Introduction
Surgical site infections (SSI) are surgical wound infections that occur within 30 days after a surgical intervention. Surgical site infections are complications accompanied with significant post-surgical morbidity and mortality (Reichman and Greenberg 2009). Astagneau et al. (2001) pointed that more than 30% of the postoperative mortality can be associated to some extend with some complications related to surgical site infections. SSI’s can vary in severity from small local inflammation on the site of incision to a serious infection that can endanger the life of the patient. The resolution of SSI can also result in serious cosmetic, functional and even debilitating consequences which can affect the future quality of life of the patient (Coello et al. (2005).
The prevalence of SSI varies between different countries. In a research conducted in United Kingdom the prevalence of SSI was estimated to 5% (Smyth et al. 2006). In United States the prevalence of SSI is estimated to rise up to 5% and is constantly monitored by the National Nosocomial Infections Surveillance System (NNIS) (Cheadle 2006). However some authors in US argue that these numbers are not accurate and the real prevalence of SSI in US is around 1% (de Lissovoy et al. (2009). However some developed western countries reported even higher rates of SSI. Couris et al. (2007) report that in the period between years 1995 and 2003 the incidences of SSI ranged between 0.2 and 10.2%. (Smyth et al. 2006) (Cheadle 2006) (Couris et al. (2007)
Current issues with SSI
The main source of infection in SSI’s is the normal skin flora located on the skin of the patient and local antiseptic measures can have a significant impact on the prevention of surgical site infections. SSI’s also accounts for about 15% of all registered nosocomial infections in US and they are the dominant cause of nosocomial infections in surgical patients. This is important having in mind that nosocomial infections are transmitted within the hospital (not originating from the normal skin flora) and in high percentages are caused by multiresistant bacteria that are difficult to treat (Reichman and Greenberg 2009) (Klevens et al. 2007). This is why at the core of the SSI’s prevention is the control of the aseptic conditions before, during and after the surgical intervention. This is a complex process that requires multiple procedures.
Surgical wound itself is naturally very important factor for developing surgical site infections. In a clean wound, as defined by the classification in the “Manual on control of infection in surgical patients”, in wounds without necrotizing tissue, foreign particles and different other contaminations SSI’s occur only in 1.3% compared to contaminated wound (Altemeier et al. 1976) (Culver et al. 1991). Usage of sterile surgical clothing, gloves, and aseptic conditions in the operating room are also very important. The preparation of the surgical incision site is also very important. A Cochran review and a systematic review have shown no benefit from hair removal prior to surgical incision on the reduction of SSI’s incidence (Tanner et al. 2006) (Sebastian 2012). Most importantly some earlier studies have actually shown that shaving (as opposite to clipping) of the hair is associated with statistically significant increase in SSI’s. This is because shaving results in micro-cuts on the skin that predispose to infections (Ko et al. 1992). Antiseptic procedure of the hands and forearms of the surgeon prior to the surgery is important, especially in the case of glove perforation. This is why double glowing versus single gloving significantly reduces glove failure (Caillot et al. 2006). Antimicrobial prophylaxis prior and post surgery is certainly very important, but also important is the accurate timing of antibiotic administration. The Medicare National Surgical Infection Prevention Project in 2003 concluded that antibiotics should be given 60 minutes prior to the intervention and the antibiotics should be terminated 24 hours after the intervention (Bratzler and Houck 2005). An important effort for reducing the incidence of SSI’s is also the implementation of the Surgical safety checklist as defined by the World health organization. Surgical safety checklist is a set of procedures specifically designed to reduce all types of incidences within the operating room, including surgical site infections (WHO 2011).
