A recipe for SSI reduction: Bundling evidence-based interventions to lower risk, improve patient outcomes

In December 1999, the Institute of Medicine published, To Err is Human: Building a Safer Health System, a report which stunned the American healthcare industry with its estimate that preventable adverse events are a leading cause of death in the U.S., claiming up to 98,000 lives each year.1

 

One adverse event type has garnered the attention of healthcare leaders: surgical site infections. In the U.S., it has been shown that up to 60 percent are preventable2,3 despite evidence-based strategies for prevention have been available for many years through global initiatives.

Concerted efforts by healthcare professionals have produced positive results. According to the CDC, hospitals reported a 17 percent decrease in SSIs related to 10 select procedures between 2008 and 2014.4

This content is sponsored by 3M Health Care

Despite this progress, SSIs remain the most common, costly healthcare-acquired infection5-7, with an estimated 160,000–300,000 SSIs occurring in the U.S. each year.8,9 SSIs can cost up to an additional $60,000 per incident.10

SSIs are a complex problem …

SSIs are a complex issue, in part, because the risk of acquiring an SSI depends upon a number of patient and process factors.

"Any surgery that causes a break in the skin can lead to a post-operative infection," said Michele Hulse-Stevens, MD, medical director with 3M Health Care. "The majority of SSIs come from bacteria already on the patient. There are many patient-related factors that are known to increase the risk of SSI, including medical conditions such as diabetes, high blood pressure or heart disease, being elderly or overweight, and smoking."

According to the CDC, there are three major variables that contribute to the risk of SSIs:11

  1. Number of bacteria
  2. Virulence of bacteria
  3. Patient risk factors

The problem of SSIs is a complex and significant one that cannot be solved by a single solution. Although the major variables are not easily controllable, the risk of SSIs can be minimized by evidence-based best practices related to the number of bacteria and select patient risk factors.

… requiring a new approach

A wave of surgical innovation — inspired in large part by the To Err is Human report — has spurred a significant acceleration in the development of new healthcare technologies and research.

Along with these advances comes the challenge of staying current on published research and evaluating the science behind the findings. Evidence-based medicine, defined as "a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values,"12 offers clinicians a way to stay informed using standardized, evidence-based protocols. Rather than relying on previously accepted facts or anecdotal experience, clinicians have access to data vetted and agreed upon by peers for use in evidence-based guidelines.

Multifaceted prevention efforts

Applied to the CDC's three variables that contribute to SSI risk, reduction efforts have been most successful when used in "bundles" — a set of evidence-based practices that, when performed collectively and reliably, have been proven to improve patient outcomes.13 In the case of SSIs, each of the bundled interventions contributes to the overall goal of SSI risk reduction in different ways.

"The perioperative care of the surgical patient is designed to address modifiable risks," said Dr. Hulse-Stevens. "Interventions such as methicillin-resistant Staphylococcus aureus decolonization, preoperative bathing and prewarming for the maintenance of core body temperature are all components of a strategy that can improve patient outcomes."

Below are just a few examples of interventions with compelling supporting evidence that can be included as part of a successful SSI prevention bundles.

Nasal decolonization, patient bathing

More than 80 percent of infections from Staphylococcus aureus, the leading cause of SSIs, come from a patient's own nasal flora, making this a major concern.14-16 Providers frequently address nasal colonization with a five-day regimen of the antibiotic mupirocin. However, poor patient compliance and antibiotic resistance can make this treatment less effective.

"Having patients bathe, shower or use chlorhexidine gluconate wipes at least the night before and the morning of surgery will help reduce bacteria on the body prior to entering the hospital for surgery," said Ellen Anderson Manz, MSN, RN, technical service manager with 3M Health Care. "Decolonizing the nares preoperatively also helps reduce the risk of SSIs when part of a comprehensive preoperative protocol."17,18

An antiseptic solution provides an alternative to the traditional antibiotic approach. 3M™ Skin and Nasal Antiseptic can address nasal carriage of S. aureus safely and effectively and is supported by an increasing amount of clinical evidence. This simple, one-time application reduces nasal bacteria, including S. aureus, by 99.5 percent in just one hour and maintains this reduction for at least 12 hours.19

"As the only nasal antiseptic supported by 10 investigator-initiated clinical studies, 3M Skin and Nasal Antiseptic provides a simple and clinically effective solution for nasal decolonization, which as part of a comprehensive protocol can help reduce the risk of SSIs," said Ms. Anderson Manz.

