In the United States surgical site infections is the leading cause of morbidity and mortality in hospital acquired infections. Surgical site infections are just one type of hospital acquired infections (HAIs) but I believe they are one of the most preventable. A surgical site infection is an infection of a wound that occurs after an invasive surgical procedure. It can take days before the patient even shows signs or symptoms of an infection. “Infection develops when the number and activity of bacteria in the wound overwhelm the patient’s immune system, resulting in tissue breakdown and delayed healing” (Gould, D.2012).
This paper will begin by describing exactly what surgical site infections are and the different types. It will also describe why it is considered preventable. While it is not possible to prevent all surgical site infections it is possible to reduce them by at least sixty percent. Next this paper will discuss some of the legal implications related to surgical site infections. There are millions of dollars that are being awarded to patients in lawsuits because of preventable SSIs.
The Center for Disease Control has guidelines that healthcare organizations must follow to help reduce the risk of SSIs; and it when these guidelines are found not to be followed that patients are wining lawsuits against healthcare professionals and organizations. A breakdown in communication can be a cause of so many surgical site infections. The breakdown can occur between medical staff or between the staff and patients. This paper will explain some ways that improved communications could assit in reducing surgical site infections.
Then this paper will explore the accreditation expectations related to surgical site infections. “The Joint Commission accredits 82% of the hospitals in the United States” (Sollecito & Johnson, 2013, p. 516). It will explain what expectations the Joint Commission have in regards to surgical site infections. And finally this paper will discuss the outcomes related to the cost and quality of surgical site infections. I will explain what continuous quality improvement strategies I would use to involve members of the healthcare team in planning and implementing improvements related to surgical site infections.
I will also discuss what strategy that I believe would generate the best outcome and cost the least to implement. Surgical site infections (SSIs) are a serious complication that occurs in approximately 2% of surgical procedures and accounts for some 20% of health care associated infections. (de Lissovoy, 2009) A surgical site infection occurs on the part of the body that the surgery took place. Our skin is our natural defense against infection so any time there is a break in the skin it can lead to infection.
A surgical site infection can develop within a few days of surgery or can take up to thirty days to occur. According to the Center for Disease Control there are three types of surgical site infections. The first type is the superficial incision SSI; this infection occurs just at the incision area of the skin. The second type of SSI is more severe and this infection occurs beneath the skin of the incision area and affects the muscle tissue and the tissue surrounding the muscles; this is considered a deep incision SSI. The third and most severe type of SSI is the organ or space SSI.
This type of infection can occur in body organs or a space between organs. (National Healthcare Safety Network, 2010). While there are many risk factors that contribute to surgical site infections there are many ways that a patient and physician can reduce the risk and help prevent it. Some of the risk factors include having a weakened immune system, diabetes, cancer, being overweight or a smoker, being an elderly adult, and having other medical problems; these are just a few of the risk factors. While it is impossible to completely prevent surgical site infections, it is possible to reduce them.
“While nationally the rate of surgical site infection averages between two and three percent for clean cases (Class I/Clean as defined by CDC), an estimated 40 to 60 percent of these infections are preventable” (Institute for Healthcare Improvement, 2012). It is impossible to completely prevent surgical site infection because there are many risk factors that are uncontrollable. For example one risk factor is being in surgery for more than two hours. There are many times that a patient has to be in surgery for longer than two hours; in time like these all medical staff can do is catch surgical site early to reduce complications.
Many times the infection occurs because of micro-organisms that are on either the surgical team or surgical instruments. Carefully monitoring the patient after surgery while still in the hospital and frequently having them come for check-ups once they are discharged are some ways to help prevent SSIs. The earlier SSI is detected the better it is for the patient and physician since there are many legal implications related to surgical site infections. Surgical site infections are not just a problem for the patients; they have legal implications that affect both the physicians and the organization.
In the United States there are twenty-seven states that have enacted laws that require hospitals and healthcare facilities to report data related to hospital acquired infections. The Center of Disease Control National Healthcare Safety is the only national system designed for the collection of hospital acquired infection incidents along with prevention data. Along with required reporting there are a few states that have also enacted laws requiring that some healthcare facilities implement infection control plans.
“The Deficit Reduction Act (DRA) of 2005 instructed the Centers for Medicare & Medicaid Services (CMS) to identify at least two hospital-acquired conditions that are high cost or high volume, result in higher payments when acquired during a hospital stay, and can reasonably be prevented by following evidence-based guidelines…In 2007, CMS selected eight conditions for non-payment by Medicare, including two hospital-acquired infections: catheter associated urinary tract infection and surgical site infection-Mediastinitis.
Two more infections were added to the Medicare nonpayment list in 2008: surgical site infections following certain elective procedures and infections following bariatric surgery for obesity. Under the rule, on October 1, 2008, hospitals will no longer receive payment for medical services used to treat any of the listed conditions if the condition was not present upon admission” (National Conference of State Legislation, 2013).
