In 2003, when JCAHO began its new emphasis on infection control measures, we undertook a major initiative to reduce the number of surgical site wound infections. But even with a multidisciplinary committee on the case and a 97 percent compliance rate for delivery of prophylactic antibiotics within 60 minutes before surgery, we still weren't able to dramatically reduce our SSIs as we would have preferred. We ended up looking at our wound closure methods, and found great success with a new protocol that doesn't call for extra manpower or supplies ' just a couple additional minutes. Here's a look at our wound closure protocol, which you can easily implement in your facility for any procedure.

The first steps
After doing the normal trending ' OR room, OR staff, surgeon, time of day, day of the week, anesthesia provider, OR team members and post-op nursing unit ' we didn't see any trends. So we took a look at our patient indicators, such as hyperglycemia (blood glucose greater than 140 mg/dL), depth of adipose tissue and hypo-albuminemia (serum albumin less than 3.3 g/dL), all of which are known to be influential as possible predictors for SSI. That's where we did start to see some trends. We found an article that indicated the incidence of infection in patients whose subcutaneous tissue depth was greater than 2.5cm was much higher than in those whose subcu depth was less than 2.5cm.1

We decided to take this information and direct it toward a target patient population of abdominal hysterectomies. Donna volunteered to review the chart of each patient who had undergone an abdominal hysterectomy and who had developed an identified SSI, noting these variables. When these three parameters were plotted, we discovered a definite trend: Each patient who had developed an SSI had one or more of the indicators. We asked the department of OB-GYN to begin instituting a wound closure protocol on all abdominal hysterectomy patients who met the inclusion criteria.

While our long-term goal was to address all the issues, we decided our first goal would be to develop the protocol for wound closure on the hysterectomy patients addressing the subcutaneous fat issue. Donna drafted the wound closure protocol that was subsequently implemented.

The criteria
The protocol (see "10-step Wound-closure Procedure") is simply a way of stringently cleaning the wound before closure. The materials required for this closure modification are included in the supplies necessary for all procedures, so no additional costs are incurred. It's a simple practice that is quick, easy, cheap and effective.

We have seven criteria for inclusion in our wound closure practice; it is followed if the surgeon requests that it be used, or if the patient is

• age 18 years to 90 years,
• female,
• obese (subcutaneous tissue depth greater than 2.5cm),
• suffering from Type I or II diabetes (regardless of glycemic control),
• with pre-op albumin greater than 3.3 g/dl or
• with pre-op glucose greater than 150 mg/dl.

Any criterion is enough for us to enact the protocol. There are only two exclusion criteria: surgeon discretion and subcutaneous tissue depth less than 2.5cm. Otherwise, regardless of surgery type, we follow the protocol.

Physician acceptance
Given the fact there would be little change in the makeup or sequence of the normal closure, we were confident our surgeons wouldn't resist the change much. We weren't asking them to change their practice with regard to suture material or method of skin closure. At the time in the closure sequence that the changes would take place, the surgeon usually has already broken scrub and the PA-C closes the remainder of the wound.

During the 90-day trial using this process, there were zero reported SSIs for our targeted abdominal hysterectomy procedures. As there were no other interventions implemented in this group of patients, we felt confident establishing a cause-and-effect relationship between our protocol and the SSI reduction. We presented the results at a subsequent OB-GYN committee meeting, and again at the department of surgery; our surgeons endorsed its application for all abdominal surgical wounds.

Preventive step
As this practice has taken hold, we've gone into a more prophylactic mode and have adopted this closure model for all our patients. Whether you're talking about C-sections and hysterectomies or arthroscopic knee procedures and laparoscopic cholecystectomies, if patients meet the criteria for inclusion ' especially those who are diabetic or obese ' this protocol is a good prophylactic measure you can easily and quickly implement for very little additional cost.

On The Web
Go to writeOutLink("www.outpatientsurgery.net/forms",1) to download a copy of the Southwest General Health Center Wound Closure Protocol.

Reference:
1. Vermillion ST, Lamoutte C, et al. "Wound infection after cesarean: effect of subcutaneous tissue thickness." Obstet Gynecol 2000 Jun;95(6 Pt 1):923-6.