Surgical site infections are a significant issue for health care managers, especially with respect to their quality control system. There are several reasons why reducing SSIs is a critical issue in health care management, including malpractice costs and patient health. For every stakeholder, reducing SSIs benefits the organization, making it one of the easier issues for which to gain consensus for a plan of action. Yet, SSIs still occur, and it is important to understand how they occur and what steps can be done to reduce their occurrence.
Surgical Site Infections
Anderson (2009) notes that despite 150 years of continuous improvement efforts to reduce the incidence of surgical site infections (SSIs), they still occur in 2-5% of patients undergoing surgery in the United States, a total of 300,000 to 500,000 incidents per year. The single most common pathogen resulting in SSI is staphylococcus aureus (staph infection). The ongoing high rate of SSIs contributes to adverse health outcomes for patients, including death, and added costs for the hospital and patient alike. SSIs almost always extend the hospital stay of the patient, adding to costs (Ibid), and there is also a risk of legal action arising from complications like SSIs.
Barie and Eachempati (2005) outline some of the causal factors for SSIs. They note that factors in the development of SSIs include “the patient’s health status, preparation of the patient before surgery and the use of appropriate antibiotic prophylaxis.” The implication of these findings is that most SSIs are preventable, given sufficient understanding of the risk factors and the execution of best practices. Thus, SSIs are as much a quality control issue and they are a medical issue for health care institutions.
There are three types of surgical site infections, according to Lauwers and de Smet (1998). These are superficial, deep incisional and organ/space. It is mainly during the surgical intervention, the authors note, that the microbial contamination occurs. Sometimes the infection occurs with the patient’s own commensal flora (Ibid), meaning that there is sometimes little that the hospital can do to prevent such an infection. However, it has also been shown that the skill of the surgeon, along with the type and duration of the surgery, are also contributing factors that affect the rate at which SSIs occur. Again, this points to an institution being able to reduce its SSI rate through training.
Financial Impact of SSIs
As noted, the financial impact of SSIs is based on a few different factors. The first is that SSIs typically result in the patient spending more time in the hospital, and sometimes the infection is a complication that results in the patient’s death. Both outcomes can have a negative impact on the hospital. For example, the more the surgery costs the patient, the less the hospital can expect to recover. Additionally, added time spent in hospital could be refused by the insurance company if it is found that the SSI was the fault of the hospital. Thus, there are direct costs associated not just with the treatment of the SSI but the added hospitalization time that it takes to deal with the SSI.
The other key cost is associated with the hospital’s insurance for malpractice. If a patient dies or suffers another negative outcome as the result of a preventable SSI, the hospital may face legal action. These costs, especially where punitive damages are relevant, can range well into the millions, and may not be covered by the hospital’s malpractice insurance. Thus, it is in the hospital’s best financial interest to work to continuously reduce the rate of SSIs.
As noted, the rate of SSI is between 2-5%. It is affected by a number of factors, including the types of surgeries that are most commonly performed, the demographics of the patients of the hospital, and the competency of the surgical staff. The rate at our facility has increased from 7% to 12%, so well above average. The facility caters to an older demographic, and it is believed that there is a higher than average rate of major surgeries performed. Thus, the SSI number is not out of line with what might be expected.
However, the rate increased significantly in the last quarter, and this fact alone is cause for action. The facility should strive to bring the SSI rate down below the expected level for the types of patients and surgeries that the facility has.
Plan of Action
In order to achieve better-than-average results in the SSI rates for our facility, there are a number of tactics that can be used. The first is that the culture of the organization needs to emphasize safety to a degree greater than the current degree. As of now, there is no particular focus on SSIs, and this contributes to a culture where there is little accountability with respect to the SSI rates, or to individual SSI cases. The organization must improve the accountability, so that staff members are specifically held accountable for the mistakes that they make that result in an SSI.
Beyond culture, there are specific things that the organization can do to promote an improved rate of SSI. The first is that the training program needs to be more extensive. The typical approach of the organization to this point is to generally assume that members of the staff are well-versed on basic SSI prevention procedures. While this might be true, the staff should be kept up-to-date on the most recent information on the subject. They should receive substantial training on the appropriate procedures. Such training can help reduce SSIs caused by procedural lapses.
One issue that contributes to the persistent high rates of SSI across the medical profession is the development of acquired microbial resistance. This occurs as the result of overuse of antibiotic prophylaxis. While antibiotics are a necessary part of managing potential SSIs, anything over 48 hours seems to contribute to acquired microbial resistance, while adding little benefit to the patient. Harbarth et al. (2000) prescribe under 48 hours of antibiotics to reduce acquired microbial resistance.
Mangram et al. (1999) also prescribe a number of tactics to reduce SSIs. These include tactics to reduce errors during transfusions, shaving the patient immediate prior to surgery, the use of preoperative antiseptic showering and specific skin preparation as well as cleanliness measures for the surgical personnel.
Surgical site infections are costly for hospitals, both in terms of patient outcomes and in terms of the bottom line. While not all SSIs are preventable, most are. This means that the hospital often bears the cost of such errors, especially when the patient does not have the means to do so. It is imperative, therefore, that hospitals take steps to address the problem of SSIs both in the short-term and the long-term. In the short-term, the use of antimicrobials is essential, as is following basic best practices with regard to hygiene in the surgical suite. The institution should also take the long-run into consideration, however, and not use antimicrobials excessively, because antimicrobial resistance is one of the major reasons why SSI rates remain persistently high despite a century and a half of continuous improvement efforts.
With specific training and prescribed best practices, the organization can begin to reduce its SSI rates. It is also worth considering that the rates will also decline with a change in the types of patients taken on, or the types of surgeries offered. In addition, education is something that must be done with the staff as well. Ultimately, from a management perspective, most SSIs are preventable, and therefore should be prevented. Hospitals can prevent SSIs by having consistent procedures that are based on evidence. Doing the right thing every time is the best way to reduce SSIs in the future.
Anderson, D. (2009). Surgical site infections. Division of Infectious Diseases, Duke University Medical Center. Retrieved September 29, 2012 from http://www.hapmd.com/home/hapmdcom/public_html/wp-content/uploads/2009/03/cirugia/bibliografica-cx/20110504_articulo_2.pdf
Barie, P. & Eachempati, S. (2005). Surgical site infections. The Surgical Clinics of North America. Vol. 85 (6) 1115-35.
Harbarth, S., Samore, M., Lichtenberg, D. & Carmeli, Y. (2000). Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. Vol. 101 (2000) 2916-2921.
Lauwers, S. & de Smet, F. (1998). Surgical site infections. Acta Clin Belg. Vol 53 (5) 303-310.
Mangram, a., Horan, T., Pearson, M., Silver, L., Jarvis, W. (1999). Guideline for prevention of surgical site infection, 1999. Infection Control and Hospital Epidemiology. Vol. 20 (4) 250-280.
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