Surgical patient safety program lowers SSIs by one-third following colorectal operations
Gerald Hurowitz, M.D.·Published 31 July 2012·11 min read
Key points
SSIs are the most common complication for this high-risk population, occurring in 15 to 30 percent of patients after colorectal operations, according to the study authors.
Most surgical site infecions can be treated with anibioics.
Further, to evaluate the association between the CUSP intervention and postoperative SSIs, the researchers studied patients undergoing colorectal operations over a two-year period.
Postoperative surgical site infections (SSIs) are a major source of morbidity in the United States.
A surgical patient safety program that combines three components-accurate outcome measurement, support of hospital leadership, and engaged frontline providers-reduces surgical site infections (SSIs) by 33 percent in patients who undergo colorectal procedures, according to a new study published in the August issue of the Journal of the American College of Surgeons.
SSIs are the most common complication for this high-risk population, occurring in 15 to 30 percent of patients after colorectal operations, according to the study authors. "Colorectal surgical site infections have been tough to prevent. This is a first step to understanding a strategy for prevention. Wound infections are an important risk factor for hospital readmission, increased length-of-stay, and reoperations," said lead study author Elizabeth Wick, MD, FACS, a colorectal surgeon at The Johns Hopkins Hospital, and assistant professor of surgery at Johns Hopkins School of Medicine, Baltimore.
The Johns Hopkins Hospital participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®). ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in private sector hospitals. While participating in a pilot program of ACS NSQIP called "Procedure Targeted Module," which monitored outcomes in all patients undergoing colorectal surgery," the colorectal operating team at Johns Hopkins discovered that they had a very high colorectal wound infection rate, approximately 30 percent.
To address the problem, Dr. Wick and her colleagues decided to apply the comprehensive unit-based safety program, known as CUSP, to colorectal wound infections. The five-step quality improvement strategy was designed to bring about patient safety improvements through an interdisciplinary team approach focusing on frontline providers with the goal of changing the unit's workplace culture.
"The CUSP program is unique because it focuses on the frontline providers-the nurses and the medical techs taking care of the patients day to day-and it gives them the power to identify and fix defects in the operating room. A key component of the program is a hospital executive is part of the team to help overcome barriers and reiterate the importance of the work," Dr. Wick said.
For the study, the CUSP team identified four defects in their surgical care: antibiotic selection and dosing, skin preparation, maintenance of normal body temperature, and intra-operative sterile technique. All defects surfaced from querying frontline providers.
What is a Surgical Site Infecion (SSI)? A surgical site infecion is an infecion that occurs ater surgery in the part of the body where the surgery took place. Most paients who have surgery do not develop an infecion. However, infecions develop in about 1 to 3 out of every 100 paients who have surgery.
Written and revised by
Gerald Hurowitz, M.D.
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Some of the common symptoms of a surgical site infecion are:
• Redness and pain around the area where you had surgery • Drainage of cloudy luid from your surgical wound • Fever
Can SSIs be treated?
Yes. Most surgical site infecions can be treated with anibioics. The anibioic given to you depends on the bacteria (germs) causing the infecion. Someimes paients with SSIs also need another surgery to treat the infecion.
What are some of the things that hospitals are doing to prevent SSIs?
To prevent SSIs, doctors, nurses, and other healthcare providers:
Clean their hands and arms up to their elbows with an anisepic agent just before the surgery.
Clean their hands with soap and water or an alcohol-based hand rub before and ater caring for each paient.
May remove some of your hair immediately before your surgery using electric clippers if the hair is in the same area where the procedure will occur. They should not shave you with a razor.
Wear special hair covers, masks, gowns, and gloves during surgery to keep the surgery area clean.
Give you anibioics before your surgery starts. In most cases, you should get anibioics within 60 minutes before the surgery starts and the anibioics should be stopped within 24 hours ater surgery.
Clean the skin at the site of your surgery with a special soap that kills germs.
Further, to evaluate the association between the CUSP intervention and postoperative SSIs, the researchers studied patients undergoing colorectal operations over a two-year period. They used one year of pre- and post-CUSP intervention SSI rates from the ACS Procedure Targeted Module, which collects outcomes data on high-risk procedures such as colectomies (surgical excision of the colon) and proctectomies (surgical excision of the rectum).
