Surgical site infections (SSIs) complicate about 780,000 procedures a year, or about 2.6 percent of all surgeries performed annually in the United States, according to the Centers for Disease Control (CDC). SSIs carry a heavy financial burden, costing U.S. hospitals more than $1.5 billion in additional medical treatment each year. Patient stays increase 20-fold and costs quintuple when SSIs are involved in the surgical recovery process. The CDC estimates an average of 12 days and more than $27,000 in additional costs as the result of one of the most common SSIs, Staphylococcus aureus, or staph infection.

While most of these infections occur in inpatients, ambulatory patients are also susceptible, and these cases are more difficult to track. An SSI that originates in your facility may take up to 30 days to appear in a patient, and you may never know about it unless that patient calls his surgeon or is admitted to a hospital for treatment and the surgeon or the facility then contacts you.

We interviewed a number of experts about how to design and implement an SSI program for ambulatory patients - one that facilitates communication between surgeons and surgical facilities, helps pinpoint the causes of individual infections and alerts the facility if there's an unexplained rise in infection rates.

Educate your patients
Tracking SSIs in ambulatory patients relies heavily on the ability of patients and their caregivers to recognize the signs of an infection (including drainage, pain, tenderness or heat at the incision site, or a persistent fever) and report them to their surgeons. Experts recommend giving patients detailed instructions in writing and emphasizing these instructions in a post-op phone call. Make sure your patients know that they should call their surgeons immediately if they notice any of these signs up to 30 days after their procedure.

Obtain surgeon buy-in
Although patients may call you directly, your primary source of information about possible SSIs will be your surgeons. Your challenge is to design a simple, seamless way to collect this information, says Farrin A. Manian, MD, infectious disease specialist at St. John's Mercy Medical Center in St. Louis. Otherwise, surgeons may tend to underreport incidences or not report them at all. Surgeons generally have three concerns about any tracking program, says Dr. Manian: "They want to know how the data will be used, if the rates are going to become public and if the data-collection process is going to be time-consuming."

It's also important to ensure that the system is collaborative and non-threatening. "The infection control department can be perceived to be like the police, and it's important to get past that," says Pam Webb, RN, CIC, infection control coordinator at Benefis Healthcare in Great Falls, Mont. "You want your surgeons to view the program as a support system, rather than a punitive system."

To address these issues and obtain surgeon buy-in, experts recommend taking the following steps:

• Emphasize that the program is designed, first and foremost, to improve patient care, not single out or punish physicians.
• Obtain backing and involvement of a few key players - ideally, the medical director and an infectious-disease physician - who can address surgeons' specific concerns.
• Point out that although you may have relied on voluntary reporting in the past, regulatory agencies such as JCAHO require that you have a more proactive system in place.
• Emphasize that individual surgeons' infection rates will not be made public, although some states have recently passed laws requiring facilities (not individuals) to report their infection rates. Tell your surgeons that the push to report institutional infection rates makes it even more important to ensure that the tracking process is credible and meaningful.
• Stay up to date on the latest research concerning SSIs, and share this information with your surgeons.

Build an infection control team
The infection control team develops and monitors an SSI-tracking program and analyzes, interprets and acts on the results. Experts recommend that the following individuals get involved:

• The medical director, to promote the program and help obtain surgeon buy-in.
• An epidemiologist or infectious-disease physician, to help design the program, follow up on specific SSI incidences and provide consultative services to surgeons.
• A statistician, to ensure that the data is analyzed in a statistically valid way.
• The surgical services director, OR manager or facility administrator, to manage the day-to-day aspects of the program and help communicate the results.
• An OR nurse, to handle survey distribution and collection.
• An infection control nurse, to review detected infections to determine if they're indeed SSIs.
• A software designer or application engineer to design, to manage and provide technical support for the computer programs that you'll need to collect and analyze the data.

Be proactive
While many facilities rely on a voluntary reporting system, experts generally agree that to get accurate, comprehensive information, you need to ask for it. To ensure cooperation from your surgeons, it's critical to keep the data-collection process as simple as possible.

