Operating Room

Surgical-site infection: Operating beyond the basics

by Susan Cantrell, ELS

Our skin is peppered with land mines, little bacterial bombs just lying in wait for the right moment to explode into action. As long as we’re healthy, they’re usually thwarted; a person who is ill, however, may have a compromised immune system incapable of raising a defense. A surgical incision may be all the provocation bacteria need for the battle to begin.

Nearly 3% of 30 million operations are complicated by surgical-site infection (SSI); patients who suffer SSI are twice as likely to die as other postoperative patients; and it has been estimated that SSIs result in $1 to $10 billion in direct and indirect costs yearly.

Surgeons, surgical nurses, anesthesiologists, infection control nurses, and sterile supply department managers are all acutely aware of published standards designed to prevent SSI. Guidelines are clear and abundant, but more is needed, obviously. Why is SSI still a problem? What more can be done, beyond the basic standards, to prevent SSI?

"Patient safety" are healthcare’s 21st century buzzwords, and SSI certainly has the attention of many healthcare-focused agencies and organizations. Healthcare Purchasing News talked to a few of the organizations involved in exploring what more can be done to prevent SSI. Here’s what they had to say.

Compliance is a problem

"It’s an interesting dilemma," said Jeffrey M. Dunn, M.D., MBA, FACS, FACPE, senior medical director, clinical performance, VHA Inc, Irving, TX. "You can look at national quality and safety, and compliance doesn’t seem to be where we would like it."

VHA wants to play a major part in improving those results. "Our goal is simple: VHA hospitals want to have the best results," stated Dunn. "A strong function of VHA is to help hospitals perform better. There are multiple ways to do this. We educate our members, bringing evidence-based reasoning to them. We also use collaboratives. VHA’s program ‘Transformation of the Operating Room,’ brings surgical teams together from 40+ hospitals with the goal of improving the SSI rate, among other things, in the operating room."

"We’ve gone far beyond the measures that the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF) have suggested to prevent SSI," averred Dunn. "There simply are more opportunities. Among the best is changing the culture of the operating room, making the operating-room team actually work as a team. It’s not just the surgeon or just the nurses or just the anesthesiologists; it has to be all of them functioning as a team. We bring teams together."

Another tool VHA employs with success, explained Dunn, is a list-serve. "We use a closed-community email, so a hospital can communicate with other hospitals, reporting and sharing their success and failures. They learn from their failures and share their successes. It’s not uncommon for a hospital to say ‘We’re having trouble with this best practice; how are you accomplishing it?’ On the other hand, hospitals will report to others, ‘We found the way to make this happen.’ We help hospitals share these best practices with each other. Our contribution is not just saying, ‘Here are the things you should do’; our contribution is helping hospitals figure out how to do it."

Newport (RI) Hospital is one facility that has benefited by joining VHA in the battle against SSI. Infection Control Coordinator Gail Jackson, R.N., BSN, CIC, told HPN that, before VHA, it was just her and the infection control committee, who met once per month, trying to enforce recommendations on preventing SSI in her hospital. Aligning with VHA made her efforts more fruitful, because administration became involved, smoothing the way for changes. "It wasn’t until we joined VHA that I had a working group helping me to promote change, with administration standing behind me. It made my job easier," explained Jackson.

"Our infection rates were already very good, generally below 1%, which is under the national average; so, there hasn’t really been change in that area. Mainly what’s different since we joined VHA are our processes, how we do things, how we are able to bring together operating-room team members."

"For instance, the recommendation is that an antibiotic be administered to the patient within 1 hour prior to incision. We developed an order sheet, divided by procedure, to help the surgeon select the appropriate antibiotic. If a surgeon doesn’t comply, it’s documented. He or she is asked to explain why the wrong antibiotic was used. A report also goes to the chair of the department of surgery if the antibiotic isn’t administered within 1 hour prior or if it’s continued longer than 24 hours following the procedure when there is no documented infection. It works well. We also got buy-in from the anesthesia department, so it’s more likely the antibiotic is administered within an hour of cut time."

Jackson continued: "VHA also provides support from other facilities, an opportunity to sit with the change makers at other facilities, a means of exchanging information, and assistance in being compliant with standards. Our Department of Performance Evaluation and Improvement, CMS, and the Joint Commission on Accreditation of Healthcare Organizations all want to know whether hospitals are compliant. From our reports, we can now show what happened and why."

Jackson believes good science is behind the standards. "Recommendations are made by a consensus of brilliant minds. If that’s the best way to prevent SSI and to provide an atmosphere of patient safety, then that’s what we’re going to do. Patient safety is why we do all we do to reduce SSI."

Disclose the infection rates

The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in healthcare safety, quality, and customer value will be recognized and rewarded. The Institute of Medicine’s 1999 report, which shocked the nation with the news that up to 98,000 hospitalized Americans die each year from preventable medical errors, provided impetus for the group. Through its Hospital Quality and Safety Survey, Leapfrog uses public disclosure of facilities’ infection rates as a way of ensuring that those in key roles are held accountable for quality and safety.

CEO Suzanne Delbanco commented on how participating in the Leapfrog Hospital Quality and Safety Survey helps hospitals to improve their SSI rates beyond just compliance with industry standards. "The Leapfrog Group is shining the light on hospital performance in the areas of patient safety and quality. It promotes adoption of safe practices endorsed by the NQF, including several related to hospital-acquired infections such as SSIs. We ask hospitals to share information publicly about the progress they have made toward implementing these practices, including whether they are measuring their rates and whether they hold management accountable for success in this area. Filling out our survey helps hospitals develop a roadmap for improvement. By reporting this information to the communities in which the hospitals reside, as well as the rest of the nation, Leapfrog provides an incentive for improvement."

