Not that long ago, the phrase “the operation was a success but the patient died” was far from a joke. Until well after the Civil War, life-saving procedures such as the amputation of a gangrenous limb routinely turned lethal when germs infected the surgical wound and grew to overwhelm the patient’s body. In retrospect, the cause was obvious. Back then, surgeons didn’t worry much about hygienic practices when they cut into the human body. A meticulous and unhurried physician might wash his hands and swab the surgical site but neither instruments nor bandages were likely to be sterile and the discovery of antibiotics to fight infection was decades off. It wasn’t until the late 1860s when pioneering surgeon Joseph Lister created primitive anti-sepsis by misting his operating room with carbolic acid that the benefits of surgery began to greatly outweigh the hazards.
Still, the advent of modern knowledge and tools hasn’t removed the risk of surgical infection. “Any time you make an incision in the body, you create a pathway for germs,” says David Classen, MD, Vice President in the Health Delivery Services division of First Consulting Group in Long Beach, California. “It’s inevitable,” he says, “so our job is to push down the infection rate as far as possible and keep pushing.” According to the federal Centers for Disease Control and Prevention, surgical site infections (SSIs) occur in 2 to 5 percent of all surgeries and as many as 20 percent — an estimated 780,000 operations. Patients contracting SSIs are twice as likely to die compared to uninfected patients and five times more likely to require hospital readmission. Their hospital stays average twice as long as uninfected patients and add as much as $50,000 to overall medical costs.
Reducing the number of SSIs is one of six targeted interventions in the 100,000 Lives Campaign launched by the Institute for Healthcare Improvement (IHI) and one of the topics in its series of Breakthrough Series Collaboratives which educate hospital teams across the country in quality improvement. In 2002-2003, a year-long National Surgical Infection Prevention (SIP) Project, sponsored by the federal Centers for Medicare and Medicaid Services (CMS) and 43 Quality Improvement Organizations nationwide, enabled 44 hospitals to reduce their overall SSI rate by 27 percent. More recently, 24 hospitals participating in a nine-month IHI-sponsored Reducing Surgical Site Infections Breakthrough Series Collaborative also produced encouraging results.
Classen, an IHI advisor, points out that some protocols for preventing SSIs are so well known that they are virtually a given. “The room, the instruments and the people all have to maintain a sterile state and the surgeon has to avoid unnecessary damage to body tissues during the procedure, which can promote infection.” However, he says, other highly-effective methods for helping to avoid infection are far less widely followed, despite a solid and long-standing evidence base. They include the following:
- Appropriate pre- and postoperative use of antibiotics:
To boost the body’s ability to fight off contamination during surgery, the patient should receive a well-chosen and carefully-timed intravenous antibiotic, says Classen. “First, because different pathogens are found in different parts of the body, the surgeon has to pick the right antibiotic for the job. Next, it has to be given on a schedule that ensures there will be a high level of it in the patient’s body during the procedure.” In most cases, that means beginning the IV within 30 to 60 minutes of the first incision, says Classen. “Finally, to avoid having the patient develop resistant bacteria, the antibiotic must be discontinued within 24 hours.”
- Postoperative monitoring of blood sugar:
Hyperglycemia encourages the development and spread of infection. Testing of blood sugar, especially in diabetic patients, allows staff to control the levels in the patient’s body after surgery.
Though reasonably simple in themselves, implementing the above protocols takes a level of coordination and precision that can be elusive in a bustling surgical unit. Reducing the number of surgical infections and keeping them down often requires customized strategies, according to several hospitals that have successfully lowered their SSI rates.
Baptist Memorial Hospital for Women, a 140-bed specialty hospital in Memphis, Tennessee, that participated in the recent IHI Reducing Surgical Site Infections Breakthrough Series Collaborative, performs 225 to 240 hysterectomies and Cesarean-sections per month. During the Collaborative, Baptist lowered its infection rate by more than two-thirds, from 1.4 percent to 0.4 percent, and doubled the number of cases between infections, from 25 to 50.
The hospital’s appropriate use of antibiotics in C-sections — sometimes an unscheduled procedure — has risen from 65 percent to 95 percent and the hospital has had only two C-section infections since January 2005, says Performance Improvement Specialist Jackie Darby, RN. “We transferred responsibility for administering antibiotics from the anesthesiology staff to pre-op nursing because we found that antibiotics just aren’t a top priority for the anesthesiologists who had to be mainly concerned with sedation and monitoring issues.”
Darby also made other changes. For example, she provided surgeons with a standardized list of appropriate antibiotics, increased the standard dosage from one to two grams — “we found that obese patients weren’t always getting enough” — and ordered staff to withdraw antibiotics after 24 hours unless a surgeon justified continuation in a written order.
