Best Practices for Monitoring of Surgical Site Infections: Thoughts From Carla Daley Shehata of Regent Surgical Health

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The following article was written by Carla Daley Shehata, vice president of operations for Regent Surgical Health.

According to the Centers for Disease Control and Prevention, surgical site infections pose significant risks to patients and are the third most commonly reported healthcare associated infections. Surgical site infections increase the cost of healthcare from $3,000 to $29,000 per surgical site infection, depending on the procedure or pathogen. This is a cost of up to 10 billion dollars annually.

The CDC defines a surgical site infection as an infection within 30 days after the operation. It can be a superficial infection, a deep incisional infection or an infection involving organ/space. In regards to implant use with deep incisional and organ/space, it is an infection within a one year period. The National Patient Safety Goal 07.05.01 for ambulatory health care gives the best practice guidelines for timelines in tracking SSIs that include implants.

A more detailed definition of each of these types of infections can be found in CDC Definitions of Nosocomial Surgical Site Infections; 1992, which can be accessed at www.cdc.gov.

Now that we have had an overview of the definition and the significant cost that SSIs impose, let's look at some best practices for monitoring SSIs.

1. Infection control program. There must be a solid infection control program in place that follows federal and state regulations along with CDC, APIC and accrediting bodies' recommendations and standards. Benchmarking with national standards should be an important piece of your program. The Ambulatory Surgical Center Association's benchmark for SSIs in the first quarter of 2012 was 0.9 out of 1,000 patients reporting a surgical site infection.

So much has been written on what is involved in setting up an infection control program that I won't get into all the details. Here is a link with CDC references that have been very helpful in establishing best practices within Regent centers.

2. Tracking instrument sterilization. The sterile processing department personnel must keep excellent documentation of everything that is sterilized within the center, as well as the preventative maintenance of all of the equipment required for the sterilization process. These records must be kept in a manner so that any person trying to find information may do so easily.

A best practice that Regent has implemented has been the use of piggyback stickers on all instrumentation packaging when going through the sterilization process. These stickers have the date and load information on them and easily peel off the packaging to then go into the patient’s medical record. This makes it easy to track whatever instrument(s) were used back to the specific load without digging through paperwork. This process is also vital when sterilizing implants. 

Instruments should never be used in patient care until the biological results have been read.  In many of our centers there is a shelf with a large sign that states "Biological Results Pending." These instruments are not used until they have been cleared and are taken off the shelf.

When there is rapid turnover of specific instrument trays the one-hour biological is used. The centers using this method do not have to worry about having to go through their entire sterile storage when a biological reads positive and they know that no contaminated instrumentation was used on a patient.

Here is a link that also has helpful guidelines.

3. Physician reporting.
Having an infection control program established with a means for physicians to easily report infections and complications on their patients is imperative. Within the Regent Surgical Health centers, we institute a monthly reporting process. A form is generated using our IT system. This form is created per physician and has a list of all the patients that had an invasive procedure performed by that specific physician. Making sure that there is 100 percent physician compliance in returning the survey form is not always an easy task and takes a great deal of vigilance.  

Having a well-established medical executive committee is definitely essential in helping to achieve and maintain the 100 percent return goal. The members of the MEC can improve physician compliance through peer review and, when necessary, peer pressure. If your facility is not achieving the high standard of physician compliance a good performance improvement project idea is right in front of you. Once your project is complete review your policies and make sure that they reflect what needs to be done. Take your findings and your reviewed policies to the MEC and the governing board. This process is part of the Centers for Medicare and Medicaid Services 2009 Conditions for Coverage.

4. Following up on reported infections.
Once a physician has reported that a patient has an infection, the designated infection control nurse has to become a sleuth. Your infection control program should have a systematic way of researching the patient visit in order to determine if this infection is an HAI or caused from circumstances outside the center. One of the problems that make it difficult to determine the origin of an infection is that many physicians do not culture the wound prior to prescribing antibiotic therapy. Encourage your physicians to culture any surgical sites showing signs of infection.

The patient's medical record is the first place to investigate.  Here are a few questions to ask yourself as you review the medical record.

  • Did the physician document that there was an infection prior to the procedure?
  • Does the history and physical reflect any previous or ongoing issues regarding infection?
  • Does the patient have a history of Multi-Drug Resistant Organism?
  • Who were the members of the surgical team? Is there a pattern of infections with any of the team?
  • Is there documentation that there were signs of an infection once the procedure was initiated?
  • Was there an implant? Remember that implant patients are tracked for infections for one year.
  • Were there any instruments that were sterilized using the Immediate Use method?
  • On the post-operative phone call, were there any significant concerns that the patient may have verbalized?
Once you have answered these questions, it is time to look at instrumentation used. If you used the piggyback stickers that were previously discussed you will be able to go right to the documentation of when and how the instrumentation was sterilized. Was there any chance that the instrument was used prior to attaining a passed biological? Pull and copy all of the sterilization records and attach to your other findings.

If there has been an increase in reported infections it is imperative that the commonalities be found. If it is with one specific procedure with different physicians, then check for damaged instrumentation. If the increase in infections is with one physician and that physician cannot self-identify the problem, have a peer that does the same case review the technique used. In the case where this is the only physician that does the procedure in your facility, contact an outside like physician to review the technique of the physician whose patient infection rates have risen.

The last step is to review the findings and discuss in the infection control or quality assurance committees. Then this information must go to the MEC and the governing board. Be sure that this is well documented in all of the meeting minutes. 

The end result of following all of these best practices should be a lower than national average of SSIs within your facility.

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