The study included 278 colorectal surgery patients in the 12-month preintervention period and 324 patients in the 12-month postintervention period. Patient risk factors were similar in both groups. In one year, researchers found that the overall SSI rate fell from 27.3 percent to 18.2 percent, a notable reduction of 33 percent in this high-risk patient population.
"Changes evolved over one year – it was not a bundle, it didn't happen all at once. Therefore, it's hard to figure out what specifically led to our wound infection reduction. But interestingly, as soon as we got this team together and engaged, our wound infection rate dropped," Dr. Wick observed. Based upon the post-CUSP implementation SSI rate, the study authors estimate that 28 infections were prevented during the study period, and that the CUSP intervention resulted in a cost savings of up to a $280,000 at the institution in one year.
"This project would not have been possible without ACS NSQIP. It gives feedback, which motivated the team to realize that this was a correctable problem and that played a role in improving patient outcomes," Dr. Wick said. "We had a clear metric and reliable data, which allowed for tangible improvements in patient safety."
The study authors speculate that widespread application of the CUSP intervention may reduce the number of SSIs by 170,000 per year, saving up to $170 million each year.
Based on these results and the successful implementation of CUSP to reduce healthcare associ-ated infections in the OR, the researchers currently have Agency for Healthcare Research and Quality funding to reduce SSIs, and other major surgical complications, through a national implementation of a surgical-based CUSP program.
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"This work is extremely important because it demonstrates it is possible to engage a team of frontline providers to solve a very difficult and common problem in surgery," said Clifford Y. Ko, MD, FACS, Director, Division of Research and Optimal Patient Care, American College of Surgeons. "The CUSP technique has achieved extremely noteworthy results in and out of surgery–both in improving clinical issues as well as culture. We are very excited to be involved in this partnership with the John Hopkins group to advance surgical care and outcomes."
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Fighting Surgical Site Infections
Postoperative surgical site infections (SSIs) are a major source of morbidity in the United States. Among the 27 million people undergoing surgery annually, approximately 500,000 will acquire a nosocomial SSI. SSIs are the third most commonly reported nosocomial infection.
A 1992 analysis of these infections showed that each SSI prolonged length of stay seven to nine days and resulted in an added cost of more than $3,000 per infection.
SSIs can be classified as incisional and organ/space manipulated during an operation. Incisional infections are further divided in superficial (skin and subcutaneous tissue) and deep (deep soft tissue muscle and fascia). Deep incisional and organ/space are the types of SSIs that cause the most morbidity. Definitions of SSIs can be found in the Centers for Disease Control and Prevention (CDC)'s Guideline for Prevention of Surgical Site Infection, 1999.
Infections may be caused by endogenous (e.g., bacteria on the patient's skin) or exogenous sources (e.g., personnel, the environment or materials used for surgery). Most SSIs are caused by the patient's own bacterial flora. The most common microorganisms causing surgical site infection are Staphylococcus aureus (20 percent), Coagulase negative staphylococcus (14 percent) and enterococcus (12 percent).
Factors that expose patients to increased risk for SSIs include diabetes, nicotine use, steroid use, obesity, malnutrition, prolonged preoperative stay, preoperative nares colonization and perioperative transfusion. Other preoperative and intraoperative risk factors for SSIs are:
- Inappropriate use of antimicrobial prophylaxis - Infection at remote site not treated prior to surgery - Shaving the site vs. clipping - Long duration of surgery - Improper skin preparation - Improper surgical team hand preparation - Environment of the operating room (ventilation, sterilization) - Surgical attire and drapes - Asepsis - Surgical technique: hemostasis, sterile field, foreign bodies
### By Bonnie M. Barnard, MPH, CIC
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 78,000 members and is the largest organization of surgeons in the world.
The known causes of SSIs are complex and multiple and, therefore, no single or simple solution is capable of eliminating all cases of SSIs. However, there is ample research data available suggesting that a number of opportunities exist whereby the risk of SSIs can be further reduced. For example, one major (and preventable) cause of potentially life-threatening SSIs is the increasing prevalence of antibiotic-resistant strains of bacteria that have developed following decades of excessive and inappropriate antibiotic use. Among these resistant bacteria, few have raised more concern than methicillin-resistant Staphylococcus aureus (more commonly known by its acronym, MRSA). MRSA is capable of causing limb- and life-threatening infections, particularly in very ill patients, and in the very young and very old. When I began my medical career, more than 20 years ago, MRSA was an exceedingly rare cause of bacterial infections. When MRSA first began to appear, this bacterium primarily caused infections among seriously ill hospitalized patients, and was rarely a source of infection among generally healthy nonhospitalized patients.
