6 Steps to Reduce Surgical Site Infections in Surgery Centers

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Peggy SaBell, RN, MS, CIC, regional director of infection prevention for Kaiser Permanente in Denver, Colo., and spokesperson for the Association for Prevention in Infection Control, shares six ways surgery centers can reduce surgical site infections.

1. Work to eliminate complacency.
Surgery centers generally see fewer complications and surgical site infections than hospitals — a trend that can be both a blessing and a curse, Ms. SaBell says. If surgery centers assume that surgical site infections will be a once-in-a-blue-moon occurrence in their facilities, they will probably fail to install a surveillance program to identify infections when they occur. "If we don't have a really good surveillance program in place, we don't actually know what's happening to our patients postoperatively," Ms. SaBell says. "That contributes to a sense of complacency that says, 'We don't have to do anything differently.'"

She says the first step in reducing surgical site infections in the ASC setting is to target that sense of complacency. Surgery centers should adopt the same "target zero" approach to surgical site infections that many hospitals have installed: Anything more than zero surgical site infections is unacceptable. This means re-educating providers on infection control practices and then holding them accountable for their actions. Providers are more likely to comply with infection control policies if ASC leadership develops clear expectations and emphasizes those expectations in writing, meetings and daily discussions. "It's about changing the culture," Ms. SaBell says. "In our ASC, we have signs outside each of our pre-operative areas that say 'Foam In, Foam Out,'" she says. "Our staff is talking about it and they are proud of what they're doing."

2. Look at outcomes and processes for every adverse event.
Every time your surgery center experiences an adverse event, staff members should discuss the processes that might have contributed to the event and the outcomes involved, Ms. SaBell says. "Every time we find out about a surgical site infection, some sort of investigation needs to be done," she says. "What happened on that day? Were we behind or rushed? What risk factors contributed to the infection?"

Once you identify the factors that contributed to the surgical site infection, write them down in a report and meet to discuss how those problems can be fixed.  If your surgery center staff failed to wash their hands because they were rushed, talk about how you can improve efficiency in other areas to leave enough time for hand-washing. If no one knew the patient had a condition that made him more likely to acquire an surgical site infection, work to improve your pre-op phone call or visit so risk factors can be identified in the future.

3. Develop relationships with hospital and primary care providers.
Unlike hospitals, where patients are likely to return to the same facility with a surgical site infection, surgery centers may not know an adverse event has occurred unless they follow up. Ms. SaBell recommends developing relationships with hospital infection prevention personnel and primary care providers in the community, if possible. A surgery center in a large city may have trouble developing relationships with every primary care provider, but ASCs in smaller communities should reach out and make sure their contact information is available to local practitioners. These contacts can alert ASC leadership when they see a patient who acquired a surgical site infection at the surgery center.

"We really have to be proactive and develop relationships with hospital infection preventionists so that they call us when they see [one of our patients] on their admit list," Ms. SaBell says. She also encourages surgery center administrators to join their local APIC chapter, which can extend their network of contacts and increase the likelihood they will hear about surgical site infections when they happen.

4. Make sure your systems encourage good practices. Surgery centers should "get back to basics" when it comes to infection prevention, Ms. SaBell says. This means ensuring proper hand-washing techniques, time-outs in the operating room, appropriate aseptic techniques and other basic policies that providers should already know. The key is making sure that your surgery center's systems encourage providers to make the right decisions. "Does the housekeeping staff have appropriate and safe cleaning products, or are the products so noxious that they can't stand to use them?" Ms. SaBell says. "Is it too difficult for staff to get things properly cleaned and sterilized because we're pushing them or we haven't got enough instruments?"

Sit down with staff and ask how infection prevention systems could be improved. They may speak up and say they need more time, better equipment, clearer instructions or more physician involvement. Once you hear their feedback, follow up promptly with a plan and begin implementing the plan as soon as possible.

5. Flatten the OR hierarchy.
Nurses and other providers may feel hesitant to speak up when they notice a physician breaking aseptic technique, Ms. SaBell says. Hospitals and surgery centers should try to break away from traditional notions of operating room hierarchy by encouraging staff members to speak up when they notice a patient safety issue, she says. "It's very similar to what the airline industry has done," she says. "Any of the personnel on the flight can speak up about a problem because they are on equal footing with the chief pilot when it comes to safety issues." She says in order to effectively "flatten" the OR hierarchy, ASC leadership should speak honestly with ASC staff about their relationships with the center surgeons. "Staff members are asked to be very honest and tell us which surgeons and anesthesiologists they do not feel comfortable discussing [patient safety] with," she says.

If your staff feels uncomfortable raising issues with your physicians, involve a respected physician leader in "flattening" the hierarchy, Ms. SaBell says. The physician champion can approach his or her colleagues and respectfully talk to them about listening to staff concerns and improving infection control practices. "Getting a physician champion makes such a difference," she says. "Having those tough conversations is easier on a colleague-to-colleague level."

6. Improve patient education.
Make sure patients understand what they have to do before and after surgery to prevent a surgical site infection, Ms. SaBell says. Develop a thorough, easy-to-read sheet of preoperative instructions and ask your surgeon's office to distribute it to patients before surgery. The sheet should include instructions on showering before surgery, wearing freshly laundered clothes and stopping medications as appropriate.

Surgery centers should take some time on the day of surgery to educate patients about postoperative practices as well. Ms. SaBell recommends talking to patients before surgery, as patients may be recovering from anesthesia after surgery and will likely be sleepy and anxious to get home. "I think the most important thing is to educate them about hand hygiene and the importance of washing their hands before and after touching their dressing," she says. She also recommends giving the patient literature on the signs and symptoms of infection and asking them to call if they notice a possible infection.

Learn more about APIC.

Related Articles on Infection Control:
New Practices at Texas Hospital Lead to 82% Decline of Infection by Multidrug Resistant Bacteria
Study: Use of Implantable Device, Urinary Catheter Insertion Among Risk Factors for Surgical Site Infection in Children
8 Infection Control Devices to Know


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