"Leapfrog spurs improvement in hospital performance by reporting their progress toward implementing key patient-safety and quality practices to the communities they serve," continued Delbanco. "Public benchmarking has been proven to provide incentive for improvement. Leapfrog measures have also been incorporated into about two dozen incentive and reward programs across the country, which inserts additional motivation into the system."

"Preventable infections are one of the most egregious examples of quality failing," noted Delbanco. She then zeroed in on the hospital’s tender parts: "Through educating consumers, employers, and large healthcare purchasers about the differences among hospitals in this area, they can make more informed decisions about where to buy care."

Improve processes

Premier’s long-term goal is to reshape healthcare by helping hospitals improve processes, which leads to better patient outcomes and reduced costs. Premier is looking toward pay-for-performance, partnering with the Surgical Care Improvement Project (SCIP), and tools they’ve developed to achieve this goal. Gina Pugliese, R.N., MS, vice president, Premier Safety Institute, outlined a few of the programs and tools offered:

• Premier, in partnership with SCIP, presented an audio conference, "SCIP—A National Quality Partnership." An audio file of the 90-minute program, handouts, final SCIP measures, and a narrative script are available at http://www.premierinc.com/all/safety/
safety-share/03-06-full-txt.jsp.

• Premier’s national pay-for-performance initiative is the CMS/ Premier Hospital Quality Incentive Demonstration. This project, with 260 participating hospitals, is designed to determine whether economic incentives are effective in improving quality of inpatient care.

• Advisor Suite uses comparative data tools and benchmarking to help facilities see how they’re performing and to identify how they can improve their clinical quality, safety, financial, and market performance.

• Rapid Improvement Portal is an online library of evidence-based clinical and financial best-practice tools, templates, and methodologies. Users may ask questions and have them answered by their peers, Premier consultants, and other experts.

• Safety Share News is Premier’s monthly newsletter promoting quality, safety, and infection prevention.

"Our resources are available to everyone, not just members. Some are fee-for-service; others, like our Advisor Live educational audio programs and Safety Web site, are open to everyone," said Pugliese.

Choose an alliance

AORN (Denver, CO), the professional organization for perioperative registered nurses, is one of the leading healthcare organizations responsible for molding standards on issues such as SSI. Joan Blanchard, perioperative nursing specialist, Center for Nursing Practice, which is the clinical section of AORN, talked to HPN about how AORN attacks SSI: "AORN has developed standards, recommended practices, guidelines, and guidance statements that help the surgical team to care for patients in a proactive way." As for going beyond the published standards and recommending participation in organizations such as those mentioned above, Blanchard said, "AORN does not specifically advise hospitals to align themselves with any particular business group, but this may be a very good business practice. Hospitals need to make the decision on which group would provide the best benefit for their setting. Many of these organizations have guidelines that may assist hospitals in preventing SSIs. It would be a good practice to choose the alliance that would benefit them the most."

Is your hospital ready to move beyond the basics? Could you use a helping hand as you ramp up your efforts to beat SSI? If you have reason to believe your hospital could benefit by aligning with an organization such as one of those above, don’t hesitate. Lives are at stake. HPN

References:

1.Institute for Healthcare Improvement. Surgical site infections. Case for improvement. http://www.ihi.org/IHI/Topics/Patient
Safety/SurgicalSiteInfections.

2.Odom-Forren J. Preventing surgical site infections. Nursing 2006;36(6):58-63.

3.Wong ES. Surgical site infections. In: Mayhall CG, editor. 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.

August 2006

 

 

Outpatient Connection

Experiments suggest an alternative to pacemakers

Patients with complete heart block, or disrupted electrical conduction in their hearts, are at risk for life-threatening rhythm disturbances and heart failure. The condition is currently treated by implanting a pacemaker in the patient’s chest or abdomen, but these devices often fail over time, particularly in infants and small children who must undergo many re-operations. Researchers at Children’s Hospital Boston have now taken preliminary steps toward using a patient’s own cells instead of a pacemaker, marking the first time tissue-engineering methods have been used to create electrically conductive tissue for the heart. In complete heart block, electrical signals cannot pass from the heart’s upper chambers (atria) to the lower chambers (ventricles), leading to heart failure. In normal hearts, electrical impulses move first through the atria, then pause at the atrioventricular (AV) node. After a short delay that allows the ventricles to fill with blood, the AV node releases the impulses, which move through the ventricles causing them to contract. In this way, the beats of the atria and ventricles are synchronized. Investigators led by Douglas Cowan, PhD, a cell biologist in Children’s Department of Anesthesiology, Perioperative and Pain Medicine, wanted to create a biological substitute for the AV node that would work in patients who have defective atrioventricular conduction. "The idea was that rather than using a pacemaker, we could create an electrical conduit to connect the atria and ventricles," Cowan says. Cowan’s team obtained skeletal muscle from rats and isolated muscle precursor cells called myoblasts. They "seeded" the myoblasts onto a flexible scaffolding material made of collagen, creating a 3-dimensional bit of living tissue that could be surgically implanted in the heart. The cells distributed themselves evenly in the tissue and oriented themselves in the same direction. Tested in the laboratory, the engineered tissue started beating when stimulated electrically, and its muscle cells produced proteins called connexins that channel ions from cell to cell, connecting the cells electrically. When the engineered tissue was implanted into rats, the implanted cells integrated with the surrounding heart tissue and electrically coupled to neighboring heart cells. Optical mapping of the heart showed that in nearly a third of the hearts, the engineered tissue had established an electrical conduction pathway, which disappeared when the implants were destroyed. The implants remained functional through the animals’ lifespan (about 3 years).