Across the United States there are thousands of patients being rewarded millions of dollars from lawsuits because of surgical site infections that could have been prevented if certain guidelines and steps were taken; such a cleaning surgical tools. One of the most important ways that surgical site infections can be prevented is by having open communication between medical staff and the patients and their families. SSIs do not always show symptoms while the patient is in the hospital, many times these symptoms occur while the patient is recovering at home.
The better informed patients are the quicker they can catch infections and notify their physician. This will aid in reducing the mortality rate from surgical site infections. The next way that communication can assist in preventing SSIs is by the physician or other medical staff checking up on the patient while at home and asking key questions about the surgical site. This can be done by simply calling the patient and discussing what to look for over the phone and asking them how they are caring for the surgical site.
Also scheduling follow ups with the patient to examine the wound and discuss any questions they might have can also help reduce surgical site infections or at least catch them in the early stage where simply antibiotics can resolve the infection. Some healthcare providers might be reluctant to discuss that a patient has a surgical site infection because the fear of a patient bringing a lawsuit as well as it reflects badly on the healthcare organization.
Since 2010 The Joint Commission has published four National Patient Safety Goals (NPSGS) that focus on Hospital Acquired Infections; one of these four focuses on SSIs. “All four NPSGs specify the evidence-based requirements for preventing or reducing HAIs. These HAI-prevention focused NPSGs do not, however, provide direction to accredited hospitals on how to effectively implement them. Accredited health care organizations have stressed to Joint Commission’s leadership that they require guidance and direction to achieve success with the implementation of the standards and NPSGs.
Some of the effective leadership practices that were found to help reduce surgical site infections were that there were resources that were available that were dedicated to decrease SSI rates, top level leaders showed support for reduction of SSI, and by offering financial incentives to practitioners to help reduce surgical site infection. Other example of ways the Joint Commission believes that SSIs can be reduced is by decreasing OR traffic, using chlorhexadine for pre-operation bathing, and acting on identified surgical site infections quickly.
“Leadership support at the highest levels of the hospital was consistently cited as a factor contributing to SSI rate decreases. Leadership can include the hospital’s board, president, chief operating officer, chief medical officer, and chief nursing officer…As part of the hospital’s SSI improvement activities, the hospital acknowledged that it dedicated specific resources for SSI prevention. Resources identified include: increased staff, increase in SSI surveillance, improvement in information technology, and additional funding for chlorhexadine preoperative baths” (The Joint Commission, 2013).
The Joint Commission has established many guidelines for hospitals to follow to be able to be considered accredited. One of the measures that they require is that surgical sites infection rates are measured for the first thirty days following an operation that does not involve an implanted device and for the first year when a procedure involved an implanted device. “In order to improve a process capability to deliver desired performance results, a systematic, fact based approach that enables you to implement permanent solutions to root causes of problems should be used” (Sollecito & Johnson, 2013).
While surgical site infections are not thought to be completely preventable it is thought that about forty to sixty percent of them can be prevented. As a leader of a team of healthcare professional there are is one continuous quality improvement strategies that I would use to implement improvement; the Six Sigma model. The “Six Sigma is the perfect quality assurance program for the healthcare industry as it concerns prioritizing, itemizing and efficiently completely processes. Education plays an important role in surgical site infections for both the patients and medical professionals.
Medical professionals need to be educated on the proper ways they need to prepare for an operation. As many people might know before surgery many times the patient is shaved; it has been found in recent years that there is a direct link between surgical site infections and hair removal. Razors have been the most common way to remove hair before a surgery but they can lead to small cuts and abrasions that can provide an area for bacteria to live and multiply and potentially infect the surgical incision site.
As an alternative some organizations have begun to use powered surgical clippers. Medical professional also need to be educated on what the early signs of infection are so that if an infection does become present while the patient is still in the hospital they are able to identify and act quickly, many times when infection is caught early it is simply a matter of antibiotics. Medical professional need to well educated so that they may also correctly and adequately inform the patient of how to care for the surgical site at home as well as inform them of what to be looking for as a sign of infection.
With many surgeries today patients are only spending minimal time in the hospital for recovery; most recovery is being done at home. Because of this it is extremely important that the patients are well educated by the medical professionals before they leave the hospitals. Like education research also plays an important role in trying to reduce surgical site infections. Each patient is not going to experience the same kind of infection form the same factor.
Researching and gathering a better understanding of how infection occurs in many different situations will drastically help in reducing surgical site infections. As I had mentioned earlier in this paper the Joint Commission has begun doing two year studies with many different hospitals trying to collect as much data as they can regarding this issue. Along with the Joint Commission, the CDC, and many other healthcare organization have begun researching data on surgical site infections across the United States in hopes to reduce the number of patients dying each year.