The worst sort of problem is one which can’t be fixed by a single, simple solution.
The problem of surgical-site infections is a complex and significant one for both healthcare providers and patients. According to a study by Hollenbeak, individuals with surgical site infections are five times more likely to be readmitted to hospitals.
They are also twice as likely to die. Furthermore, surgical site infections result in cost totals ranging between $5 billion and $10 billion per year, without taking into account additional expenses related to factors such as job loss or malpractice litigation. While there are ways for hospital staff and administration to reduce the prevalence of surgical site infections at their respective facilities, they remain a significant problem for many facilities.
“We’ve made headway over the last few years in some arenas, and not at all in others,” admits Carolyn Twomey, VP of Clinical Affairs for IrriMax Corporation, a provider of infection prevention products.
“Sometimes we take an inch, which is totally fine, but it kind of gets expanded to a mile in cost savings, time savings, or effort savings,” says Wava Truscott, PhD, MBA, Director Medical Sciences and Clinical Education for Kimberly-Clark Health Care, a provider of infection prevention products.
Truscott suggests the problem begins with hospital workers, who she believes are getting somewhat lax when it comes to surgical scrubbing. Generally speaking, she says, today’s workers are less mindful of the frequency and quality of their scrubs.
“People are starting to not give a good scrub in the morning or perhaps in the afternoon after they eat lunch,” she continues. “They are getting things under their nails because you just can’t get the alcohol inside your nails. I’m not an advocate of scrubbing every single time, but at least one or two times that day to get all the dead cells and everything off.”
Then there is the question of what surface disinfectants are being used and if they are being used properly in hospitals and medical facilities.
Truscott says it is a matter of awareness on the part of a hospital staff. Personnel must take note of their own behaviors and keep tabs on the cleanliness of equipment such as carts, apparel, or surgical drapes.
“Sometimes it is just bad habits and practices,” she says. “We lose five million skin cells a day, and at least 10 percent have bacteria on them. So it can be quite easy to contaminate a surgical area and not even realize it.”
Keeping surgical instruments covered until surgery is under way is one key behavior, as is using products that reduce the presence of particulates in the air. Such products include powder-free surgical gloves, low-lint gowns, drapes, wraps, towels, and blankets.
“Lint can get inside of the wound,” says Truscott. “Then you get what is called immune distraction. It certainly can carry organisms into the wound itself, and that can contaminate the surgical wound. But just the presence of those particles, the immune system sees those as a much larger threat than the tiny bacteria, that it focuses on the particles instead of the bacteria and allow the bacteria to multiply to the point where you can’t stop the infection.”
What hospital staff doesn’t know can definitely have negative repercussions. Consider the fact that there is no post-discharge follow-up for infection control other than what surgeons report or when patients come back to the hospital. As a result, it remains difficult to get an accurate handle on the magnitude of problems related to surgical site infections. Of greater concern for many facilities is the potential cost consequences can lead to significant ramifications for healthcare providers thanks to the way Medicare and Medicaid reimbursements occur these days. And if a patient has a resistant infection, particularly if it’s a blood stream or SSI, it is likely going to cost that provider dearly . We are, in fact, seeing patients with infections today that are resistant to all known antibiotics, says Twomey.
Once an incision is made, the cut or hole is a portal of entry for infection. Focusing on what transpires in the operating room in the time between the first cut and the final moment of wound closure is critical to reducing the incidence of surgical site infections. “All other things being equal, the longer the surgery, the greater the risk of SSI” says Twomey, “not only because of the potential for wound contamination but back-table contamination as well. I also note a wide variety of surgical irrigation practices, an area which lacks an evidence-based, standardized approach. In fact, the evidence that is available, suggests that the common approach of irrigating with saline mixed with antibiotics, will do more harm than good.”
“Those people who have a resistant infection are certainly prone to having more resistant infections says Twomey. “I think that while we’ve heard for a long time that the anti-microbial era is almost over. Today, we’re staring it in the face.”
According to Tom Stang, CRCST, CHL, Clinical & Education Manager for Key Surgical, a provider of sterile processing supplies, a successful defense against surgical site infections begins in the decontamination area of any central service or central processing department.
“It is where you are going to disinfect and clean these instruments before they even go to the sterilizer,” says Stang. “If they are not clean, they are never going to be sterile.”
He also suggests improper cleaning at bedside is a factor into why surgical site infections are an issue for many facilities. Nurses are working quickly to deal with patients, and in some cases, they just don’t simply have the time to do it effectively or correctly. Furthermore, some hospitals are operating with fewer surgical techs on staff, so nurses have been forced to take on many added responsibilities in the operating room.
“I think a lot of it comes down to budget and money,” says Stang. “That’s what I’ve always heard… not having the budgets to hire the appropriate staff to do the job correctly and giving more work to fewer people.”
Adequate staff training, clear expectations, effective policies and procedures, as well as helpful feedback from staff are critical to dealing with some of these issues.
“All hospitals are looking at ways to prevent patients from coming back,” says Stang. “Insurance companies aren’t going to pay. Medicare is not going to pay. So they are doing everything they can do.”