When Joe Corcoran, MD, performed a procedure, he was meticulous in taking precautions to prevent infections both in and out of the OR. He wouldn't even wear his surgical scrubs outside the sterile core. As chair of the OB/GYN department in a Florida hospital and father of two young children, he knew how important it was for his patients - women with new babies - to be able to go home and enjoy the first few days of their newborns' lives. He kept up to date on SSI literature and ensured prophylactic steps were taken in his ORs.

When he could still practice, that is.

In 2003, Dr. Corcoran underwent surgery for a herniated disc. He ended up with an SSI of devastating proportions, one that essentially ended his clinical career. He experiences pain in his legs and lower back daily, even though he routinely undergoes physical therapy. His household income has plummeted to one-quarter of what it once was.

In short, it's turned his life upside-down.

As Dr. Corcoran has learned, the smallest breach, the tiniest break in infection protocol can change a patient's life forever. Further, even one SSI can affect everyone on the healthcare chain: you, your surgeons, your facility's bottom line. Here's what you need to know to understand the impact of SSIs.

Raw statistics
The CDC estimates that 320,000 SSIs occur each year, accounting for as many as 16 percent of all healthcare-acquired infections. In fact, SSIs are the third most common type of nosocomial infection behind urinary tract infections caused by catheters and various pneumonias. They can result in death or, as in Dr. Corcoran's case, a lifetime of disability.

There are two kinds of SSIs, as defined by the CDC: superficial and deep incisional. The soft-tissue infections usually appear three to five days post-op, and some of the most severe infections can appear up to a year after the procedure. As the severity of the infection increases, so does the cost of aftercare.

Overall, SSIs incur $1 billion to $10 billion annually in direct and indirect medical costs, according to the CDC. It's estimated that this complication costs each hospital an average of $1.3 million. A 2004 report on Pennsylvania hospitals released by the Pennsylvania Health Care Cost Containment Council showed patients with healthcare-acquired infections cost hospitals seven times more than patients who didn't develop an infection and result in 1,456 more patient deaths and 227,000 additional hospital days.

Tracking SSI costs
While many hospitals don't track SSIs (because most don't have to - only six states currently require hospitals to report SSIs), the CDC does. It uses what it calls targeted surveillance to run the National Nosocomial Infections Surveillance. This technique calls for tracking only certain types of SSIs in acute care units of member hospitals. Because this method doesn't cover all SSIs or track all hospitals, the overall financial impact of SSIs can only be estimated. But there are many factors to scrutinize in order to get a better sense of the subtle but tremendous effect of how SSIs can hurt profits.

An estimated 47 percent to 84 percent of SSIs occur after discharge, with nearly one in four patients admitted for SSIs ending up at a facility other than the one in which they had the initial surgery. Likewise, the CDC estimates that 24 percent of the costs attributed to an SSI occur beyond the cost accounting system of the hospital where the procedure initially took place.

Enough resources?
The most obvious impact of SSIs comes from extended hospital stays. On average, a patient prolongs his time in the hospital by seven or eight days.

Robin Chard, RN, MSN, CNOR, clinical assistant professor at Florida International University, explains: "Normally, if you look at the path of someone having a surgery, there is an expected length of time for them to have a procedure. If there's a possibility of infection, it could delay discharge. Or they could be readmitted long after going home. The institution is going to incur the cost of caring for the patient."

When this happens, bed utilization becomes more of an issue since patients aren't turning over as planned, says Janice Rey, MT (ASCP), CIC, an infection control practitioner at St. John Hospital and Medical Center in Detroit. This trickles down to more demands on staff time, antibiotics, dietary needs, linens, hospital equipment and even utility costs. Plus, SSI patients are more likely to require radiology tests.

If SSI patients are at home, they're more likely to require home healthcare provider visits, and they'll likely want more home health visits than Medicare or a third-party payer allows. Dr. Corcoran received home healthcare visits for 14 weeks, in addition to making a weekly visit to the wound care clinic at the hospital.

In addition, SSI patients are more likely to call their doctors and want a 24-hour hotline to contact a healthcare practitioner. They're also more likely to visit the emergency room and more likely to require a stay in a skilled nursing facility, say experts. Those consequences translate into a cost burden on hospitals and patients if insurance companies aren't willing to shoulder the SSI cost.

Left vulnerable
The current trend of shorter post-op stays has also affected SSIs.

"Now, it's in and out. You can have major surgery and go home the same day," says Ms. Chard. "Patients are going home with fresh wounds and they have to do more for themselves. They're sent home with drains and catheters, so home care becomes important."

If patients aren't thoroughly educated or don't receive adequate home care, there's a higher chance SSIs may occur. Further, obese or diabetic patients have a higher probability of suffering SSIs. Smoking history also affects the chances SSIs will develop, warns Ms. Rey.

The recent Pennsylvania study estimates that Medicare and Medicaid paid out $614 million in 2004 for healthcare-acquired infections. However, hospitals may not be compensated if patients come in for one treatment and develop other problems.

ASCs not immune
There's not a lot of accurate data that outlines how SSIs financially impact ASCs, says Jan Schultz, RN, MSN, president of Jan Schultz and Associates, an infection control consulting firm, even though four of five surgeries take place in an ASC. While ASCs may feel the effects down the road in the form of lower reimbursements from third-party payers trying to recoup profits, hospitals are often left to absorb the costs, as a patient experiencing SSI symptoms would likely go to a hospital to have the surgical wound checked.

If your infection rate runs high, word will get around in the medical community, likely not only among patients and potential patients, and "the physicians may decide to go somewhere else," warns Ms. Schultz.

That's because physicians want to minimize the risk that they'll be sued, in a time when medical malpractice suits are on the rise and related insurance costs are skyrocketing. Dr. Corcoran says he "chose not to sue because I felt my surgeon had done everything he could to prevent an SSI."

But many patients don't have that sort of confidence in their surgical teams and may feel it's their right to sue when an unplanned complication such as an SSI occurs, say experts. Plus, there are plenty of malpractice lawyers advertising their services and promising the world. An SSI patient could potentially sue the doctor, the facility and even the surgical team.

Many ASCs don't have a lawyer on retainer, says Ms. Schultz. If a patient decides to sue, this means forking over the funds for a lawyer in addition to the cost of a settlement or defending a suit. A lawsuit could also mean a potential loss of revenue-generating business.

Stepping back
Comprehending the entire SSI picture is not an easy task. At first, the bottom-line numbers may not all look concrete, but the consequences can be far-reaching: In addition to the burden SSIs place on the healthcare system, consider that 46 million uninsured in the country suffer SSIs. These patients may have to pay out of pocket for medical expenses, often digging them deep into debt.

More importantly, the patient's world can be deeply affected, as Dr. Corcoran's has been. Still, he holds no ill will toward his surgeon, whom he calls a "perfectionist." It's not clear how Dr. Corcoran developed a SSI, but he's confident his surgical team was just as painstakingly careful as he himself had always been.

He theorizes the cause was simply something the housekeeping team might have coughed or sneezed in the room or into the air supply system. That small breach in sterility, which probably happens daily in ORs nationwide, has ended the career he's trained for since he was a teenager. Dr. Corcoran endures discomfort every day, and his doctors tell him it's unlikely that his pain will ever subside.

His story reminds that the care you provide extends beyond the patient's discharge. When you combine that with the opportunity to maintain your surgical facility's profits by taking precautions to prevent SSIs, the need for more work and better data in this area is clear.