Out of Site: Neutralizing the Threat of SSIs

Out of Site: Neutralizing the Threat of SSIs

By Kris Ellis

Surgical site infections (SSIs) can have dire consequences for ambulatory surgery centers (ASCs). As the second most common cause of nosocomial infections, SSIs can lead to increased patient hospitalization and mortality, along with the resulting increases in healthcare costs.¹ As ASCs strive to maintain and improve upon the quality of care that they deliver to their patients, SSI prevention must occupy a prominent place on the agenda.

The effort to keep SSIs out of surgery centers can begin well before patients are taken to the operating room (OR), in the form of patient screening. Specific patient risk factors identified by the Centers for Disease Control and Prevention (CDC) include:

• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Coexistent infections
• Microorganism colonization
• Altered immune response
• Length of preoperative stay²

“With anybody who’s got diabetes or obesity or any underlying condition, you have to assess them carefully to see if they could be pre-disposed for infection, even in our environment,” says Sarah Martin, RN, BS, regional vice president of Symbion, Inc. “Many times we can see that the patient has poor hygiene or has these underlying physical maladies that don’t allow them to heal well, that pre-dispose them to infection. Of course you also want to look and see if they’re on any type of steroid; that can impact their healing.”

Ann Geier, RN, MS, CNOR, vice president of operations for Ambulatory Surgical Centers of America (ASCOA), explains that the elderly population must also be carefully evaluated in terms of the condition of their skin. “The greatest risk if you’ve got an elderly patient is that they’ve got skin breakdown — if they come in and don’t think to tell us that they’ve got an open sore or something on their body,” she says.

The very young may pose a challenge in this respect as well. “You have the risk in children of scrapes and bumps and bruises that they have that we don’t see,” Geier continues. “Plus some of them come in and are already sick with something else because they’re coming in to have ear infections cleared up, for example, and so they already have something in their bodies. Now with teenagers you’ve got the tattoos and piercings, so that’s an issue because you don’t always see a navel ring, and they just had it done and it’s red and inflamed — you’ve got an infection already there.”

The potential danger of an existing infection is one that must be taken very seriously. “The first thing is that we would not do any patient who already has an active infection, or anybody with a contagious disease of any kind,” says Susie Winterling, RN, administrator of Asheville Eye Surgery Center. “We also look at an ocular history, and if they have diabetes, because that’s another indicator that they could be more susceptible to infection. Then the physician clears the patient pre-operatively for anesthesia and surgery.”

“There are some patients who just have poor hygiene,” Martin says. “Certainly if a patient is running a high temp when they come in, if there are any cuts or marks, especially in the orthopedic area, we assess that very carefully with the physician to make sure they don’t think that patient’s going to be compromised if we proceed with surgery. There certainly have been times when we’ve cancelled it because we thought they had a cut that was too close to the operative site or something like that.”

Once in the OR, the primary means of preventing SSI is strict adherence to aseptic technique by all members of the OR team. It is possible that anesthesia providers or other personnel outside the sterile field, but in the near vicinity, may cause an infection.² “In the centers I have managed, we also don’t let people wear artificial nails if you’re in the surgery environment,” Martin points out. “That’s still a huge thing in surgery centers — I’ve been in other facilities consulting where they still allow the OR staff to wear them, but we elected to go with the CDC guidelines and we completely did away with artificial nails if you’re in the OR suite at all.”

“We use the same aseptic technique as in a regular OR — we don’t compromise on that,” Geier says. “The thing about ASCs is that, like with eye cases for example, the room is considered a sterile room, just like in an OR. What we won’t do is go through and mop between cases, because you don’t contaminate the floor in eye cases — it’s not like you’ve done an arthroscopy and gotten fluid all over the place. So you use some common sense. As far as technique goes, we follow AORN (Association of periOperative Registered Nurses) standards.”

ASCs face a significant challenge in their ability to evaluate the condition of the surgical site post-operatively. Diligent follow-up inquiries form the basis of this effort at most facilities, and can be critically important in identifying potential issues.

“We don’t see our patients the day after surgery, so you kind of have to know what to ask the patient so you can discover if they’ve got a problem,” Geier says. She explains that the process of asking effective questions, without leading patients into giving false descriptions, is vital. “There are ways that you can talk to them and ask them how they feel and ask if they have any questions, but when you get to the infection part of it, you just have ways of asking things like, ‘how does your incision look to you today?’ You don’t ask if the skin around the incision is red or if they are having any greenish or yellowish drainage.”