Discussion of the financial impact of SSI
The prevalence of SSI in 2006 in United Kingdom was estimated to 5% (Smyth et al. 2006). These infections lead to almost twofold increase in hospital stay duration and increase of the individual health care costs that ranged between £814 and £6626 depending on the type of surgery and infection (Coello et al. 2005). As a result of this the increase in annual health costs due to surgical site infections solely, in UK are estimated around £457 million (NICE 2008). In United States the prevalence of SSI is estimated to 5% (Cheadle 2006). It is estimated that SSI in US prolong the hospital stays on average for 7 to 10 day’s which results in increase of the health care spending in US for about $20,842 per patient on average. This drains additional 1,6 to 3.3 billion dollars annually from the US health system. Another aspect of SSI’s is that these incidents are usually subjected to litigation payments and it is estimated that during the period between years 1995 and 2009 a total of 20 thousand claims of negligence were started in UK, which resulted in additional spending of £3.7 billion from the National Health Service in UK (NHS 2010).
In this facility the Surgical Site Infections (SSIs) have increased from 7% to 12% in the last quarter. This information shows that SSI infections rate in the facility are much higher than the average incidences in US and UK which is up to 5%. The SSI’s incidence in the facility is even higher than the highest recorded level in France for the last 17 years. This is sticking data because France is a country that reported one of the highest SSI’s from the countries in the western world (Smyth et al. 2006) (Cheadle 2006) (Couris et al. 2007). These data also show that the SSI’s rate on the beginning of the last quarter was 7% which is also a value above UK and US average. Based on this information’s it can be concluded that the problem with high incidence of SSI’s in the facility is not a new problem but have been present even before the last quarter.
This is unacceptable condition and the ethnology of this trend should be meticulously investigated and recognized. This means that the etiologic factors that lead to high SSI’s incidences were present longer that 4 months and there is a need of a new set of procedures and protocols that should be carefully elaborated and implemented.
CQI plan to improve your facility’s data
Surgical site infections are a recognized health problem worldwide and already there are multiple initiatives and research in order to reduce the incidence of SSI’s. Implementation of the WHO Surgical site checklist is certainly one of these procedures that should be carefully implemented (WHO 2011). It is a well designed list of procedures that should be performed before every surgical intervention and can ensure that all of the necessary precautions have been made in order to prevent any harm to the patient. Another specific protocol for reducing the incidence of SSI’s are the Guidance’s for reducing SSI’s recommended by the National Institute for Health and Clinical Excellence (NICE 2008). This is a set carefully designed procedures that have in mind the new research data. NICE guidance’s for example do not recommend surgical site shaving as WHO Surgical site checklist does, but instead recommend hair clipping using automatic hair clippers. However this disagreement does not mean that the WHO Surgical site checklist should be banned, because the National Institute for Health and Clinical Excellence itself recognizes the benefit from following the WHO Surgical site checklist (NICE 2008).
These sets of procedures should be meticulously implemented and their implementation should and will be monitored by a separate staff-member. This staff-member will manage a specially designed chart that will record the implementation of every procedure from the WHO Surgical site checklist and NICE Guidance’s for reducing SSI’s recommend. These records will then be analyzed on a weekly, monthly and quarterly periods in order to locate the weak points and eventual causes of the high SSI’s incidence.
Conclusion
Surgical site infections are a serious health problem worldwide that can have significant effect on the morbidity and mortality of the patients. SSI’s also have significant economic impact on the health system in one country which can be a important additional burden of the health system. Therefore there is a need for careful preventive measurements because prevention is the most benign and cost effective method for reduction of SSI’s.
