Reducing hospital-acquired infections is a top priority for CMS, the CDC and healthcare providers. While significant progress has been made over the past decade to decrease certain types of hospital acquired infections (HAIs), progress on surgical site infection (SSI) reduction has been mostly stagnant.
This article was written in collaboration with Prescient Surgical.
Overall, SSIs occur in 2 to 5 percent of all inpatient surgeries and affect as many as 300,000 patients every year. The estimated annual cost of treating SSIs ranges from $3.5 billion to $10 billion, according to research compiled by the American College of Surgeons.
While the overall SSI rate is alarming — especially since many SSIs are preventable — even more concerning is the rate of SSIs for high-risk surgeries. For example, colorectal surgery is associated with SSI rates that are 5 percent to 45 percent higher than other forms of surgery.
Becker's Hospital Review recently spoke with three leading surgeons about SSIs and what actions can be taken to help protect high-risk surgery patients from these infections. The surgeons discussed why SSI rates remain so high for abdominal surgeries and what their organizations are doing to help reduce SSIs.
Participants included:
• J. Augusto Bastidas, MD, surgical director of Los Gatos, Calif.-based National Surgical Associates
• Kevin Chan, MD, associate clinical professor in the division of urology and urologic oncology in the department of surgery at Duarte, Calif.-based City of Hope
• Ran Kim, MD, colon and rectal surgeon with Concord, Calif.-based John Muir Hospital Dr. Bastidas' practice focuses on gastrointestinal surgery, including patients with gastrointestinal cancers. His patients represent a high-risk population as they tend to be older and frail. Dr. Chan specializes in bladder reconstruction for patients with bladder cancer. Dr. Kim performs several types of complex abdominal surgeries.
Dr. Bastidas' practice focuses on gastrointestinal surgery, including patients with gastrointestinal cancers. His patients represent a high-risk population as they tend to be older and frail. Dr. Chan specializes in bladder reconstruction for patients with bladder cancer. Dr. Kim performs several types of complex abdominal surgeries.
Note: Responses have been edited for length and clarity.
Question: Why do SSIs remain such a significant problem, especially for abdominal surgery?
Dr. J. Augusto Bastidas: No part of the human body is sterile. There are bacteria on the skin and in the gut. Wound infection will occur in any environment. Because I have a high-risk patient population, I expect a soft tissue infection rate in the 10 percent to 20 percent range.
Dr. Ran Kim: Abdominal surgeries deal with cutting and perforating the intestine, and exposure of intestinal contents. These surgeries often involve a big incision, often around 10 inches. The bigger the wound, the greater the risk of contamination from bacteria.
Dr. Kevin Chan: The surgeries I perform involve making a new bladder, which is very complex. The bowel is open for a long period, typically over an hour. It's messy, and complications, infections and readmissions are common. It is part of the nature of the surgery.
Q: Is the SSI problem being overlooked or taken for granted? Do some surgeons believe their SSIs rates aren't a problem?
Chan: I certainly don't overlook or take SSIs for granted. Radical cystectomy with urinary diversion has an expected 60 to 80 percent complication rate and about 30 percent of major complications are infections. My mission in life is to lower complication rates. Working to further lower SSI rates is essential because SSIs have costs to the hospital and to patients. There is morbidity, there is pain for patients, there are readmissions and additional procedures and there are a lot of downstream consequences.
Kim: When I did my residency training, which was before 2000, there was no talk about SSIs. But about seven or eight years ago that changed. It was driven by hospitals, which realized that SSIs and readmissions are very costly. Most hospitals and health systems have now made surgeons aware of the problem.
Bastidas: I think many surgeons are unaware of their actual complication rates. There are not always systems in place to track infections and provide data to the surgeon. That’s a big problem because if you are not aware of the data, you can't address it.
Q: What are you and your hospital doing to decrease SSI rates for high-risk surgeries?