However the situation is approached, the possible existence of indicators such as swelling, extreme soreness, or excessive warmth to the touch must be ascertained. “That’s why it’s so important to reach these patients after surgery, because we don’t see them again,” Geier continues. “It’s not like with inpatients where you can always follow-up by going on the floor. Surgery centers are really into this — this is not just an incidental exercise for them.”

“I think one of the biggest things is that we do a monthly review of every surgeon and every patient as to whether or not there have been any post-operative complications or infections,” Winterling explains. “That letter goes out to the surgeons and they have to reply within 30 days, and if there had been an infection, then we would do an in-depth review and then a peer review of that chart.”

Geier explains that consistently initiating and completing the follow- up process is an important link in the overall chain of quality for every center. “It’s considered very important, because accreditation depends on it; they want to see your infection tracking,” she says.

“Your licensing and Medicare can depend on it; basically it’s a quality of care issue that should be reported back to the board. You do infection and complication surveys, and you have to be diligent in making sure that you’re catching 100 percent of your cases.”

If connecting with patients for a follow-up conversation becomes difficult, options do exist for obtaining the information. “Then we can look at the patient’s chart and see when her post-op appointment was, and then we try to do it through the doctor’s office,” Geier notes. “I had a surgical tech who would dump our surgery schedule into Excel and then send it out to each doctor, so each doctor would get his surgeries for whatever time frame she was working on. The important thing was that she made sure she got 100 percent of the surveys back. That’s in addition to the follow-up phone calls. You can’t do a random sample for your infection control — you’ve got to have a mechanism that works for you in place to screen all your patients.”

Another daily task that carries the utmost importance in terms of preventing SSIs is instrument sterilization. “It’s basic stuff, but you’ve got to have those instruments sterilized properly,” says Martin. “A lot of the things we’re using now have many working channels, so you have to make sure that they’re cleaned properly.”

Depending on the size and specialty mix of any given ASC, techniques and staffing used for instrument processing may be quite different. “In the past I managed four surgery centers in the Memphis, Tenn., area, and three of our centers had a dedicated instrument tech based on when their cases occur and the volume,” says Martin. “If the staff is trying to turn things over quickly, sometimes you have to balance the cost of having a full-time tech with the cost of turnover and the cost of infection, because many times instrument techs are not going to be as expensive as your surgical techs are, so it’s usually a cost that’s well worth it because then your staff doesn’t have to worry about the cleaning or wrapping of instruments.”

“We have a very small staff — we are currently staffed with all RNs, and the RN who is scrubbing, or it could be the one who is circulating. We take care of all of our own instrumentation,” Winterling says. “With eye instruments it’s quite a bit easier — we flush out all of our cannulas on the back table and then all of our instruments are mainly flash sterilized.”

Martin explains that having the right attitude about infections can be key in promoting quality at ASCs. “For us, one infection was too much,” Martin says. “There are some centers that think if they’re under the national norm it’s acceptable, but that’s not good enough. We always wanted to benchmark against the top percentile, which is zero. If we even have one, we get upset.”

Martin goes on to describe a situation in which one of her facilities was confronted with two infections within a month, and was forced to thoroughly evaluate all possible causes. “We ended up doing a lot of research and what we found was that it behooved us on the large orthopedic cases to go ahead and get that antibiotic in 30 minutes prior to cut time, and so we did do that. A lot of the physicians still like to shave, and we have encouraged them not to shave. That’s a harder sell with the physicians, but those are the two things we came up with that we thought would be more appropriate.

“Last but not least, people need to be checking their temps and humidity, because if those are not in the proper range, you can increase your risk of infection, so people need to be monitoring that on a daily basis,” Martin continues. “These things aren’t rocket science, but I can tell you that they make all the difference in the world, and if you have a pairing of a couple of these things, it can spell disaster in terms of infections.”

CDC recommendations for temperature and humidity in the OR are 68 to 73 degrees Fahrenheit, depending on normal ambient temperature, and 30 percent to 60 percent, respectively.² Airflow is recommended to move from clean to less clean areas, and a minimum of 15 total air changes per hour are specified.

For patients undergoing hip or knee arthroplasty, cefazolin and cefuroxime are the preferred prophylactic antimicrobials.1 Studies have shown that there are no advantages to prolonged prophylaxis in joint arthroplasty cases, and it is thus recommended that the antimicrobials be discontinued within 24 hours after the end of the procedure.

Circumstances may arise in which the source of an outbreak may be extremely difficult to determine. Geier notes that ASCs should not be afraid to look for help in such a situation. “Don’t forget that you can always call your hospital infection control nurse,” Geier says. “They are not going to refuse to help you. Even though you may be competitors, they are still nurses, and if you have a question you can usually call and if they can’t help you because of the competition, they will refer you to someone who can.”