In a landmark study by the Centers for Disease Control, and published in the Journal of the American Medical Association in 2007, a remarkable 58 percent of invasive infections caused by MRSA in 2004 and 2005 occurred in nonhospitalized patients, while 27 percent of MRSA infections arose among hospitalized patients. This tectonic shift in the epidemiology of MRSA (and other emerging strains of antibiotic-resistant bacteria and fungi, as well) has grave implications for preventing SSIs, as the majority of SSIs are known to arise from the surgical patient’s own native bacteria.
Two important new studies related to SSI prevention, and just published in The New England Journal of Medicine, offer important new ammunition in the ongoing fight against potentially deadly SSIs.
In the first study, from the Netherlands, patients being admitted to the hospital for elective surgery were tested for the presence of Staphylococcus aureus bacteria in their nasal passages. In this prospective, randomized, placebo-controlled, double-blind, multi-center clinical research trial, 6,771 patients were screened for the presence of nasal Staphylococcus aureus, and 1,251 of these patients were confirmed to be nasal carriers of this bacterium. A total of 917 of these patients were subsequently enrolled into this clinical research trial. These 917 patients were then divided into an "experimental" group and a "control" group, although neither the patients nor the research assistants in this double-blind study were permitted to know which group any patient was assigned to until after the study had been completed. Patients randomized to the "experimental" group were treated, before surgery, with antibacterial ointment (mupirocin) applied to their nasal passages, and with showers using antibacterial soap (chlorhexidine), in an effort to eradicate surface bacteria (including Staphylococcus aureus) from their noses and skin. The "control group" of patients received identical-appearing nasal ointment and skin soap, but without mupirocin or chlorhexidine.
All study patients were tracked following surgery, and the incidence of SSIs was then analyzed. In this highly-powered randomized, controlled clinical research trial, there was a 58 percent overall reduction in the relative risk of SSIs among the "experimental group" of patients when compared to the patients who received only placebo ointment and placebo soap. The benefit of preoperative treatment with mupirocin ointment and chlorhexidine soap was even more pronounced for SSIs involving deep body spaces, in this study: the relative risk of deep body space SSIs was reduced by 79 percent in the "experimental group" of patients. Therefore, the results of this powerful prospective clinical trial suggest that SSIs following elective surgery can be significantly reduced by, first, testing patients for evidence of colonization with Staphylococcus aureus bacteria and, secondly, by "decolonizing" the nasal passages and skin of already-colonized patients with antibacterial ointment and soap, respectively. Many hospitals already selectively apply nasal cavity testing for MRSA (either before or following surgery), and recommend a shower with chlorhexidine soap prior to surgery. The results of this important public health study suggest that the incidence of SSIs can probably be further lowered by more rigorous and more universal preoperative screening programs for nasal Staphylococcus aureus (including both MRSA and non-MRSA Staphylococcus aureus) directed at all patients who are undergoing elective surgery.
The second, and related, study evaluated the impact of two different preoperative skin prep solutions on the incidence of SSIs.
For decades, now, iodine-based skin cleansing solutions have been applied to skin surfaces just prior to the start of surgery, in an effort to kill skin-surface bacteria that can lead to SSIs. While these traditional iodine-based antibacterial skin prep solutions are active against many bacteria and fungi that are known to cause SSIs, their antibacterial and antifungal activity rapidly dissipates after being applied. Newer surgical skin prep agents that contain alcohol and chlorhexidine have been shown by recent research studies to not only have a wider spectrum of activity against skin bacteria and fungi than traditional iodine-based prep solutions, but these newer surgical prep solutions also sustain their antibacterial and antifungal activity over a much longer duration than their iodine-based counterparts. In this new prospective, randomized clinical research study, 849 patients undergoing elective surgery were randomized to one of two groups. One group of patient volunteers underwent preoperative skin preparation with a commercially available chlorhexidine-alcohol solution, while the second group was randomized to undergo skin preparation with the traditional povidone-iodine solution.
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Sally Garneski pressinquiry@facs.org 312-202-5409 American College of Surgeons
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