Follow these steps for low infection rates
Follow these steps for low infection rates
Surgical technique, monitoring are the key
With good infection control practices, such as attention to aseptic technique and proper use of antimicrobials, infection control experts report that postoperative infection rates can be less than 1% for most same-day surgery procedures. The experts offer the following advice for keeping your infection rates low:
• Maintain meticulous surgical technique.
"The No. 1 way to prevent an infection from occurring is appropriate, careful surgical technique," says William Jarvis, MD, chief of the investigation and prevention branch of the hospital infections program of the Centers for Disease Control and Prevention in Atlanta. "Many if not most of the infections that do occur are due to surgical technique and small breaks in aseptic technique or from the patient’s own flora."
At the Henry Ford Health System in Detroit, which includes three freestanding surgery centers and numerous physician offices, infection control officers conduct observational surveillance of staff, says Jan Jennings, MS, CIC, manager of clinical resource improvement services. "We will do spot checks to make sure people are observing proper sterile technique and to make sure they’re reprocessing equipment properly."
When breast biopsies moved to a procedure room at Ben Taub General Hospital in Houston, the staff became too relaxed about aseptic technique and infection rates rose, says Letha Johnson, RN, CIC, infection control coordinator. (See cover story, p. 97.) "We need to be sure that the staff in that [procedure] area receives the same education that the OR staff receives so they can be educated about OR procedures."
• Monitor infection rates.
While that advice sounds simple, surveillance of postoperative infections in same-day surgery is actually problematic. Should you monitor all procedures or just high-risk ones, such as those that break a contaminated membrane? Should you ask your physicians, your patients, or just review medical records?
"We tried everything and narrowed it down to what worked best for us," says Jennings.
Henry Ford Health System surveys physicians with "varying success," she says. Patient surveys are not necessarily a good source of information about infections because the patients may not know whether they have one, she adds. For example, they may not know the difference between a stitch abscess and a surgical wound infection.
The health system set up an infection control hotline for physicians, nurses, or other care providers to report complications confidentially. They report the patient’s name, the medical record number, and the possible problem, Jennings says. "It’s a convenient way for people to report a possible adverse occurrence without having to fill out a piece of paper."
Henry Ford Health System also has "computerized encounter information" showing when patients have visited any part of the system doctors’ offices, hospitals, or clinics. Through that database, infection control officers can determine if the patient sought treatment for an infection within 30 days of surgery.
Jennings advises same-day surgery managers to conduct a focused study before and after moving procedures to a less sterile environment. "Then you have the data to say, Are we doing something that is increasing risk to our patients?’"
Same-day surgery managers may target certain procedures for routine or periodic monitoring, such as certain GI or gynecologic procedures that are considered "clean-contaminated" because they break a contaminated membrane. Procedures that involve an implant are considered higher risk, says Jarvis. Other procedures might be monitored on a spot basis.
Another approach is to monitor compliance with surgical standards rather than calculating infection rates, Jarvis says. "It may be that surgical site infections for these [outpatient] procedures is very, very low, and doing surveillance is a waste of time," he says. "It might make more sense to look at [such practices as] prophylactic use of antimicrobials."
• Maintain proper use of antimicrobials.
Antimicrobial prophylaxis is widely recognized as an important tool for preventing surgical wound infections in procedures with high infection rates, implantation of prosthetic material, or those in which infections would be very serious, such as cardiac surgery.
A recent issue of The Medical Letter, a biweekly newsletter based in New Rochelle, NY, that provides medical information on drugs and therapeutics, recommends prophylaxis for vaginal hysterectomies, incisions through the oral or pharyngeal mucosa, and patients with common duct stones undergoing biliary tract surgery. It was not recommended for cardiac catheterization, gastrointestinal endoscopy, herniorrhaphy, or most plastic surgery procedures. (For ordering information, see source box, above.)
The effectiveness of prophylaxis is dependent on its timing, says John P. Burke, MD, professor of medicine at the University of Utah and chief of clinical epidemiology and infectious disease at LDS Hospital, both in Salt Lake City. Optimally, it should be given within two hours of the surgical incision.
A number of factors can lead to improper timing of prophylaxis, Burke says. "It was usually a failure of handoff between specialties," he says. "The surgeon would write the order to give the antibiotic, without specifying the time the antibiotic should be given with regard to the surgical incision. If there were delays, it could be four, five, or six hours before the antibiotic was given. Each patient had a unique circumstance relating to the failure."
The solution: LDS Hospital assigned responsibility to the supervising nurse in the pre-op holding room to make sure the appropriate patients receive antibiotics. Burke and his colleagues developed computer programs within the hospital’s clinical information system to tag patients who meet criteria for prophylaxis as determined by the hospital’s own surgeons.1
The pre-op nurse identifies patients who don’t have appropriate orders and tracks down the physicians, Burke says. "We’ve been able to increase our appropriate timing to as high as 99% for patients who meet the criteria for prophylaxis and receive it in a timely manner."
• Assign one staff person the responsibility of monitoring infection control.
"If you don’t have one person who takes principal responsibility for the infection control program, then things get missed," says William Schaffner, MD, hospital epidemiologist at the Vanderbilt University Medical Center in Nashville, TN, and chairman of the hospital’s infection control committee.
Hospitals have a department of infection control, and chains of surgery centers often have an infection control expert. An individual surgery center may gain that expertise from a consultant, but it is advisable also to assign responsibility for infection control to a staff person, says Jennings. That may be the same person who monitors quality improvement or risk management.
Infection control needs to be considered with other issues as changes are made in the surgery center’s procedures or facility, says Schaffner. "[Nurses and physicians] are making decisions based on cost-effectiveness, or what seems good to them, but not from a background in infection control."
Reference
1. Pestotnik SL, et al. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996; 124:884-890.
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