POST-OP INFECTION A patient whose post-operative wounds didn't heal properly contracted MRSA 2 years after breast reduction surgery.

As a high-volume orthopedic facility that uses implants in almost every case, we're especially concerned about surgical site infections. Two-plus years ago, we set out to reduce MSSA (methicillin-sensitive Staphylococcus aureus) and MRSA (methicillin-resistant S. aureus) infections, and our efforts are paying off. Here are the key elements to our protocol:

• Universal screening. We proactively screen all patients for MRSA with nasal swabs within 30 days of their scheduled procedure. One of the benefits of universal screening is that there's never a question as to who gets screened and who doesn't.
• If a patient tests positive We educate and treat all patients who test positive. We give patients who test positive 5-day supplies of both mupirocin in nasal vestibules and chlorhexidine gluconate (CHG) wipes. Insurance usually covers the expense of screening and treatment, but not the wipes. But providing the CHG wipes to the doctors' offices at our expense promotes compliance. We've learned that patients are much more compliant if they don't have to go out and get the wipes themselves. For elective surgeries, we've achieved 100% compliance with getting patients to use the wipes. Yes, it's unusual for facilities to provide wipes, but we've found that going the extra mile pays off.
• Retest for MRSA. Forty-eight hours after positive patients finish the 5-day supply of mupirocin and daily CHG wipes, we test them for MRSA again.
• Wipes for all. We give CHG wipes to all patients, regardless of whether they're positive. We give patients who don't test positive a smaller supply of wipes and instruct them to wipe down their entire bodies the night before and morning of surgery.
• Right before surgery Just before the patient goes into the OR, nurses do a final wipe down of the surgical area with the CHG wipes. In addition, they do a nasal swab with povidone-iodine to clean the nares.

Our preemptive measures are paying off
For the last 2 years, we've reduced our infection rates to well below the national average for total hips, total knees, laminectomies and spinal fusion. Having seen the results, all of our surgeons now fully embrace the effort. Our plan going forward is to look for other evidence-based initiatives that might further reduce our infection rates.

Since staff education plays a big role in everything we do to reduce SSIs, we meet periodically to discuss and review our efforts — both for more in-depth initiatives, like this one, and to review the basics, like hand-washing. We have people keeping tabs on how compliant our staff and physicians are, and we make sure we display our results. We also make sure the staff has a stake in the outcome. Our SSI rate is one of the metrics they need to meet to achieve performance bonuses. When you consider how much it costs a facility any time a patient ends up with an infection, preemptive measures are just good sense, even if they mean taking a little extra time and spending a little extra money.