High rate of surgical site infections (SSIs) in our nation’s hospitals

By now, most healthcare professionals — and many well-read consumers — are aware of the disturbingly high rate of surgical site infections (SSIs) in our nation’s hospitals.

Each year, approximately 500,000 surgical patients develop SSIs. In some types of operations, such as colorectal surgery, the rate is close to 10%.

Many hospitals submit information about SSIs in their institutions through the CDC’s National Healthcare Safety Network (NHSN), a web-based surveillance system for capturing data about adverse events.

However, with current trends toward shortened hospital stays and increased outpatient surgery, statisticians estimate that from 47% to 84% of SSIs may occur after discharge and thus go undetected by hospital infection surveillance programs.

The hospital costs associated with these infections are in excess of $7 billion (in 2002 dollars). When the substantial indirect costs to patients, their families, their communities, and their employers are factored in, the impact is even more dramatic.

To me and many of my colleagues, the most frustrating aspect of this issue is that a majority of these infections are preventable — and we know how to prevent them!

The simplest, most effective (and cost-effective) prevention strategy is caregiver handwashing.

Often overlooked strategies include such things as appropriate prophylactic administration and attention to blood glucose control for surgical patients with diabetes.

Today, no hospital or health system would be caught without specific protocols for preventing SSIs, but many organizations fall short when it comes to employing standardized methods for measuring and reporting compliance with these protocols.

Moreover, with the increasing number of specialties and the trend toward outpatient surgical care, it has become more difficult to ensure that the right information is getting to patients in a way that is understandable, meaningful, and useful.

So, how do we go from “easier said than done” to “mission accomplished?”

As we’ve discovered in other areas of healthcare quality and safety, the key to reducing SSIs lies in “teamwork.”

All stakeholders — governments and regulatory agencies, medical professional organizations, hospitals and health systems, health insurers, employers and other purchasers, and patients — working together in partnership to foster a “culture of safety.”

The recently launched Safe Surgery Initiative, is an example of such a multi-stakeholder approach to SSI prevention and puts an important new spin on the relatively commonplace concept of “toolkits.”

The Safe Surgery Initiative toolkit is conceived as a primary resource to reduce the incidence of SSI by raising awareness of best practices, increasing knowledge, and changing behaviors at every level and patient touch point.

Available free of charge on line, this resource represents the collective work of an academic team and collaborating stakeholders put together by us here at Jefferson School of Population Health with support from Johnson & Johnson Health Care Systems.

It is a compilation of the most up-to-date, publicly available, validated information on SSI prevention from sources including the CDC and the Agency for Healthcare Research and Quality.

Although a majority of the resources are directed towards patients — e.g., English and Spanish versions of general information on how to speak to their doctor, how to prepare for surgery, and what to look for after surgery — there is also educational information for healthcare providers regarding key pre-, intra-, and post-operative processes and procedures that have an impact on SSI.

A big “plus” is that users can package and customize any of the materials in a manner that is most appropriate for their intended audience, whether it be a healthcare provider, employer, or health plan.

Although the items can be used as stand-alone documents, this comprehensive package provides the foundation for a robust collaborative initiative for partners interested in an innovative education program.

I am optimistic that a multi-stakeholder approach such as this will help us gain some much needed traction in our efforts to stem the tides of SSIs and other hospital-acquired infections.

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    The writer is “disturbed” that wound infections occur in 10% of elective colorectal cases. He then declares that most of these infections can be prevented by simple measures such as “hand washing”.

    Dr Nash, when we perform colectomies we actually put on sterile gowns and gloves. We even scrub our hands like the the doctors do on TV. And guess what? The colon is the organ that houses feces. Feces contain bacteria (lots of it, actually). Bacteria can cause…..wait for it….infections.

    I don’t know of any surgeons out there in America who don’t administer peri-operative antibiotics during colon resections. Furthermore, most hospitals won’t let you start a case until you have documented that the Cefotetan has been given..