References:
Smyth ET, McIlvenny G, Enstone JE, Emmerson AM, Humphreys H, Fitzpatrick F, Davies E, Newcombe RG, Spencer RC; Hospital Infection Society Prevalence Survey Steering Group (2006), Four country healthcare associated infection prevalence survey 2006: overview of the results, J Hosp Infect. 2008 Jul;69(3):230-48. doi: 10.1016/j.jhin.2008.04.020. Epub 2008 Jun 11, PMID: 18550218
de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB (2009), Surgical site infection: incidence and impact on hospital utilization and treatment costs, Am J Infect Control. 2009 Jun;37(5):387-97. doi: 10.1016/j.ajic.2008.12.010. Epub 2009 Apr 23, PMID: 19398246
Coello R, Charlett A, Wilson J, Ward V, Pearson A, Borriello P (2005), Adverse impact of surgical site infections in English hospitals, J Hosp Infect. 2005 Jun;60(2):93-103, PMID: 15866006
Cheadle WG (2006), Risk factors for surgical site infection, Surg Infect (Larchmt). 2006;7 Suppl 1:S7-11, PMID: 16834549
Réseau d'Alerte R d'investigation et de surveillance des infections nosocomiales. Enquête nationale de prévalence (2003), Résultats. Saint-Maurice (France): Institut de Veille Sanitaire; 2003. p. 22. Available from http://www.invs.sante.fr/publications/2003/raisin_enp_2001/raisin_enp_2001_p_19_50.pdf.
Couris CM, Rabilloud M, Ecochard R, Metzger MH, Caillat-Vallet E, Savey A, Fabry J, Vanhems P (2007), Nine-year downward trends in surgical site infection rate in southeast France (1995-2003), J Hosp Infect. 2007 Oct;67(2):127-34. Epub 2007 Sep 27, PMID: 17900755
Astagneau P, Rioux C, Golliot F, Brücker G; INCISO Network Study Group (2001), Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance, J Hosp Infect. 2001 Aug;48(4):267-74, PMID: 11461127
National Institute for Health and Clinical Excellence (NICE) (2008). Costing statement: Surgical site infection: prevention and treatment of surgical site infection, Available from: http://www.nice.org.uk/nicemedia/pdf/CG74NICEGuideline.pdf
National Health Service (NHS) (2010), Litigation Authority - Factsheet 3: information on claims. Available at: www.nhsla.com/Publications/ Accessed 23-11-2010.
Klevens RM, Edwards JR, Richards CL, et al. (2007). "Estimating health care-associated infections and deaths in U.S. hospitals, 2002". Public Health Rep 122 (2): 160–6. PMC 1820440. PMID 17357358
David E Reichman and James A Greenberg (2009), Reducing Surgical Site Infections: A Review, Rev Obstet Gynecol. 2009 Fall; 2(4): 212–221, PMCID: PMC2812878
Altemeier WA, Burke JF, Pruitt BA, Sandusky WR (1976), Manual on Control of Infection in Surgical Patients, Lippincott Williams and Wilkins (November 1976), ISBN-10: 0397503555, p-56
Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS, et al. (1991), Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System, Am J Med. 1991 Sep 16;91(3B):152S-157S, PMID: 1656747
Tanner J, Woodings D, Moncaster K (2006), Preoperative hair removal to reduce surgical site infection, Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004122, PMID: 16856029
Sebastian S (2012), Does preoperative scalp shaving result in fewer postoperative wound infections when compared with no scalp shaving? A systematic review, J Neurosci Nurs. 2012 Jun;44(3):149-56. doi: 10.1097/JNN.0b013e31825106d2, PMID: 22555352
Ko W, Lazenby WD, Zelano JA, Isom OW, Krieger KH (1992), Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations, Ann Thorac Surg. 1992 Feb;53(2):301-5, PMID: 1731672
Caillot JL, Paparel P, Arnal E, Schreiber V, Voiglio EJ (2006), Anticipated detection of imminent surgeon-patient barrier breaches. A prospective randomized controlled trial using an indicator underglove system, World J Surg. 2006 Jan;30(1):134-8, PMID: 16369716
Bratzler DW, Houck PM (2005), Surgical Infection Prevention Guideline Writers Workgroup (2005), Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project, Am J Surg. 2005 Apr;189(4):395-404, PMID: 15820449
WHO (2011), The WHO Surgical Safety Checklist: to reduce harm by consistent use of best practice, National Patient Safety Agency, Quality and productivity example, ID: 10/0008, Published: August 2011, Available from: http://www.evidence.nhs.uk/qipp
