Cost of SSI

Infection of surgical-sites, formerly called surgical wounds, is the third most frequently reported hospital-acquired infection.1 The price in patient morbidity and mortality is high, as are the related costs of treatment. Surgical-site infections (SSIs) have been estimated to result in $1 to $10 billion in direct and indirect medical costs each year.2-4 A study by Kirkland et al found that ". . . patients who develop SSI [surgical-site infection] have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital."5

3M‘s Tegaderm Ag

That doesn’t mean that, if you go to the hospital for say a face-lift or even a colostomy, you should fear you won’t ever be going home again. Certain factors have bearing on the likelihood, or not, of contracting an SSI, factors that include but are not limited to category of surgery, ie, some surgeries are "cleaner" than others, eg, eye surgery would be less likely to result in infection than bowel surgery; length of hospital stay and length of surgical procedure; age, particularly very young or very old; and health status of the individual, because underlying illnesses can reduce the ability of the immune system to do its job. It’s a wonderful thing that advances in health care, including infection control, allow us to live longer now; unfortunately, with ripe old age can come chronic, debilitating, immunocompromising diseases that could render us more susceptible to infection. This particular population can really crank up those infection rates.

The good news is that means of caring for wounds due to surgery and combating potential infection of those wounds are constantly being sought or tweaked. For instance, we now know that preoperative prophylactics should be administered to nip bugs in the bud; clippers, not razors, should be used to remove hair from surgical sites prior to surgery, because shaving can leave tiny cuts on the skin, providing an open invitation to bacteria; monitoring patients’ glucose, even if they’re not diabetic, is important; and normothermia, keeping patients warm, improves results, as can supplemental oxygen. In a study from a surgeon’s perspective, Nichols highlighted these and other important factors: "The most critical factor in the prevention of postoperative infection, although difficult to quantify, are the sound judgment and proper technique of the surgeon and the surgical team, as well as the general health and disease state of the patient. Other factors influence the development of postoperative wound infection, especially in clean surgical procedures, for which the infection rate (<3%) is generally low. Infections in these patients may be due solely to airborne exogenous microorganisms."6

The Centers for Disease Control and Prevention concluded, "Thus, to reduce the risk of SSI, a systematic but realistic approach must be applied with the awareness that this risk is influenced by characteristics of the patient, operation, personnel, and hospital."1

Products good for the patient and the pocketbook

Accompanying aseptic technique in the battle against infection are a myriad of products designed for the care of surgical wounds. Angela Box-Peterson, a wound-care nurse, is the special programs coordinator in a hospital in the Birmingham, Alabama, area who spends most of her time with patients who have wounds and ostomies. "Most of my time is spent with complicated post-op wounds," explained Box-Peterson. "My input into post-op care would usually involve application of the wound vac in the operating room, recovery room, or during the post-op recovery period in the hospital room.

BlueSky Medical’s
wound vacuum system

I work closely with our surgeons and doctors to develop a plan of care that is simple, effective, and cost-effective in meeting the goal of healing the wounds with as much patient independence and participation as possible. The typical patient I may see has a wound in an area of their body with a high risk of contamination. The patient is usually nutritionally compromised with limited mobility. Fecal incontinence only adds concern to our plan of treatment. This may be further complicated by infection with Clostridium difficile, resulting in frequent liquid stools. Many patients and their family members do not want temporary diverting colostomies, which would provide better opportunities for a clean wound environment in certain areas of the body. There are several products in use at our facility, in accordance with purchasing contracts, to help us reach our goals in providing care to these patients and their wounds." Box-Peterson described some of the products that have benefited their patients’ healing process, the hospital’s pocketbook, and the nurses by saving them time and labor.

"The Fecal Management System (FMS), by ConvaTec, is a device that can be placed into the rectal vault to capture semi-solid and liquid stool. It can stay in place for several weeks and is especially helpful in reducing fecal contamination in wounds in the peri-anal area, sacrococcygeal area, perineal area, etc. This is also helpful for patients who have C diff colitis, and it applies to patients who have limited mobility, also. This item can save in linen and definitely saves in labor."

"The V.A.C. Therapy System (Vacuum Assisted Closure), by KCI, can be used to close wounds quickly, using negative-pressure wound therapy (NPWT), and therefore often reduces length of stay. It can help reduce contamination of a wound environment due to the occlusive nature of the dressing. Labor costs can also be reduced, as the dressings are generally changed 3 to 4 times a week, and not daily or twice daily, etc."

