Are same-day surgery infection rates low - or just unknown?
Are same-day surgery infection rates low or just unknown?
Infection control experts urge monitoring of rates, processes
As procedures move from inpatient to outpatient settings or from surgery centers to physician offices, are infection rates increasing? No one knows - and that lack of information is cause for concern, infection control experts say.
"Some surprisingly invasive procedures are being done in a clinic setting," says William Schaffner, MD, hospital epidemiologist at the Vanderbilt University Medical Center in Nashville, TN, and chairman of the hospital’s infection control committee. "We are watching a flood of change of practice, but no group has looked at these changes from the point of view of infection control," says Schaffner, referring to groups such as the Atlanta-based Centers for Disease Control and Prevention (CDC) and the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC).
Research related to infection rates in outpatient surgery also is sparse, particularly considering the rapid growth of the field, says Schaffner. One study indicates that changing a procedure to a less controlled setting, along with lax compliance with established OR procedures, can lead to a dramatic rise in infection rates that is difficult to detect without specific surveillance.1
An ambulatory surgery focus group of APIC formed four years ago to facilitate the sharing of information about infection control in the outpatient arena. (For more information, see source box, p. 99.) Areas of concern include whether standards of sterile technique and criteria for patient selection should be different from those in the inpatient setting, says Jan Jennings, MS, CIC, manager of clinical resource improvement services for the Henry Ford Health System in Detroit and leader of the APIC ambulatory care focus group.
When people look at their infection rates in same-day surgery, she says, the rates look lower than among inpatients. "But on the other hand, are you capturing everything [that occurs after discharge]?"
Schaffner calls surveillance of postsurgical infections in same-day surgery "primitive to nonexistent" and stresses that SDS managers need to develop methods for determining whether changes in practice sites affect infection rates. (For specific infection control recommendations, see story on p. 99.)
Relaxed practices lead to more infections
When Letha Johnson, RN, CIC, infection control coordinator at Ben Taub General Hospital in Houston, focused on the high-volume procedure of breast biopsies, the findings were alarming: a surgical wound infection rate of 6.6%.1
Johnson conducted the review of surgical wound infections retrospectively by taking charts of 121 patients who had undergone a breast biopsy and checking for follow-up visits within 30 days of surgery. The records reflected those patients who had been treated for surgical wound infections.
Breast biopsies had been moved from the OR to a minor surgery clinic in the hospital, says Johnson. "We went back to look at some of the practices in the setting," she says. "We found that some of the practices that are needed for aseptic technique were very relaxed. [The clinic] also had poor housekeeping practices."
For example, Johnson and her colleagues found dust in the procedure room and sterile supplies that were not stored properly. The procedure room didn’t have a place for surgeons to do a surgical scrub. There was too much traffic in the area, and the nurse who assisted with the procedure also had to monitor the reception desk, she says.
When breast biopsies moved back into the OR, the infection rate dropped to 1%, Johnson says. Ben Taub is now reviewing that procedure area to bring it up to the standards of the OR, a process that will include additional staff training. "We’re asking our surgery service to look at the procedures that are performed there and give us recommendations [for changes]," she adds.
Currently, only noninvasive procedures are performed in the procedure area, but breast biopsies may move back there when the problems are corrected, Johnson says. Meanwhile, she suggests same-day surgery managers periodically monitor even those procedures that are not considered high-risk.
"Our staff had gotten real relaxed," she says. "You have to continue to do some [surveillance] in those areas."
Schaffner notes that Ben Taub General Hospital didn’t pick up the increased infection rate until specific monitoring occurred. "Unless you do surveillance, you don’t know," he says. "Your casual impressions can be misleading."
Though rare, outbreaks of post-op infections can stem from an environmental cause. At one surgery center, the intermittent use of the heating, air conditioning, and ventilation system (HVAC) and inadequate maintenance led to an outbreak of post-surgical infections.
In 1992, investigators from the CDC visited a cataract center where several patients had contracted infective endophthalmitis. They discovered a contaminated high-efficiency particulate air filter in the heating, air conditioning, and ventilation system and replaced it. Then, the following year, four more patients contracted endophthalmitis.2
After the first outbreak, the HVAC ducts were cleaned and sanitized with glutaraldehyde every six months. But another investigation by the CDC revealed that the air also went through a humidifier that didn’t have proper drainage and was contaminated with Acremonium kiliense the same fungal organism that infected the patients, says William R. Jarvis, MD, chief of the investigation and prevention branch of the CDC’s hospital infections program.
Patients were significantly more likely to have contracted the infection if their procedures occurred at the beginning of the week, when the HVAC system was activated. The CDC investigators speculated that turning the system off and on dislodged fungal spores and increased the risk of infection, Jarvis says. That is a situation that has never been addressed in hospital infection control, where maintenance of HVAC systems is often required by state health departments, and intermittent use of the systems is rare, he adds.
"There are no rules or regulations with regard to ventilation systems [in the ambulatory setting]," says Jarvis. "There are no rules or regulations with regard to shutting a system off. It showed the difficulty of grappling with a problem like this."
While such incidents are rare infective endophthalmitis occurs in .08% to .5% of cataract patients2 Jarvis advises same-day surgery managers to become familiar with their HVAC systems by knowing how the system is designed and how the air is filtered, to use high-efficiency particulate air filters, and to maintain the system well.
The appropriate use of prophylactic antibiotics before surgery also can reduce the risk of postoperative infection if the antibiotics are given in a timely fashion.3 In a study at LDS Hospital in Salt Lake City, patients who received antibiotics preoperatively within two hours of surgery had the lowest rate of post-op infection (.6%). Patients who received their prophylaxis earlier had an infection rate of 3.8% more than six times higher. Late prophylaxis also was associated with increased rates.3
LDS Hospital now monitors the timing of preoperative prophylaxis, says John P. Burke, MD, professor of medicine at the University of Utah in Salt Lake City and chief of clinical epidemiology and infectious diseases at LDS Hospital.
"What we found is that maintaining these types of results requires constant vigilance," says Burke. "If you relax your efforts, the proportion of patients receiving appropriate timing [of prophylaxis] will fall." After the first year of increased monitoring, when the problem was thought to have been corrected, the proportion of patients receiving properly timed prophylaxis fell from 95% to 80%, he adds.
In fact, vigilance is the message of infection control experts. They say same-day surgery programs need to monitor compliance with such practices as aseptic technique and prophylaxis.
"Managers of surgery centers need to start thinking about their entire infection control program, which includes surveillance of operative infection," says Schaffner. "It ought to be a part of their quality assurance activities."
References
1. Johnson L, et al. Influence of surgical setting on surgical wound infection rates following breast biopsy. Presented at the sixth annual meeting of the Society for Healthcare Epidemiology of America. Washington, DC; April 1996.
2. Fridkin SK, et al. Acremonium kiliense endophthalmitis that occurred after cataract extraction in an ambulatory surgery center and was traced to an environmental reservoir. Clin Infect Dis 1996; 22:222-227.
3. Classen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326:281-286.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.