Jim Kling

May 10, 2011

May 10, 2011 (Dallas, Texas) — A multidisciplinary approach reduced the rate of deep surgical-site infections (D-SSI) in orthopedic surgeries, according to a study presented here at the Society for Healthcare Epidemiology of America 20th Annual Scientific Meeting.

Joint-replacement surgeries are an increasingly common procedure, and D-SSIs cause serious morbidity, often necessitating the removal and replacement of the joint and significantly adding to healthcare costs.

In an effort to improve outcomes, the researchers convened a multidisciplinary working group. After analyzing processes and institutional infection data, the working group developed 4 initiatives to reduce D-SSI: refresher training for operating room staff on aseptic technique, sterility, and standardization of skin-site preparation; development of a skin-site preparation procedure using a chlorhexidine gluconate (CHG)-based skin antiseptic; patient education about the importance of CHG bathing in advance of the procedure; and standardization and the addition of vancomycin to the preoperative antibiotic regimen.

In the 12 months after the implementation of the initiatives, the researchers noted a 66% reduction in hip arthroplasty D-SSI (1-tailed P value of regression line = .0194) and an 80% reduction in knee D-SSI. The improvements continued for an additional 6 months after that.

"We think part of the benefit was that we bundled several [initiatives] together and rolled them out over a short period of time, and they became a standard of practice," Judith O'Donnell, MD, chief of infectious diseases and hospital epidemiologist at the Penn Presbyterian Medical Center in Philadelphia, Pennsylvania, who presented the research, told Medscape Medical News.

Before the changes, physicians used a variety of skin-site preparations. "We think making this a uniform process was very beneficial," Dr. O'Donnell added.

Similar programs could be implemented elsewhere, but "everyone who is involved with patient care has to be on board with these kinds of initiatives. I think the refresher course [for operating room staff on aseptic procedures] and going over best practices is something any institution should do on a routine basis, especially if they have a high turnover of staff. The only thing not applicable broadly is our decision to use vancomycin. There are many places that have lower [methicillin-resistant Staphylococcus aureus] rates than we do, so they would not have to use vancomycin," said Dr. O'Donnell.

The results are impressive, but the skill of the surgical team could have influenced the observed improvement. Surgical skill is "very hard to measure, of course, but we all celebrate that success," Steven Gordon, chair of the Department of Infectious Disease at the Cleveland Clinic, Ohio, told Medscape Medical News.

"I think that model of a system approach is something that most people are beginning to understand. It's not just what happens in the operating room. You want to be sure that the team is educated up and down, from the preoperative team, the perioperative team, to the postoperative," Dr. Gordon added.

The study did not receive commercial support. Dr. O'Donnell and Dr. Gordon have disclosed no relevant financial relationships.

Society for Healthcare Epidemiology of America (SHEA) 20th Annual Scientific Meeting: Abstract 473. Presented April 3, 2011.