The Comfort Shield, by Sage, is a wipe that provides easy and quick clean up of urinary or fecal incontinence while placing a skin barrier at the same time. This item can save labor and linen costs, as the product is disposable, while increasing the skin’s resistance to breakdown, which may lead to a decrease in length of stay. The patient and family member may be able to learn to use this product to make a better and easier transition to the home environment. We also have used the wipe in conjunction with the FMS. In the first 24 to 48 hours of use, the special rectal tube may leak some fecal matter, so we have placed the wipe in the area around the tube to keep the stool from leaking into the wound area. When the patient is more mobile, this wipe is especially helpful in keeping the wound environment clean, while being easy to use. My hospital has been using the Sage Comfort Shield for over 2 years, hospital-wide, for incontinence care. The ease of use, disposability of the product, and reduction of steps to ensure protection of the skin after cleansing are a few of the aspects of this product that make it well-liked by staff, therefore increasing the compliance of recommended skin care and protection. Recently, our corporate wound-care council met and decided to make this product available in all of our hospitals. It seems to be the best product available for the cost. In my hospital, we were able to eliminate another product that we had available, perineal cleansing foam, and this helped save money."

Speaking of saving money, products impregnated with ionic silver are on the rise, and wound dressings are no exception. Knowledge of the possibilities for ionic silver has been around some years but has only recently been brought to the forefront. The advantages of ionic silver are impressive: it’s a natural broad-spectrum antibiotic; it’s activated by wound exudate; bacteria are attracted to it; and bacteria don’t grow resistant to it. Anything that can kill harmful bacteria while not engendering resistance is "a good thing," as Martha would say.

Nino Pionati, vice president, global marketing and research development, ConvaTec, Skillman, NJ, described their ionic silver wound dressing, AQUACEL Ag: "AQUACEL Ag Hydrofiber is a silver-impregnated antimicrobial dressing. The ionic silver in the dressing kills wound bacteria held in the dressing and aids in creating an antimicrobial environment. This dressing absorbs high amounts of wound fluid; traps and kills bacteria; creates a soft, cohesive gel that intimately conforms to the wound surface; reduces the risk of peri-wound maceration; delivers sustained amounts of silver in a moist wound-healing environment; causes less trauma upon removal; hydrates necrotic tissue; and aids debridement. Although unit cost may be higher than gauze, AQUACEL Ag dressing improves cost of care by reducing the number of dressing changes, which may result in lower total costs for management of wounds."

3M recently launched a silver-impregnated wound dressing, an expansion product to their Tegaderm line: Tegaderm Ag Mesh Dressing with Silver. 3M touts it as noncytotoxic, nonirritating, minimally (if any) skin-staining, comfortable, easy to apply, easy to cut, and affordable, providing a 7-day antimicrobial barrier for a variety of wound types, including surgical.

Another technique that’s been around for a while but is just now getting the attention it merits is NPWT. Richard Weston, president, BlueSky Medical Group, explained how NPWT works: "NPWT is a technique to apply sub-atmospheric pressure to a wound bed to remove exudates and help grow new tissue. It can jump-start healing in a wound because it pulls off the old fluid, thereby reducing bioburden, and it increases circulation by bringing fresh blood flow to the surface. Basically, it takes out the bad and brings in the good."

BlueSky’s wound vacuum system, Versatile 1 (V1), includes a drainage tube and a dressing comprised of a non-adherent, porous, antimicrobial-impregnated gauze and transparent adhesive film. "Levels of suction are in the 60 to 80 mm range, which helps pull off fluid and grow tissue with a fair degree of comfort for patients," said Weston. "The antimicrobial fill can stay on for a few days. The first dressing change would be at 48 hours, then every 2 or 3 days subsequently. You don’t have to cut the dressing to fit the wound, so it’s simpler and involves less time."

Silver(Ag) is the active ingredient
 in ConvaTec’s Aquacel Ag dressing

A study by Philbeck et al confirms the general advantages of NPWT: ". . . healing time can be as high as 61% faster and 38% less costly with combination treatment utilizing a controlled suction drain system."7

"NPWT therapy is still in the early stages," said Weston, "but nurses find it to be effective. The Cleveland Clinic in Ohio is performing a clinical trial on the V1, and in 2005 BlueSky was awarded Medicare coding for NPWT. It can be used in acute-care, long-term care, or home-care settings. The technology is good, and more innovation is coming down the line. There will be significant advances coming in dressing applications."

Wound care is only one aspect of surgical practice and care that is constantly evolving. For more information in advances in the surgical arena, please see our "Surgical Instruments Guide" in this issue on page 40. HPN

REFERENCES

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

2. Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis [serial online] 2003 Feb. Available from URL: www.cdc.gov/ncidod/EID/vol9no2/02-0232.htm.

3. Wong ES. Surgical site infections. In: Mayhall CG. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia, PA: Lippincott; 1999:189-210.

4. Holtz TH, Wenzel RP. Postdischarge surveillance for nosocomial wound infection: a brief review and commentary. Am J Infect Control 1992;20:206-213.

5. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725-730.

6. Nichols RL. Preventing surgical-site infections: a surgeon’s perspective. Emerg Infect Dis [serial online] 2001;7(No. 2) :Mar-Apr. www.cdc.gov/ncidod/eid/vol7no2/nichols.htm.