PROACTIVE PREP The cost to treat a single SSI depends on the seriousness of the infection.

We all know that a surgical site infection exacts a heavy toll on our patients, who are subjected to months of antibiotic therapy, readmission, reoperations and extended physical therapy. But SSIs aren't just painful for patients. Treating them is also costly for your facility, especially those of us working in hospitals. Under terms of the Affordable Care Act, CMS will stop paying hospitals for the follow-up care of infections they deem preventable.

Yes, first and foremost, reducing SSIs is about protecting patients from harm, but there's no denying the financial impact. To prove that investing in preventative measures would pay for itself in the long run here at the Iowa City VA Healthcare System, I set out to identify how much it really costs to treat infections. An awful lot, as it turns out. For a study I co-authored in JAMA Surgery (tinyurl.com/khonvrc), I found that preventing SSIs during procedures performed in high-volume specialties could save hospitals in the Veterans Affairs health system more than $13 million annually in follow-up care costs. Let me share with you what our findings mean to your facility.

Significant savings
Our review of 55,000 patients who underwent high-volume procedures in 129 VA acute care facilities revealed 3.2% experienced an SSI. That percentage is in line with national averages — the literature says SSI rates typically range from 2% to 5% — but like many infection control experts, I'd like that rate to be zero.

The cost to treat a single SSI depends on the seriousness of the infection (superficial or deep), patient comorbidities and surgery type, not to mention the facility where the surgery took place and the follow-up care. The average 30-day post-op cost of caring for patients who suffered SSIs was $52,620, compared to $31,580 for patients who came out of surgery free of infection — a more than $20,000 difference. Treating deep surgical infections cost nearly $75,000, compared to about $45,000 for treating superficial infections. Among the 5 highest-volume specialties we studied, infections after neurosurgery were costliest to treat ($23,755), followed by orthopedic ($15,243), general ($10,849), peripheral vascular ($7,354) and urology ($4,842).

Although we found neurosurgery had the highest SSI-related cost of care, you should obviously consider your case mix. The CDC says 40% of reported SSIs occur following orthopedic procedures, compared with roughly 2.5% following neurological surgery, so focusing on preventing infections following orthopedic cases has the most potential to save.

We're one of the first sites to break down the costs of treating infections that occur after different types of surgery. It was challenging to do. Obviously, patients have other underlying issues — including potential comorbidities such as diabetes and issues related to the surgery — but we included confounding factors into our research model. That's why our costs are lower, and arguably more accurate, than SSI-related costs identified in previous research.

Bundled benefits
Staphylococcus aureus was the most common cause of SSI in our study, and 30% of the population carry the bacteria in the nose without knowing it. We encourage surgical facilities to swab patients' noses at least a week before surgery for traces of S. aureus. We give patients who test positive an ointment to apply for 5 days before surgery to clear out the bacteria. We also encourage patients with signs of S. aureus to prepare their skin with chlorhexidine gluconate wipes or soap for 5 days before surgery. But because the pre-op washes and wipes are inexpensive and easy to use, we also ask non-carriers to apply CHG the night before and morning of surgery.

We also encourage the appropriate use of pre-op antibiotics. Patients who carry methicillin-resistant S. aureus (MRSA) receive vancomycin — because it's active against MRSA — in addition to the standard dose of cefazolin. The timing of vancomycin administration is important; it takes a while to become active in the bloodstream, so have a system in place between the OR and pre-op to ensure the drip starts about an hour before surgery begins.

In a study published in the journal BMJ (tinyurl.com/o5v4tys), we showed that a bundled approach used to prevent surgical site infections before cardiac and orthopedic procedures — which included nasal decolonization and antibiotic prophylaxis with glycopeptide antibiotics such as vancomycin for patients with MRSA — significantly reduced overall risk of SSIs by 1% and resulted in a 0.5% risk-reduction of gram-positive SSIs. Doesn't sound like much of a difference, does it? But it is clinically significant when you consider that roughly 300,000 cardiac procedures and approximately 900,000 orthopedic procedures are performed each year. Reducing infection risk by such a seemingly small amount would actually prevent upwards of 12,000 SSIs each year.

The BMJ study shows the benefits of a bundled approach, but is it applicable outside the pages of medical journals? We recently implemented the program before hip and knee procedures and cardiac surgeries at 20 hospitals nationwide and saw similar dramatic decreases in infection rates, proving that it works in the real world, too.