Surgical site infections (SSIs) impact nearly 750,000 individuals in the United States (1), lengthening a patient’s hospital stay for as many as ten days and increasing costs by $20,842 per admission (2). As 2009 comes to an end and a resolution on new healthcare legislation appears imminent in 2010, reform remains top of mind. On December 6-9, the Institute for Healthcare Improvement’s 21st Annual National Forum brought together industry leaders, highlighting quality-improvement issues such as SSIs that influence the healthcare reform debate.
Three pivotal studies at this year’s conference demonstrated how simple measures – such as applying skin antiseptic before surgery – can significantly decrease surgical site infections. Preoperative antiseptic skin preparation to reduce infection-causing microorganisms is recommended for the 27 million patients in the US undergoing surgery each year, but there is still a need for education and practical application (3).
With the introduction of 2% chlorhexidine gluconate (CHG) non-rinse cloths into their preoperative skin preparation regimen, these three hospitals were able to quantify the clinical and economic returns of shifting to a preventative approach to patient care.
St. Mary’s Regional Medical Center in Russellville, AR significantly reduced SSIs by standardizing a skin preparation protocol in the orthopedic operating room. After Monica Baxter, RN, MSN, CIC noted an increase in joint infections, the center implemented a preoperative skin preparation regimen for “night-before and morning-of” surgery.
Two percent CHG non-rinse cloths were used on patients undergoing orthopedic surgeries. While the medical administration record was utilized for tracking the “morning of” skin preparation, monitoring compliance to the “night before” skin preparation required staff to instruct some patients on how to take care into their own hands.
Due to their preventative measures, St. Mary’s Regional Medical Center had substantial economic savings from a cost-avoidance standpoint. The cost of utilizing the 2% CHG cloths was $1,080. The facility reduced their SSI rate by 66 percent and saved approximately $123,920 compared to SSI-related costs incurred pre-intervention.
In another study, total joint SSI rates decreased from 3.2 to 1.1 at Lakeview Hospital in Minnesota when they revised their skin preparation protocol in April 2006 to include treatment with 2% CHG cloths the night before and day of surgery. To ensure compliance, patients’ at-home skin preparation was reported to the preoperative holding area and the number of 2% CHG cloths distributed per surgery was recorded.
According to Deb Eiselt, RN, BSN, and author of the study, patients and those involved in their care were strongly encouraged to participate in a total joint class prior to the surgery.
The class provided information on preoperative skin preparation and gave patients the 2% CHG cloths to utilize the night before. “Educating patients on preoperative skin prep is critical, otherwise they just wouldn’t do it- placing not only themselves but the hospital at risk,” said Eiselt. “Patients deserve to know what measures they can take to stay healthy.”
In yet another example of simple solutions in prevention, the Medical Center of McKinney (Texas) utilized 2% CHG cloths to facilitate SSI prevention in the Labor & Delivery area.
A 2005 survey by the World Health Organization reported that women who have cesarean sections are five more times more likely to develop infection than those who have a vaginal delivery. When the Infection Control Department noted in 2006 that the SSI rate associated with C-section delivery was over the national benchmarks, the team focused their quality improvement effort on preoperative skin preparation, which included whole-body skin prep with 2% CHG cloths the night before surgery.
In 2007, the Medical Center of McKinney saw SSI rates decrease, but not all were eliminated. A chart review revealed that some patients were not able to receive the night-before skin prep. As a result, the team changed the protocol, adding a whole-body skin prep in the Labor and Delivery area. By the end of July 2009, the facility saw a 73 percent relative reduction in SSIs.
“Our protocol changed in August 2008 when it was decided that the orders for C-section would include 2% CHG. This assured the use of the cloths but also seemed to enhance the value of 2% CHG preparation- a simple front-end component that can enhance progress towards safer care,” said Thomas Button, RN, NE-BC, CIC, lead researcher of this study. “The OB/GYN Medical Staff have been instrumental in documentation of use and ensuring protocol compliance.
Staff communication is fundamental to realize what opportunities we have to effectively improve prevention efforts. By sharing our outcomes, hospitals can learn that paying attention to infection control can be a crucial step towards healthcare reform in the right direction.”
(1) Perencevich EN, Sands KE, Cosgrove SE, et al. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis. February 2003;9(2):196-203.
(2) de Lissovoy G, Fraeman K, Hutchins V, et al. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387-397.
(3) Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250-78;quiz 79-80.