    This post is absurd. He confuses surgical site infections (an ineradicable problem, never to be lowered to 0% no matter what we do) with “hospital acquired” infections, i.e. pneumonia in the ICU, cdiff colitis, urinary tract infections from prolonged Foley catheterization.

    • elmo

      Agreed buckeye
      His line of reasoning is the same as the CMS genuises who declared DVT’s in the hospital “never” events. No basis in evidence.

  • Mike

    Furthermore, he has displayed no evidence that the initiative has actually been shown to be effective (which I have not seen to be the case). Safety initiatives are great, but they should be held to the same standards as medications.

  • http://www.medicalmegatrends.blogspot.com Stephen Schimpff MD

    Dr Nash, in my opinion, should not have used colorectal surgery related infections as an example that would be benefited from hand-washing. But his more basic point is correct. There are many hospital acquired infections that are all or nearly all preventable. A good example is line infections where proper insertion technique is essential but all too often not followed. There are well documented approaches and these need to be adhered to scrupulously. When they are followed the line infection rate goes to zero or near zero.

  • surgical resident

    Very poor post. He would be better served to have used HAP, UTI’s, etc. The SCIP guidelines are controversial anyways. He mentions tight glucose control. Without question there is evidence supporting decreased SSI’s with tight control, but now many many people are moving away from ultra-tight glucose regulation as the risk of hypoglycemia is greater than the benefit of reduced SSI?

    I’ve often thought of placing a wound vac/wet-to-dry after every surgery that I do rather than close skin. Sure, the wound will suck, more money will be spent on wound care, and the patient will suffer, but at least my superficial wound infection rate will be zero!

  • Outrider

    I’m an equine veterinarian. I refer patients for emergency colic (abdominal exploratory/GI) surgery regularly. The rate of incisional infections at my surgical facility of choice is close to zero, in fact, neither I nor my colleagues who also refer to this facility have ever seen one over the last decade. Keep in mind that we work with a huge, hairy species that lies down in manure and filth. Colic patients are often especially dirty because horses roll to escape pain and are not too fastidious when they’re really painful.

    Why is that hospital’s rate of infection so low? Better surgical technique. The surgeons at this hospital are quick, skilled, and experienced. Here’s a quote from good old _Equine Surgery_, by Auer and Stick: “incisional infection rates can be decreased by shortening surgery time, using adequate draping, isolating any enterotomy incision from the clean surgical field and minimizing trauma to the incision during exploration of the abdomen… Care should be taken not to take overly large bites and to avoid excessive force when tightening sutures, since this can lead to ischemia, predisposing to incisional infection.”

    The local veterinary school has a much higher infection rate (close to 10%) – partly because they train residents, partly because most of their attendings simply aren’t as good as those employed by the other hospital.

    What troubles me is I know which surgeons I’d choose for my horse, but not for myself.

    • Leo Holm MD

      Horses are far healthier than people to start with. They also turn their nose at hospital food.

      • Outrider

        Any of my clients who have paid for colic surgery ($10-12,000) certainly wish that were the case. A majority of the horses undergoing colic surgery are older and suffer from comorbidities just like humans.

        Surgeons are no doubt partially responsible for their patients’ incisional infection rates. Basic principles of surgery are timeless; lousy surgeons will still produce a high rate of incisional infections. If you’re a surgeon, you have to own that and try to do better.

  • Michael

    Other factors in surgical wound infection: 1. Co-morbid risks (diabetes, OBESITY, immunocompromise), 2. Instrument processing, 3. OPERATING ROOM TRAFFIC. An interesting study by orthopedic surgery shows a decrease in infections if TRAFFIC in and out of the O.R. is limited. Many of these “visits” distract the surgeon and are unnecesary (such as SHIFT CHANGES and LUNCH RELIEF and conversations NOT related to the patient on the table).

    • Outrider

      Oh, agreed, especially non-essential conversation during the surgery. Those masks aren’t perfect.

      I try to minimize conversation during the minor surgeries I perform because I’m usually out in the middle of a field somewhere. I need every advantage I can get.