FOREIGN BODY The implants used in hip and knee replacement procedures make these patients particularly vulnerable to surgical site infections.

What makes hip and knee replacement patients particularly susceptible to infection is the fact that we're introducing a foreign body in the form of an implant, which increases the risk for infection. Here are 4 pre-operative steps that can help prevent SSIs in your joint replacement patients and the subsequent complications that require readmission.

Screen for staph. Implement an infection-screening program that tests patients for Staphylococcus aureus infections before surgery and decolonizes those patients who are carriers. The nose is a virtual reservoir for staph infections. Obtaining a pre-op nasal culture from hip and knee replacement patients is the simplest and most effective way to screen for staph infections. The risk for staph infection after surgery will still be present, but screening and decolonizing before the procedure can decrease the likelihood of infection occurring during the intraoperative period, when the patient is most vulnerable. To screen, culture the nares with a swab. Treat carriers of S. aureus with a 5-day course of Bactroban ointment (mupirocin) in the nose and chlorhexidine baths.

Administer antibiotics. Give prophylactic antibiotics to hip and knee replacement patients about 1 hour before the initial incision, typically when the patient is in the OR or the pre-op holding area. This timeframe is particularly important because you want to have good antibiotic levels in the blood and at the surgery site when the surgery begins and throughout the procedure. Quick-acting antibiotics such as Cefazolin target bacterial infections in the joints and don't typically cause adverse reactions. For patients with a history of MRSA, or those at high risk for MRSA — including those who have been hospitalized for more than 48 hours and those who reside in long-term care facilities — prophylaxis may also include Vancomycin, a naturally occurring antibiotic indicated to treat MRSA.

REHOSPITALIZATION The average hospital stay for study patients rehospitalized for SSIs was 8.6 days, costing an average of $26,812.

THE STEEP PRICE OF SSIs

Rehospitalizations Cost Healthcare System Millions

It costs as much as $65 million a year to treat complications in patients who develop infections after hip or knee replacement, according to a recent Detroit Medical Center and Wayne State University study.

Among the study's 174,425 patients who underwent hip or knee replacement, 2,134 (1.2%) were hospitalized for a surgical site infection within 1 year of their procedure. Among them, 267 (12.5%) were subsequently rehospitalized in the year after the initial SSI hospitalization due specifically to SSI-related issues. Data also showed that 40.8% of patients with SSIs were hospitalized for other reasons — labeled as "all cause" — within the first year after their diagnosis. This accounted for 1,770 readmissions.

The average hospital stay for study patients rehospitalized for SSIs was 8.6 days, costing an average of $26,812. Additional "all cause" hospital readmissions were associated with an average hospital stay of 6.2 days, with an average cost of $31,046.

— Mark McGraw

Tell patients to bathe. Before surgery, it's important to reduce the normal skin bacteria that can cause infection at the surgical site. Advise patients to shower or bathe the night before and the morning of surgery with chlorhexidine gluconate (Hibiclens). The soap comes in a liquid form or in a scrub-brush applicator, either of which is acceptable to use. Provide patients with written bathing instructions for the night during their pre-op visit. Patients should apply the chlorhexidine soap to the entire chest and abdomen area, only from the neck down. Using the soap on the face or genitals can cause permanent injury to those areas. Patients should wash thoroughly but gently for 5 minutes, paying special attention to the area where the surgery will be performed, and turning the water off to prevent rinsing the soap off too soon. Patients shouldn't wash with regular soap after using chlorhexidine. Nor should they apply lotion, powder, deodorant, perfume or any type of aftershave.

NO NICKS Removing hair with clippers instead of a razor doesn't create nicks for bacteria to enter.

Remove hair. Removing the hair around the surgical site before joint replacement is a common practice at many facilities. How you remove the patient's hair, or if you remove it at all, is typically a matter of physician preference. But from an infection control standpoint, avoiding hair removal altogether is advised. If hair must be removed, using clippers instead of a razor is the safest pre-op hair removal option for hip and knee replacement patients. Have a nurse or other staff member remove the hair with clippers immediately before the procedure. Shaving with a razor creates nicks, nooks and craters in the skin that provide bacteria with multiple points of entry and reservoirs in the skin and subcutaneous regions that increase the risk of infection. Surgeons who favor razors typically cite the ability to get a closer shave, but clippers should be able to adequately clear the small amounts of hair around the hip or knee area without the risk of nicking the skin.