How We’re Winning the Fight Against SSIs

Preventing SSIs isn’t solely an infection control issue; you need to get a variety of departments involved — the bigger the team, the better. We put together a multidisciplinary group that included surgical nurses, anesthesia providers, an infection control practitioner, surgeons, and reps from environmental services and sterile processing. The team, which reported to our infection control committee, utilized lean management principles, which are strategies designed to minimize waste in every process, procedure and task through an ongoing system of improvement. Using lean methodology, all members of the organization, from clinicians to operations and administration staff, continually strive to identify areas of waste and eliminate any step that does not add value to patient care. We got an additional boost from our lean consultant, who helped the SSI-reduction team create the right action plan and fine-tune the areas that needed improvement.

One of the important lessons we learned while implementing lean principles was to focus on the area that needs the most improvement first. Consider making the following changes to your pre-op process to better prepare patients for surgery. If your experience is like ours, you’ll find the practices provide the greatest opportunity to address risk factors of SSIs. 

• Partner with patients. Contact all patients prior to their procedures to make them aware that they’ll play an active role in your efforts to prevent post-op infections. At our facility, patients are seen preoperatively in the preadmission testing department, where their lab work is done, and pre-surgical assessment and preoperative teaching take place. During these appointments, patients receive written instructions, which include detailed directions on using chlorhexidine gluconate (CHG) wipes to clean around the surgical site for several days leading up to their surgeries as well as an explanation on the necessity of taking full-body CHG showers the night before and morning of their procedures.

• Manage modifiable risk factors. Diabetes and high blood glucose levels are linked to higher infection rates, so work to normalize serum glucose levels for all patients — not just those diagnosed with diabetes. Patients with high glucose levels on the day of surgery (300 to 500 milligrams per deciliter) are evaluated preoperatively by our anesthesia team with the consideration of postponing elective procedures until the levels are normalized.

Another patient-controlled area that increases SSI risk: smoking. Advise patients to stop or at least reduce smoking prior to surgery. We make it clear that going smoke-free is critical, because research shows it reduces the risk of infection and leads to faster wound healing.

As a level II Trauma Center, we perform all types of procedures, including general, robotic, orthopedic, bariatric, gynecology, urology, ENT, vascular and neurosurgery. If we get any type of trauma patient, we don’t have control over their glucose levels or smoking status before surgery; however, we do manage these factors postoperatively to reduce the risk of an SSI.

Pre-scheduled procedures are a different story altogether. All of these patients are evaluated by a nurse in pre-admission testing, educated on the importance of taking care of themselves, and given actionable steps they can take to reduce the risk of an infection.

• Standardize skin prepping. Once you address patient education, make sure your staff complies with proper skin prep and infection prevention procedures. For instance, when performing a CHG skin prep, you must scrub the skin around the surgical site for at least 30 seconds and make sure the solution dries for three minutes before the incision is made. Try to get a physician on board to help with your compliance efforts. We worked with a surgeon champion who helped our nurses make sure they applied the prep correctly and tracked the proper dry time.

There is no single action alone that will improve your SSI rates.

• Individualize antibiotic dosing. Anesthesia providers should focus on following the correct weight-based protocol for pre-incision antibiotic administration. Previously, most of our patients received two grams of cefazolin at least 30 minutes before incisions were made. However, we discovered that weight-based dosing proved much more effective in preventing SSIs, so that became our standard. This is a key part of SSI prevention because, according to our research, preoperative antibiotic prophylaxis decreases the risk of postoperative infections by as much as 80%.

• Classify wounds. Proper wound classification also makes a significant difference in terms of patient tracking because some wounds have a higher risk of infection. For example, a wound resulting from trauma is considered contaminated and has a very high risk of postoperative infection. This is different from an incision made for an elective surgery that is considered a clean wound. Proper classification can assist in determining appropriate postoperative care, and accurate tracking of sources of SSIs.

The wound type also dictates the prepping agent we use. Our standard prep is CHG. However, it is not used on open wounds due to its neurotoxicity or during procedures performed above the neck and spine cases. Povidone-iodine is used as an alternative for open wounds, spine surgery or if a patient has a known allergy to CHG. A hexachlorophene detergent cleanser is used for prepping the face.

• Focus on surface disinfection. Work with your surgical team members or environmental services to ensure ORs are thoroughly cleaned and sanitized. In addition to robust manual cleaning, we also utilize UV technology during overnight terminal cleanings of ORs that accurately calculates the precise dose of UVC light needed to kill up to 99.9% of harmful pathogens. ATP testing is randomly done on terminally cleaned rooms, and in rooms with a known infected procedure, to ensure the surfaces were properly disinfected before another patient enters the space.

• Create a culture. Include comprehensive training of your facility’s infection control practices during new staff orientation. Every facility has a different culture and can use different prepping agents and practices, so we make sure all new staff members were educated and trained on how to properly apply the CHG skin prep, the solution we most commonly use in our ORs, as well as its proper dry time. New staff are also educated on our practices regarding strict aseptic technique and all standards of care related to infection prevention in general.