Pre-operative showers, baths or wipes are used to cleanse and reduce the bacterial load on the skin. Preoperative bathing with CHG is effective in reducing skin flora; the same effect is not achieved with the use of soap alone.20-22

"While the skin can contain over 1 million bacteria per square centimeter, when an implant is involved as few as 10 microbes per sq. cm to cause an SSI,"23 said Ms. Anderson Manz. "Reducing the number of microorganisms can reduce the risk of infection."

Use of a non-rinseable form of CHG (2 percent impregnated cloths) results in a significantly better reduction in skin flora compared to 4 percent CHG showers.24 A recent systematic review that included studies with consistent bathing protocols of two pre-operative baths found that the use of 2 percent CHG cloths significantly reduces SSI risk.25

Minimize bacterial contamination from the patient's skin

Proper surgical skin preparation can further reduce bacterial contamination of the surgical site. Effective surgical skin antiseptics should be fast-acting and have persistent activity to reduce microorganisms to sub-pathogenic levels with minimal skin and tissue irritation.26

"While surgical skin preps help to reduce bacteria on the skin, they do not sterilize the skin, so there will still be some level of bacteria remaining," said Ms. Anderson Manz. "One effective method to help prevent residual skin bacteria from being carried on gloves and instruments into the surgical wound is to apply an incise drape as part of the skin preparation process."

An incise drape provides a sterile surface to the wound edge, locking any remaining bacteria underneath. An antimicrobial incise drape contains an antiseptic in the adhesive layer and has the added advantage of killing bacteria left on the skin after application of the skin prep.

In a recent ex vivo study on human skin, the iodine in an iodine-impregnated surgical incise drape was shown to be present at concentrations effective against MRSA at a depth of 1,000 microns, in the deeper layers of the skin where hair follicles are present.27

Several new studies further outline the impact of using an antimicrobial incise drape. A randomized controlled trial compared microbial wound contamination in hip preservation surgery using 3M™ Ioban™ 2 Antimicrobial Incise Drapes compared to using no incise drape at all. The study showed that the Ioban 2 antimicrobial incise drape was significantly more effective at reducing microbial wound contamination compared to not using an incise drape.28

In a recent study of patients undergoing cardiac surgery, 3M Ioban 2 antimicrobial incise drape was associated with a significant reduction (71 percent) in the overall incidence of SSIs when compared with the use of a non-antimicrobial incise drape.29

Maintaining normothermia

The clinical benefits of normothermia maintenance in surgical patients is well established, and temperature management is included in clinical practice guidelines worldwide.

Maintaining a patient's normal body temperature, or normothermia, has been shown to correlate with decreased SSI rates30-32; it can also help reduce blood loss33,34, shorten the length of hospital stays35, and help hospitals avoid additional costs.36 Increasingly, the practice of prewarming, or actively warming patients before surgery, is being recognized as an effective way to head-off unintended hypothermia before it can begin.

Prewarming with a forced-air warming system before surgery can reduce an anesthesia-induced decline in core temperature called "redistribution temperature drop" experienced by anesthetized patients.37,38 Prewarming coupled with intraoperative FAW can prevent unintended hypothermia in procedures over one hour in length while reducing the frequency of hypothermia's associated negative outcomes.

"Redistribution, not heat loss to the environment, is the dominant cause of intraoperative hypothermia, especially in shorter duration surgeries," said Al Van Duren, director of scientific affairs & education with 3M Health Care. "Even vigorous intraoperative warming cannot rapidly reverse the effect of redistribution; therefore, continuous intraoperative normothermia in adults is virtually impossible without prewarming."

Conclusion

Preventing SSIs requires the implementation of clinically effective interventions to counteract or offset the variables known to cause infection. The goal is to prevent bacterial contamination of the surgical site and neutralize bacteria that could otherwise infect the wound.

Using guidelines and evidence-based best practices — like those above — can have a positive effect on reducing the risk of SSIs.

References:

1. Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi:https://doi.org/10.17226/9728.

2. Meeks DW, Lally KP, Carrick MM, et al. Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? Am J Surg. 2011; 201(1):76–83. [PubMed: 20573335]

3. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32(2):101–114. [PubMed: 21460463]

4. CDC National and State Healthcare-Associated Infections Progress Report, published March 2016, available from: www.cdc.gov/hai/surveillance/progress-report/index.html

5. Anderson DJ, Pyatt DG, Weber DJ, Rutala WA. Statewide costs of health care–associated infections: estimates for acute care hospitals in North Carolina. Am J Infect Control. 2013; 41(9):764–768. [PubMed: 23453162]

6. Lewis SS, Moehring RW, Chen LF, Sexton DJ, Anderson DJ. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol. 2013; 34(11):1229–1230. [PubMed: 24113613]

7. Zimlichman E, Henderson D, Tamir O, et al. Health care– associated infections: a meta-analysis of costs and financial impact on the us health care system. JAMA Intern Med. 2013; 173(22):2039–2046. [PubMed: 23999949]

8. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project—statistics on hospital stays. 2013. http://hcupnet.ahrq.gov/. Accessed February 15, 2013

9. Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Centers for Disease Control and Prevention; Atlanta: 2009. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. Accessed December 14, 2013.

10. Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS ONE. 2009;4:e8305.

11. Mangram AJ, Horan TC, Pearson ML, Silver LC, and Jarvis WR. Guideline for prevention of surgical site infection. Infection Control and Hospital Epidemiology. 1999;4:247-278.

12. Masic, Izet, Milan Miokovic, and Belma Muhamedagic. "Evidence Based Medicine – New Approaches and Challenges." Acta Informatica Medica 16.4 (2008): 219–225. PMC. Web. 6 Apr. 2017.

13. Resar R, Pronovost P, Haraden C, Simmonds T, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Joint Commission Journal on Quality and Patient Safety. 2005;31(5):243-248.

14. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med. 2002;346:1871-1877.

15. Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, et al. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical site infections in orthopedic surgery. Infect Control Hosp Epidemiol.2000;21:319-323.

16. Kluytmans JAJW, Mouton JW, Ijzerman EPF, et al. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis. 1995;171:216-219.

17. Phillips M, Rosenburg A, Shopsin B, et al. Preventing surgical site infections; A randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidomiol. 2014;35:826-832.

18. Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg. Published online March 04,2015.doi:10.1001/jamasurg.2014.3480.

19. 3M Study-05-011100.

20. Garibaldi RA Prevention of intraoperative wound contamination with chlorhexidine shower and scrub. J Hosp Infect 1988;11(Suppl B):5–9.

21. Hayek L, Emerson JM, Gardner AMN. A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates. J Hosp Infect 1987;10:165–72.

22. Murray MR, et al. Efficacy of preoperative home use of 2% Chlorhexidine Gluconate cloth before shoulder surgery. J Shoulder Elbow Surg 2011; 20: 928-33.

23. Feldman G, Fertala A, Freeman T, et al. Recent advances in the basic orthopedic sciences: osteoarthritis, infection, degenerative disc disease, tendon repair and inherited skeletal diseases. In: Austin MS, Klein GR, ed. Recent Advances in Orthopedics. 1st ed. New Delhi. Jaypee Brothers Medical Publishers (P) Ltd; 2014: 256.

24. Edmiston CE Jr. et al. Preoperative shower revisited: Can high topical antiseptic levels be achieved on the skin surface before surgical admission? J Am Coll Surg 2008;207(2):233-9.

25. Karki S, Cheng AC. Impact of non-rinse cleansing with Chlorhexidine Gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect 2012; 82:71-84.

26. AORN. Guideline for Preoperative Patient Skin Antisepsis. Guidelines for Perioperative Practices. Denver, Colorado: AORN, Inc. 2017.

27. Casey AL, Karpanen TJ, Nightingale P, Conway BR, Elliott TSJ. Antimicrobial activity and skin permeation of iodine present in an iodine-impregnated surgical incise drape. J Antimicrobial Chemotherapy. 2015.

28. Chen et al. Incise Draping (Ioban) is Protective against Surgical Site Contamination during Hip Surgery: A Prospective Randomized Trial. Abstract presented at MSIS Annual Conference, Aug 5-6, 2016

29. Bejko et al. Comparison of efficacy and cost of iodine impregnated drape vs. standard drape in cardiac surgery: Study in 5100 patients. J Cardiovasc Trans. Res. 2015; 8:431-437

30. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996;334:1209e1215.

31. Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology 2001;95:531e543.

32. Seamon MJ, Wobb J, Gaughan JP, et al. The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies. Ann Surg 2012;255:789e795.

33. Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet. 1996;347:289–292.

34. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008; 108(1): 71-77.

35. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996; 334(19):1209-15.

36. Mahoney, C.B., and Odom, J. Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs. American Association of Nurse Anesthetists Journal. 1999 Apr;67(2): p. 155-63.

37. Sessler DI. Perioperative heat balance. Anesthesiology. 2000; 92(2):578-96.

38. Andrzejowski, J. Hoyle, J. Eapen, G. et. al. Effect of prewarming on postinduction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general Anaesthesia. BJA. Nov.2008;101(5):627-631.

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