Surgical site infections in hand cases had long been a problem at our large orthopedic center. As our infection preventionist, I can't say for certain which of the many initiatives we implemented deserves the credit for the significant decrease in hand SSIs, but the one thing I do know is that our SSI surveillance program set the stage for improvement. Monitoring and tracking SSIs and trends made it possible to determine what problems existed and whether our interventions were helping.
Currently, surgical centers aren't required to report SSI rates to the Centers for Disease Control and Prevention, so there aren't published rates we can use to benchmark against. (Rumor has it that may change soon.) But we know we're making strides, and will continue to do so. Here's how we did it, and how you can implement an SSI surveillance program.
Gain support from leadership and decide who'll oversee the program. This is crucial. Make leadership aware that CMS Conditions for Coverage require facilities to:
- maintain an infection control program that seeks to minimize infections and communicable diseases;
- designate a dedicated individual with infection control training to direct the program and activities; and
- have a mechanism in place to immediately implement corrective actions and preventive measures.
In our case, the director of nursing, the director of the ASC and the director of clinics went to our CEO and asked for and got the support we needed.
Decide what types of cases you're going to do SSI surveillance on and how you're going to do it. There are many ways to go about it. We track every procedure. Some monitor specific problem cases for example, total hips, or all foot and hand cases, because those seem to be more prone to post-op infections. If you don't have time or resources to do every single case, you might decide to pull random cases, say, one of every 10. You can get the information you need by checking post-op notes or by e-mailing physicians and asking for reports on patients who've had surgery that month. Facilities with EMRs may also be able to create reports to enhance SSI detection, such as weekly culture reports and/or hospital readmission reports.
For examples of SSI surveillance documents, see outpatientsurgery.net/resources/forms.
Develop a risk assessment and plan. It's important to document your goals, the strategies you'll implement to meet them, your evaluation methods and your progress. Again, make sure leadership is on board and also make sure you regularly update staff members so that they understand the program.
Determine the criteria you'll need put in place to limit your cases to patients with low risk of postoperative complications. For us, that meant patients with ASA classifications of 1 or 2, age 5 or older, non-smokers preferred, and with no communicable diseases or active infections not related to surgical procedures (measles, tuberculosis and chicken pox, for example). We refer patients who don't meet those criteria to a nearby inpatient facility where our surgeons also practice.
Determine which perioperative best practices you'll implement regarding: hair removal, nasal decolonization, maintaining perioperative normothermia, pre-operative skin prep, and timing and selection of antibiotic prophylaxis, based on communicable disease history.
Monitor employees and your environment. Audit hand hygiene compliance. Determine whether staff are following dress code requirements. Do they sometimes have masks hanging around their necks? That's something we've had problems with off and on. Are they changing masks between cases and fully tying them? Some people may tie the top, but not the bottom. During cases, we require anybody who has not scrubbed in to wear a buttoned-up scrub jacket. Monitor wound-care competency. Any staff member who does post-op checks on wounds should complete a wound-care competency assessment every year and be able to pass a quiz. You should also conduct environmental rounds to monitor the temperature and humidity in perioperative areas.
Finally, be sure to document all SSIs that meet the CDC event definition (tinyurl.com/ns4pcy9). You can use paper worksheets, document them on a spreadsheet or use another kind of database. But it's important to always document in the same manner, so you can easily reference data and monitor trends.
Stay on course
As new evidence-based guidelines come forth, we'll evaluate them and implement them if we think they'll help. We know the robust program we currently have in place has improved patient care and safety, and we want to continue to get better.