At St. John's Mercy Medical Center, every surgeon receives a monthly survey that includes a paragraph that emphasizes the importance of cooperating with the tracking process and lists the CDC criteria for wound infection. The survey then lists each patient's name and the date of surgery and asks the surgeon to indicate whether an infection was present. "This keeps the process very simple for the surgeon - it's not at all labor intensive," says Dr. Manian. The surveys are sent at least 30 days after the date of surgery to ensure that enough time has passed for an infection to show up - surgeons won't be queried about June's patients, for example, until late July or early August.

Getting surgeons to fill out and return surveys might be particularly difficult in ambulatory surgery centers, as physicians come from a multitude of different areas, says Anne Cole, director of the Ingalls Same Day Surgery Center in Tinley Park, Ill. Our experts offer the following tips to encourage surgeons to respond promptly:

• Make sure that a nurse or other staff person who has a good working relationship with surgeons is in charge of distributing and collecting the surveys. "We've designated an OR nurse, who has a great rapport with the surgeons and works with them every day, as the point person for survey collection," says Ms. Cole. "This way, surgeons don't feel as if they're responding to a purely management initiative - the push comes from the OR itself."
• Inform the administrative staff at each surgeon's office about the importance of the tracking program so they're more likely to bring the surveys to the surgeon's attention.
• Make it easy for surgeons to respond - if you're mailing surveys, include a self-addressed stamped envelope, or have them fax surveys back to you.
• If you get no response from a surgeon, have someone from management, such as the medical director or administrator, make a follow-up call.

The experts we spoke with who regularly send out surgeon surveys boast a 90 percent to 100 percent response rate, but this didn't happen overnight. Almost everyone reported some initial surgeon resistance, which they overcame with persistence and communication.

Network with neighboring facilities
Besides being notified by surgeons and patients, you can be alerted to an SSI that originated at your facility if a patient is admitted to another facility for treatment of the infection. Freestanding surgery centers, in particular, must develop good relationships with neighboring hospitals that might admit patients for SSI treatment, says Dr. Manian.

When you detect an SSI
When an SSI is detected at your facility, you'll need to examine all the documentation pertaining to the case, including the patient's chart, the surgical notes and the sterilization records, to pinpoint the cause. Factors to consider include:

• the OR the procedure was performed in,
• surgical team members,
• the patient's clinical status before surgery (whether the patient had a preexisting infection, for example),
• the reason for the surgery,
• the use of any new products or any new protocols and
• microbiological or wound culture data.

You also want to ensure that every precaution was taken to prevent infection, from administering prophylactic antibiotics, if warranted, to using clippers instead of razors to remove hair from the surgical site.

It's likely that you'll find that the infection was an isolated incident and doesn't indicate a system-wide problem. But it's important to investigate each incident in detail so you can identify trends and pinpoint possible causes. Infections can be linked to specific procedures, surgeons or even the time of year. For example, a study at St. John's Mercy Medical Center showed that patients having spinal procedures on the same day of their admission to the hospital during the warmer months had a significantly higher risk of developing SSIs than inpatients having the same procedures during the same months, even though the former patients were generally healthier. Lack of uniform skin cleansing and disinfection and possibly increased sweating due to heat and humidity were thought to be contributing factors. The hospital acted by having patients wash their backs with chlorhexidine soap the night before.

Analyzing the data
Enlist the services of a statistician to ensure that you analyze your data in a statistically valid way, advises Jane Garb, a biostatistican and epidemiologist at Baystate Medical Center in Springfield, Mass. For example, you'll want to establish benchmarks for "usual" levels of infection and derive a statistically valid definition of "excess" levels of infection for each type of procedure, says Ms. Garb. The result is a more refined, meaningful rate.

Finally, experts suggest that you report on your SSI tracking system's overall findings at least once a year. Have rates increased or decreased? What about rates for specific procedures? Some facilities present the information at various committee and staff meetings; others publish the data in internal newsletters. Whichever method you choose, it's important to let everyone know that your tracking program is alive and kicking.