Infection prevention and control has taken on new importance given the rise of multi-drug-resistant bacteria and increased attention from government, accreditors and professional organizations. Many states now mandate the reporting of healthcare-associated infection rates and Medicare's revised ASC Conditions for Coverage require, among other prevention and control measures, safeguards for detecting and responding to infection incidents. Is your facility ready to take corrective action in the worst-case scenario of a surgical site infection outbreak? The following advice may improve your answer.

What do you know?
Identifying surgical site infections presents a special challenge in the ambulatory surgery setting, where patients are discharged long before such complications become apparent. As a result, it's essential to review your facility's infection risks before an incident or outbreak occurs, and to establish a plan for post-op surveillance to alert you if it does.

Advance preparation can help you to understand what you're potentially up against and even keep you ahead of the curve. At our surgery center, a team of employees conducted an infection risk assessment in which we examined each department and its processes — from pre-op, the OR and PACU to central sterile to the administrative and business offices — to identify existing risks as well as the factors that might increase or decrease those risks. We've followed up with quarterly rounds to keep tabs on infection prevention compliance and address newly discovered risks.

In terms of post-op surveillance, an educated patient is your best early warning system. Along with their discharge instructions, our patients receive a safety information sheet that reminds them to complete their antibiotic regimen as prescribed, observe proper and hygienic wound care and report any symptoms of SSI — redness or pain around the surgical site, cloudy fluid drainage from the wound or fever — to their surgeons.

You'll want to enlist the assistance of, and rely heavily on the surveillance provided by, the physicians who perform surgery at your facility. We supply post-discharge SSI reporting forms to each practice and ask them to notify our infection prevention team of any incidents diagnosed during follow-up visits. It's a faxable form, to make it easy and quick for them to report back to us.

Once a month we also fax them a list of their patients on whom they've performed the procedures that our state requires us to report infection rates, and we track their responses to ensure 100% compliance. We include the faxable SSI reporting form with it as well as the Centers for Disease Control and Prevention's criteria for classifying SSIs. And we monitor communications with local hospitals' infection preventionists for any positive culture reports or hospital admissions that may involve SSIs among our patients.

Reaction time
We routinely log and investigate every SSI incident reported to us. While reviewing this post-discharge outcome data, patient charts, lab reports and other records, we look for commonalities between incidents that might indicate a trend. An outbreak or epidemic is often defined as an incidence rate in excess of the baseline level within a specified area. But if we were to see a trend in SSI incidents involving the same organism, the same type of procedure, the same physician or staff member or the same room, that would raise a red flag. When a trend is identified as a potential outbreak, a special investigation is immediately necessary to determine the magnitude of the problem and take corrective action.

Medicare's Conditions for Coverage for ASCs require each facility to employ a staff member who has been trained in the field of infection prevention, but it's strongly recommended that this special investigation be led by a certified infection control practitioner (CIC), one who understands surgical and sterilization processes and is qualified to conduct an epidemiological investigation. If your facility doesn't have a CIC on staff, but you're affiliated with a hospital or healthcare network, you may have expert resources at your disposal. Alternative-ly, you might confidentially contract the services of a nearby regional hospital's infection preventionist or seek recommendations from APIC, AORN or local or state public health departments.

In addition to analyzing all available documentation and data, the investigation should methodically break down the cases in question, step by perioperative step, in order to locate the source of the infections. For example: What was the pre-op condition of the patient's surgical site? Did they exhibit any pre-existing risk factors for infection? Which skin prep was used? Which drains and dressings? Which surgical instruments? Were they flashed or wrapped? Track the instruments back to their reprocessing, reprocessor and reprocessing equipment. Consult the equipment's biological indicators. Examine any machinery used for the case. Your infection risk assessment may prove useful at this stage of the investigation.

Interview any personnel who came in contact with the patient, as well as the patient himself and his caregiver. Culture the surgical environment, products used and attending personnel if necessary. Compare the infection incident cases with cases sharing similar commonalities to determine whether other patients may be at risk of infection, or what differed in those cases that may have forestalled infection.

Lessons learned
The most important part of the investigation is the interpretation of the results. As soon as you're able to develop a tentative explanation for an SSI outbreak, including the organism, method of transmission and likely source, and test it through comparison with clinical literature or other epidemiological reports, you'll need to initiate control and prevention measures based on your findings. Are hand hygiene enforcement efforts in order? Was a load of improperly sterilized surgical instruments at fault? Do you need to change your environmental cleaning or disinfecting products or techniques?

Whatever the reason, communicate your findings with your facility's administration and staff. Incorporate them into your quarterly (or more frequent) infection control rounds and possibly even your quality improvement efforts. Your surveillance activities should prove a reliable source for evaluating the effectiveness of your infection control and prevention measures: If the SSIs you've been investigating don't reappear, you'll know they're working.

The guidelines on the following page may serve as a reference in preparing for and responding to an SSI outbreak.