Introduction

One of the most common causes of postoperative complications is nosocomial (health care associated) infections, commonly caused by surgical site infections (SII). The Centers for Disease Control and Prevention’s (CDC) National Nosocomial Infections Surveillance (NNIS) system has defined surgical site infections as those associated with surgical procedures that occur at or near the surgical incision within 30 days of an operative procedure, or within one year if an implant is left in place (Horan et al, 1992). According to a study that analyzed 20% of annual hospital discharges, postoperative complications accounted for 3-21% of excess mortality among patients (Zhan and Miller, 2003). Furthermore, surgical site infections account for 14%-16% of all hospital-acquired infections and are common complications of surgery, occurring in 2%-5% of patients after clean extra-abdominal operations and in up to 20% of patients undergoing intra-abdominal operations (Bratzer et al, 2005). In addition to patient injury, mortality, suffering, and life-style changes, there are substantial costs associated with surgical site infections. Studies have shown that hospital cost attributable to infectious complications result in a $1398 increase per patient (Dimick et al, 2004).

In an effort to reduce these burdens, the Surgical Infection Prevention Project (SIPP) headed by the Centers for Medicare and Medicaid Services in collaboration with the Centers for Disease Control and Prevention was formed in 2002 (Schraag, 2007). One of their main objectives is to decrease the morbidity and mortality associated with postoperative surgical site infections, by promoting appropriate selection and timing of prophylactic antimicrobials (Medqic, 2007; Bratzler et al, 2004). To build upon these efforts, the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations committed to improving the safety of surgical care, was created. In 2005, the SCIP set a goal of reducing preventable surgical morbidity and mortality by 25%, by the year 2010. In order to accomplish this feat, they focused on 4 major causes of surgical complications; one being prevention of surgical site infections (Medqic, 2007). Hospitals participating in these efforts reported a mean 27% reduction in their SSI rates (Dellinger et al, 2005).

Additionally, the Joint Commission developed 3 performance measures as an ORYX core measure set, based on the Surgical Infection Prevention Project, and the Centers for Medicare and Medicaid Services also requires hospitals to submit data on 5 SCIP measures to avoid a 2% forfeiture of their Medicare reimbursement. These measures include (1) prophylactic antibiotic initiated within one hour prior to surgical incision, (2) giving the patient the right antibiotic, (3) prophylactic antibiotic discontinued within 24 hours after surgery end time, (4) ordering the proper prophylaxis, and (5) making sure that the proper prophylaxis was given to the patient. In addition to prophylactic antibiotics, there are other prevention methods currently used to reduce surgical site infections. A SCIP recommendation currently being reviewed for potential performance measurement relates to proper hair removal technique (use of clippers instead of razors).

Goal

The Joint Commission is interested in gathering feedback on issues related to surgical site infections. Primarily, we are looking for your help in answering the following questions:

• What are specific challenges you face in the prevention and monitoring of surgical site infections?
• What are some best practices used in your institution related to the prevention and monitoring of surgical site infections that would be helpful to share with others?
• How do you use data about flash sterilization to evaluate and make improvements to the prevention strategies of surgical site infections?

References:

Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706-15.

Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, Wright C, Ma K, Red L. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg 2005; 140:174-82.

Dellinger EP, Hausmann SM, Bratzler DW, Johnson RM, Daniel DM, Bunt KM, Baumgardner GA, Sugarman JR. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005; 190(1)9-15.

Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr., Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004; 199:531-7.

Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13:606-8.

Schraag J. New initiatives, practices make strides in fight against ssi’s. Infection Control Today. March 2007. Available at: www.infectioncontroltoday.com

Surgical Infection Prevention homepage. Available at: http://www.medqic.org/sip Accessed: 18 September 2007

Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003; 290: 1868-1874.

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