At the 770-bed Tallahassee Memorial Hospital, the region’s main acute care facility located in Tallahassee, Florida, discouraging the use of razors in the operating rooms proved to be surprisingly difficult. “”We banned them two years ago,” says Anne White, RN, CNOR, Nurse Director of the main operating room, “but when we went looking for them, we still found plenty. One reason was that no one told the woman who does the ordering not to order more and the surgeons kept asking for them.” White informed the clerk to cut off the supply, of course, but didn’t stop there. “We told the surgeons that the protocol was ‘no shaving’ so, if they insisted on a shaved site, they had to bring their own razor, do it themselves and enter that fact in the patient record. We’ve had much better compliance since then,” says White. Indeed, while Tallahassee Memorial had been averaging well under 100 cases between infections since September 2004, the number recently increased to 180.
Todd Schneider, Improvement Advisor/Management Engineer in the Performance Improvement Department at Tallahassee Memorial says that one key to sustained success is to bring everybody to the table and make sure they all understand the evidence. “If a surgeon calls the pharmacy or infection control and asks why something has to be done a certain way, we want that person to have a better answer than ‘because CMS wants us to’. We want everyone to understand the ‘why’ and ‘how’ behind what we’re doing.”
Porter Hospital, a 45-bed acute care facility in rural Middlebury, Vermont, also participated in the IHI Collaborative. Its SSI rate dropped from almost 3 percent in October 2004 to zero — 302 infection-free cases — through July 2005, says Performance Manager Ann Beauregard, RN, BA. One successful strategy: “We switched from using ear thermometers in the surgical unit to a more exact measure. Now we use a machine that scans the temporal artery, which is equivalent to core body temperature so we’re always sure the patient is warm enough.” Just as critical, though, says Beauregard, was to share the credit for improvement. Good news about the hospital’s sharply-reduced SSI rate was presented to the Board of Directors not by Beauregard’s division but by the post acute care nursing unit. “They were the ones in the front lines implementing the changes so they deserved the credit and they got it,” she says.
Benefis Healthcare in Great Falls, Montana, the state’s largest hospital, already had an impressively low overall SSI rate of 0.54 percent in 2001 before joining the federal CMS collaborative. However, says Pam Webb, RN, CIC, the Infection Control Coordinator for the 344-bed two-campus acute care facility, “our rate after coronary artery bypass grafts (CABG) was 8 percent — it had been as high as 12 percent earlier — and we sure wanted to change that.” And they did. The hospital has pushed its SSI rate for CABGs down by 85 percent to 1.2 percent currently and the overall SSI rate down to 0.4 percent by implementing all the required protocols — plus a few more of their own.
For instance, since heart disease patients are often diabetic, it’s especially important to monitor their glucose levels closely, says Webb. “We did the post-op testing, of course, but we gradually moved the monitoring process into the surgery itself, including an insulin drip during surgery if the patient needs it.” Another improvement, says Webb, is that every surgical patient is checked for existing infections, such as urinary tract infections, bronchitis, even abscessed teeth. “We make sure those are taken care of before the patient has surgery,” says Webb.
One other innovation had to do with local culture. “We’re a rugged and rural state,” says Webb, “Our patients are scattered across nearly 35,000 square miles and they’re used to being self-sufficient. They don’t like to ‘bother’ other people so when they developed the symptoms of infection, they weren’t reporting it. We often found out only when they came in for regular checkups or physical therapy.” An educational booklet provided after surgery now alerts both patients and their families to the signs of infection and urges them to seek immediate help.
As part of IHI’s 100,000 Lives Campaign more than 1,800 hospitals across the United States have committed to reducing SSIs. IHI Director Fran Griffin, RRT, MPA, who ran the just-concluded IHI Collaborative, says that this dedicated effort presents an extraordinary opportunity to prevent infections and save lives and she offers some concluding advice for team members or others determined to improve their performance. “Remember that it is not easy to make changes, even if they do seem simple. You will be trying to change practices that were probably part of training and thus well-ingrained, especially for surgeons. Use the evidence to support the case, and be patient with people in the beginning.”
Griffin, who planned content, coached participants, reviewed reports, and compiled data for the IHI Collaborative, says the most successful teams are those in which members collectively take ownership of the processes — surgeons, anesthesiologists, nurses in all surgical areas and pharmacists, focusing on what is best for the patient. “Always remember this,” says Griffin. “If you or a member of your family were the patient, would any reason for not meeting the process measures be acceptable to you if an SSI occurred?”