Kim: The first step my hospital took was to make doctors aware of SSIs by assigning surgeon and physician leaders to talk about it. The next thing was to adopt the national Enhanced Recovery After Surgery protocols. These protocols focus on ensuring patients recover quickly. ERAS protocols include practices to minimize ileus, such as having patients chew gum shortly after surgery. Protocols also include identification of specific antibiotics to prevent an SSI. ERAS is not done by individual surgeons; it has to be driven by the institution.
Bastidas: There are many things we try to decrease the infection rate. One is to adopt bundles to address risk factors preoperatively, perioperatively and postoperatively.
Q: What new technologies are emerging to fight SSIs? What are your experiences with them?
Kim: There are two types of technologies: "system" and "device" technologies. System technology means using protocols and taking more of a team approach.
In terms of device technology, there are vacuum-assisted wound closure technologies that capture drainage from a wound and filter it through a sponge. These technologies help a wound heal faster and are used after surgery.
A new device used during surgery that can prevent infections is CleanCision. It uses the idea introducing a wound protractor into the abdominal cavity, but CleanCision is also expandable. This technology also allows a wound to be irrigated during surgery with an IV fluid containing antibiotics. It prevents infections through these two mechanisms: protecting the wound with a plastic guard and providing constant irrigation during surgery.
Bastidas: There is a new device (CleanCision) that not only provides a physical barrier in the wound to protect the exposed incision from contamination, but it is also constructed to irrigate and maintain the subcutaneous tissues and skin. There are good data showing that this significantly decreases bacterial contamination.
I’m very happy with the results. The effect of the irrigation system is evident. Most of my operations are four, five or even six hours. When you take the device off and look at the wound, you can tell that the tissues are healthier and cleaner than without the technology. We are early in our experience, but we expect to see a lower wound infection rate. One technology will not eliminate SSIs, but this is the best I have seen.
Chan: This new device from Prescient Surgical is very promising. It seems like a potentially low-cost measure to continuously irrigate the wound throughout the operation. It seems like a no brainer that could improve surgical site infections. It's one of the best things that have come along in the 15 years that I’ve been in practice.
Q: What have been your experiences evaluating, adopting and advocating for emerging technologies?
Chan: Ideally, it is beneficial to do a prospective trial. But that’s not always possible. Every surgeon has to use their judgment and determine, "Does this make sense? Is it going to hurt the patient?" Hospital leaders also need to look at the costs of a new technology. For CleanCision, it's an easy decision. It doesn't add time to the surgery. There is no downside for the patient. It's not super expensive and if you can eliminate even one or two infections, you make your money back.
Kim: Fortunately, my hospital is open minded. They think about how technology decisions will benefit both patients and costs to the hospital. Since we do not yet have data on CleanCision, I have anecdotally told stories about how it works and benefits patients. I have explained that there are no extra incisions. There is no trauma to the organ tissues. The surgery itself doesn't take any longer. And, there are benefits to patients because it cuts the infection rate. My hospital said let's do a one-year trial to gather data on the infection rate.
Bastidas: I perform surgeries at three hospitals. Each has a different process for bringing in new technology. Some hospitals focus on the added cost of a device, while others focus on the overall savings. Since a wound infection might cost $15,000 to $30,000, it is a simple analysis to show that dropping your SSIs has high value.
Conclusion
Abdominal surgeries are complex and by their very nature increase the risk for SSIs. Surgeons are aware of the consequences of SSIs for patients and the financial implications for hospitals. Surgeons, in conjunction with hospital leaders, are embracing protocols and bundles to reduce SSI risks by implementing disciplined processes before, during and after surgery. However, to date most efforts to address SSIs have concentrated on activities before or after surgery. CleanCision provides an innovative tool to be used during surgery that has the potential to dramatically decrease infections. Surgeons who have used CleanCision are effusive in their reaction that this innovative device can reduce infections by protecting incisions from contamination and by continuously irrigating wounds with antibiotics. It is clear that adopting new technologies requires surgeons to make the case for how the technology will reduce SSIs, benefit patients and protect hospitals financially by preventing readmissions and reducing costs.