114.

8. Boyce JM, Pittet D, Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(RR 16):1-52.

9. Mahoney CB, Odom J. Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs. AANA J 1999;67:155-163.

10. American Society of PeriAnesthesia Nurses. Clinical guideline for the prevention of unplanned perioperative hypothermia. Cherry Hill, NJ: ASPAN; 2002.

11. Association of periOperative Registered Nurses. 2003 Standards, Recommended Practices and Guidelines. Denver, CO: AORN 2003:192-193.

12. Stanley TO, Grocott HP, Phillips-Bute B, Mathew JP, Landolfo KP, Newman MF, et al. Preliminary evaluation of the Arctic Sun Temperature-Controlling System during off-pump coronary artery bypass surgery. Ann Thorac Surg 2003;75:1140-1144.