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When surgical infection control practices work best

SurgeryInfectionInfection control practices that focus on perioperative patient skin and wound hygiene, as well as transparent display of data, not operating room attire policies, correlated with surgical site infection rates, a US hospital study found.

While hospitals grapple with what operating room (OR) infection control procedures work best, a study of Texas hospitals has determined two areas that stand out: mandating sterile operating conditions at or close to the wound itself; and tracking in-hospital outcomes on surgical site infections (SSIs) and sharing that information with surgeons and other OR staff.

"In contrast, our research team found that policies regulating the attire of OR personnel had no measurable impact on infection rates," said lead author Dr Thomas A Aloia, department of surgical oncology, the University of Texas MD Anderson Cancer Centre, Houston.

"Every institution wants to lower complication rates and, in particular, wound infection rates," Aloia said. "However, we have limited resources to carry out quality assessment and quality improvement. What's important about this study is that it brings feasibility to hospitals that may be considering 80 possible variables to intervene on. To get off to a strong start, they can begin by looking at conditions right at the wound and their reporting practices. A focus on these elements should produce the biggest impact for quality improvement initiatives."

He added, "our findings can really help individual hospitals that are working on OR attire policy and other standard operating procedures and regulations to appropriately scale what they are going to emphasise."

SSIs impose a significant burden and cost on the healthcare system. A recent study found that 1% of all surgical patients develop a SSI during their admission for surgery, but rates are 30% higher for patients having gastrointestinal operations. A study of non-cardiac operations at Veterans Affairs hospitals reported a surgical site infection rate of 4.6%.

SSIs account for almost one in six hospital-based infections and lead to higher rates of patient death and longer hospital and intensive care unit stays. Studies have estimated that cost for a patient with an SSI is almost double that of a patient who's had an uneventful operation. For gastrointestinal surgical patients, SSIs were found to increase hospital stays by an average of 10 days and add $20,000 to the cost.

In response, several professional organizations have recommended a host of infection control practices, which hospitals have adopted to varying degrees. For this study, Aloia and his colleagues surveyed surgeon leaders at 20 Texas hospitals affiliated with the Texas Alliance for Surgical Quality (TASQ), a collaborative of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®).

The survey asked respondents to rank how well the three key disciplines on the surgical team – surgery, anaesthesia, and nursing – adhere to 38 separate infection control practices in six different categories: attire; preoperative preparation; during-surgery protocols; antibiotics; postoperative care; and outcomes reporting. The study used a four-point scale to rank the level of adherence.

The researchers also collected outcomes data on risk-adjusted odds ratios of surgical site infections contained in the July 2016 ACS NSQIP hospital-level risk-adjusted reports. They then compared compliance rates between the best and worst performers.

Almost all hospitals reported maximal adherence to surgical care improvement project metrics, including removal of patient hair around the wound site with clippers and proper use and dosing of preventive antibiotics. The subset of hospitals that were most compliant with eight other practices demonstrated the lowest surgical site infection rates. These practices included the patient showering before an operation; best practice preparation of the skin in the OR; and use of clean instruments, gowns, and gloves for closing wounds and changing dressings, Aloia said.

"The best performing hospitals were vigilant about skin prep, using a clean closure and giving antibiotics appropriately – all those things that happened right at the level of the wound," Aloia said. "In addition, the hospitals that reported out their data on a formal basis – monthly or quarterly – to their surgeons, departments, and institutions also had the highest performance."

"These findings are supported by three recently published studies, including surgical site infection guidelines from the US Centres for Disease Control  and Prevention (2017) and the American College of Surgeons and Surgical Infection Society (2016)," the authors noted.

By the same token, Aloia and his colleagues found that OR attire practices, particularly those that apply to OR personnel away from the immediate field of surgery, had no impact on SSI rates. These practices included implementation of specific rules for surgical caps, undershirts, and shoes and shoe coverings; restrictions on jewelry and nail polish; coverage requirements for forearms and head and facial hair; and even presence of personal bags in the OR.

Those types of regulations actually provided the impetus for the study, Aloia explained. "Although we would never advocate sacrificing safety, such regulations don't seem to have data to back them up," he said.

The next step, Aloia said, is to feed back the data to the participating programmes and to revisit in a year how the lower performing programmes have changed their infection control practices to be more vigilant about effective practices at and near the surgical field and report outcomes and if the SSI rates improve as a result. "If that happens and their performance improves, that improvement would validate the effects we saw in our study," he said.

Background: In an effort to reduce surgical site infection (SSI) rates, a large number of infection control practices (ICPs), including operating room attire policies, have been recommended. However, few have proven benefits and many are costly, time-consuming, and detrimental to provider morale. The goal of this multi-institution study was to determine which ICPs are associated with lower postoperative SSI rates.
Study Design: Twenty American College of Surgeons NSQIP and Texas Alliance for Surgical Quality-affiliated hospitals completed this Quality Improvement Assessment Board-approved study. Surgeon champions at each hospital ranked current surgery, anesthesia, and nursing adherence to 38 separate ICPs in 6 categories (attire, preoperative, intraoperative, preoperative, intraoperative, antibiotics, postoperative, and reporting) on 4-point scales for general surgery cases. These data were compared with the risk-adjusted general surgery SSI odds ratios contained in the July 2016 American College of Surgeons NSQIP hospital-level, risk-adjusted reports. Compliance rates were compared between the 7 best (median SSI odds ratio, 0.64; range, 0.56 to 0.70) and 7 worst (median SSI odds ratio, 1.16; range, 0.94 to 1.65) performers using ANOVA.
Results: Nearly all hospitals reported maximal adherence to hair removal with clippers (Surgical Care Improvement Project measure Inf-6) and to best-practice prophylactic antibiotic metrics (Surgical Care Improvement Project measure Inf-1-3). Variable adherence was identified across many ICPs and more frequent compliance with 8 ICPs correlated with lower SSI odds ratios, including preoperative shower; skin preparation technique; using clean instruments, gowns, and gloves for wound closure and dressing changes; and transparent internal reporting of SSI data. Operating room attire ICPs, including coverage of nonscrubbed provider head and arm hair, did not correlate with SSI rates.
Conclusions: This analysis suggests that the subset of ICPs that focus on perioperative patient skin and wound hygiene and transparent display of SSI data, not operating room attire policies, correlated with SSI rates. Implementation of this subset of evidence-based ICPs may improve SSI rates at lower-performing hospitals.

Catherine H Davis, Lillian S Kao, Jason B Fleming, Thomas A Aloia

[link url=""]Infection Control Today material[/link]
[link url=""]Journal of the American College of Surgeons abstract[/link]

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