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To Eliminate SSIs, We Went Back to Square One
The way we'd always done things wasn't good enough.
James Harrop
Publish Date: July 25, 2014   |  Tags:   Infection Prevention
administer antibiotics ON TIME, EVERY TIME The literature is clear: When you administer antibiotics is of the utmost importance.

As healthcare providers, we talk a lot about eliminating surgical site infections, but unfortunately, we’re not progressing the way we’d like. We hear success stories, but we’re also confronted daily with the fact that hundreds of thousands of SSIs still happen every year, and that they exact a crushing toll in both dollars and lives.

One reason is that in many facilities, this is the typical scenario: Day-to-day operations hum along the way they normally do, until suddenly one week, month or quarter there’s an unexpected peak in infection rates. No one really understands why, but there’s a lot of talk about what people must be doing wrong and how to do things better. So the facility doubles down and tries to “fix” things without really getting to and understanding the root causes. People pay more attention to sterile technique and guidelines and the rate goes down without a clear understanding. But then, sometime further down the road, it unexpectedly rises again, and the scenario repeats itself.

Sound familiar? One problem is that usually the increased infection rate involves a significantly sized group of surgeons and providers, each of whom does things a little differently. The resulting large number of variables makes it very difficult to isolate probable causes. Unfortunately, unless you drill down to that level of detail, the problem is bound to keep coming back.

The stakes are too high to rely on that approach. SSIs lead to revision surgery, delayed healing, increased use of antibiotics and increased length of stay, all of which in turn lead to increased costs, reduced profits and decreased patient satisfaction.

In the spine department at Thomas Jefferson University Hospital, we set a goal of zero infections. To get there, we decided to try a somewhat radical approach. We rejected the tendency most surgeons have, which is to do things the way they’ve always been done or the way they’ve always done them. We were and are willing to totally change, if there’s evidence to support changing.

We asked ourselves, what are we missing? What can we do better? To start getting answers, we conducted a systematic review of the literature. We looked closely at every relevant piece of information we could find about the things that happen before, during and after surgery — anything that might have an impact on SSIs. And rather than confine our search to the types of surgery we were doing, we looked at all the surgical literature and adapted findings from other areas when we thought it could help further our goal. Here’s some of what we learned and some of what we now recommend.

importance of standardizing STANDARD PROCEDURE Make sure nurses and anesthesia providers recognize the importance of standardizing everything they do.

1. Standardize. As surgeons, we needed to standardize everything we did and make sure we had both nurses and anesthesiologists on board with the idea. We have a standard method for closing, standard sutures and so on. The idea is to eliminate places where things can fall out of the system. That way when an infection occurs, we’re able to confine ourselves to a much smaller set of variables and improve our chances of zeroing in on the cause.

2. Use pre-operative wipes. We all carry bacteria around on our skin. We can’t eliminate it, but the more we can decrease it, the less chance there is of introducing it into the surgical site. To minimize the risk, we tell our patients to use chlorhexidine wipes 24 hours before surgery.

3. Carefully time prophylactic antibiotics. Multiple articles show that the timing of antibiotics is exceedingly important. Too early and the effect will have worn off. Too late, and there won’t be enough time for it to get into the patient’s system. We have a strict protocol and make sure administration takes place within 1 hour of surgery for cefazolin and within 2 hours for vancomycin.

4. Check noses. A certain number of patients carry bacteria in their noses, and a patient with MRSA in his nose has a much higher chance of getting an infection. So as part of our protocol, we now swipe everyone’s noses before surgery. If a patient has MRSA, we treat it ahead of time with a dose of antibiotics.

5. Warm consistently. It’s clear that keeping patients warm before, during and after surgery reduces the chance of infection. This is especially important during longer surgeries — 2 hours or more — which often tend to be more complicated and involve sicker patients. The concern may not be as obvious in outpatient environments, where shorter procedures are the rule, but as more and more procedures migrate to outpatient settings, it’s going to become an increasingly important point to keep in mind.

6. Be mindful and maintain perspective. Your operating room is theoretically supposed to be sterile, but chances are it’s not as sterile as everyone thinks it is. There are organisms everywhere. The more you can limit exposure to them, the better off your patients will be. Should you open a particular instrument at the beginning of surgery, or should you wait until you need it? The more things lie out, the more likely they are to be contaminated. Education and self-discipline are important components. Anything that increases the odds that an organism will come into contact with a patient isn’t a good thing.

Striving for zero
We’ve come a long way since we started this protocol — from an infection rate of about 6% to one that’s between 1% and 2%. But it’s an ongoing process. We continually review the literature to refine our best practices. We determine why every infection occured and how we can prevent it the next time. We consider every infection a failure. That’s what motivates us to keep striving for zero.

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