Surgical site infections (SSIs) are a serious concern for healthcare providers due to the significant clinical and financial burdens associated with them. Although infection control practices have advanced in recent years, including improved operating room ventilation, sterilization methods, barriers, surgical techniques and availability of antimicrobial prophylaxis, SSIs remain a substantial cause of morbidity, prolonged hospitalization and death.
SSIs are associated with a mortality rate of 3 percent, and 75 percent of SSI-associated deaths are directly attributable to the SSI.1
Even though most operations in the United States are now performed in outpatient settings, SSI rates and morbidity and mortality statistics come from the acute care hospital setting. Very little is known about infection rates following these outpatient procedures or how best to monitor for these complications. Recent reports of serious lapses in infection control practices at ambulatory surgery centers—combined with continued growth of procedures in outpatient settings—show the importance of preventing SSIs.2,3
The guidelines and the bundle recommendations are the same for the ambulatory surgery center (ASC) and the acute care hospital, but there are also unique differences between the two. Where the acute care hospital, for the most part, has oversight of the surgical process from pre-op through post-op, the ASC generally only has oversight from the time the patient walks in the door to the time he or she is released. Even the strongest ASC infection prevention program can be thwarted by inadequate preparation and monitoring of the patient pre- and post-operatively.
Traditional post-op surgical site infection surveillance methods, which focus on inpatient hospitalization and readmission at the facility where the procedure was performed, have proven to be inadequate for monitoring complications following ambulatory surgery. The same can be stated for SSI pre-op prevention strategies.
In the pre-operative phase, physician pre-op instructions are rarely standardized, and patient compliance is difficult to track and minor. Lack of standardization and variance in practice can be detrimental to any infection prevention program, while consistent execution of best practices drives optimal outcomes. It may be difficult, but collaborating with your physician groups to develop a standardized, evidence-based approach will be rewarding in the end. Without a program intentionally designed to standardize practices, you likely won’t achieve your clinical goals.
Patient compliance with pre-op instructions may be the more difficult issue to tackle. Both the ASC and acute care settings are struggling in this area. The key is to develop standardized practices that are easy for a patient to understand and use. There are four key components that can help drive patient compliance:
- Bundling supplies into a kit that can be given or easily obtained by the patient;
- Providing an explanation of why it is important for the patient to comply;
- Providing instructions that use simple, everyday words or pictures; and
- Using technology to remind patients when they need to perform a procedure and to document compliance.
This must be a collaborative effort with buy-in from the management team, physicians, nurses, techs and, most important, the patient. This type of effort, if implemented correctly, can enhance the patient’s pre-op experience.
As surgical procedures increasingly shift to ambulatory settings, tracking postoperative complications will become critical, not only from a patient safety perspective but also from a reimbursement and financial perspective. Hospital-based surveillance methods can be inadequate because SSIs following ambulatory surgery often do not require hospitalization. Many SSIs acquired via a surgical procedure in an ASC are managed in an outpatient setting such as a primary care physician’s office or the surgeon’s office. Furthermore, if hospitalized, patients who underwent surgery at a freestanding ambulatory surgery center will likely be treated at a different facility. Currently, surveillance requires self-reporting from the surgeon or primary care physician’s office. This is not idea, and a more robust and manageable method must be developed.4
Utilizing a bundled approach to the prevention of SSIs (and other healthcare-associated infections) is gaining acceptance. Maureen Spencer, RN, M.Ed, infection preventionist consultant, has developed the 7 S Bundle for the prevention of SSI, based on current guidelines from the CDC/HICPAC and the recommendations of national societies such as AORN and SHEA. The results obtained by Spencer and her colleagues showed that better outcomes were obtained when the bundle was used as a whole, instead of only using individual components of the bundle.5
The seven steps of this bundle are:
- Safe operating room practices
- Screen for risk factors and MRSA/MSSA
- Showers with chlorhexidine
- Skin prep with alcohol-based antiseptics
- Sutures with an antimicrobial
- Solution to irrigate with chlorhexidine
- Skin adhesive or antimicrobial dressings to protect incision
SSI prevention strategies should encompass the entire continuum of the surgical procedure: the pre-operative, intra-operative and post-operative periods. Improvement processes to prevent SSI should be driven by leadership with a commitment to provide adequate resources and attention to the initiative. In the ASC setting, commitment from all parties that touch the surgical process and procedure is imperative for success.
This article originally appeared in Outpatient Outcomes magazine.
- Awad, SS. “Adherence to surgical care improvement project measures and post-operative surgical site infections.” Surgical Infection (Larchmt) 13(4): (2012):234-7.
- Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA. 2010;303:2273-2279.
- Outbreaks and patient notifications in outpatient settings. CDC website. http://www.cdc.gov/HAI/settings/outpatient/outbreaks-patient-notifications.html. Accessed June 14, 2016.
- Rhee C, Huang SS, Berrios-Torres SI, et al. Surgical Site Infection Surveillance Following Ambulatory Surgery. Infection control and hospital epidemiology. 2015;36(2):225-228. Doi:10.1017/ice.2014.23.
- Spencer M. Establishing a culture of safety: the 7S bundle to prevent surgical site infections. http://www.7sbundle.com. Accessed June 16, 2016.