Regardless of the place and procedure, undergoing surgery is often associated with anxiety and concerns. After all, how can a patient be certain their doctor is following best practices to ensure a safe and successful procedure?
Even in common procedures like hip and knee replacements, surgical site infections (SSIs) – an infection occurring at the site of the surgery – can occur. Almost 300,000 SSIs occur annually in the United States. Estimates suggest that up to half may be preventable with the use of current evidence-based strategies. Additionally, due to antimicrobial–resistant pathogens, the costs and challenges associated with treating SSIs is growing.
A guideline published this month in JAMA Surgery by the Centers for Disease Control and Prevention, and supported by Craig A Umscheid, MD, MSCE, vice chair for Quality and Safety at Penn Medicine and an associate professor in General Internal Medicine, and his team, provides the most up to date recommendations for clinicians and organizations about how to prevent SSIs in their care settings.
The guideline is based on a systematic literature review of 170 studies conducted by Umscheid and his colleagues, and examines 10 core domains that pertain to all surgical procedures and 10 additional areas that pertain strictly to orthopaedic surgery. For example, one core recommendation suggests providing a higher percentage of inspired oxygen to reduce the risk of surgical site infections for patients who are intubated (i.e. have a tube inserted into their throat to help them breathe) during their procedure. Other core recommendations advise surgeons about how to administer intravenous antibiotics during a procedure, and to limit antibiotics after a procedure when there is no benefit and only harm.
The section on joint replacement makes recommendations about the use of blood transfusions, what to do for patients who are on steroids to minimize infection risk during a surgical procedure, and biofilms on prosthetic joints. If a patient gets a joint infection, one of the biggest problems is that the inserted hardware can also get infected, and an impenetrable biofilm can form around the infected hardware such that antibiotics cannot clear the infection, thus forcing surgeons to remove the prosthetic joint.
In 1999, the Centers for Disease Control and Prevention published guidelines on surgical site infection prevention. The update to that guideline began over five years ago, but Ebola, Zika and other national and international healthcare emergencies delayed its completion.
The news blog checked in with Umscheid to see what the major takeaways are from this guideline and how it can improve the safety of surgical procedures.
Q: Why is this update timely and significant?
A: SSIs are increasing, and can be particularly devastating in relatively common procedures like joint surgery, where you can get an infection of your prosthetic joint, or in heart surgery, where you can get an infection of your sternotomy site, which is where an incision has been made through your chest bone to reach your heart. That said, when current evidence-based strategies are used SSIs are often preventable, so we have opportunity here to strengthen care.
Q: Can you give us an example of how one of these recommendations might change care?
A: One of the core recommendations is about keeping patients warm during surgery. If the patient gets cold in the operating room, this can increase the risk of surgical site infection. So the surgical team should use blankets and devices like bear huggers to keep patients warm during the operating room procedure to reduce the risk.
Q: In the study, the team discusses how best to administer intravenous antibiotics or prepare a surgical site before a surgeon makes an incision to prevent infection. You also provide recommendations about how to control blood sugar levels. These seem like standard practices, but is it concerning to you that some places have not implemented all of these?
A: Many health care organizations have implemented most or all of these practices, but we hope this work informs those who have room to improve – institutions that might have practice gaps between what we know works and what their practicing in the real world. Most importantly, we hope this guideline helps address the ongoing debates over some of the controversial issues in SSI prevention – such as how to prepare a surgical site, how long to give antibiotics after a procedure, how much oxygen to give patients during a procedure, whether to use triclosan coated sutures to prevent SSI, and so on.
Umscheid directs the Center for Evidence Based Practice, and his team has worked on quality and safety issues related to healthcare associated infections for years. The team tackled preventing catheter-associated urinary tract infections in a 2010 CDC guideline in Infection Control and Hospital Epidemiology. A year later, they co-authored a CDC guideline with recommendations to hospitals about how to prevent norovirus gastroenteritis outbreaks. They published another CDC guideline in 2013 on preventing infections during solid organ transplantation, and two years later, the Agency for Healthcare Research and Quality funded the group’s work to systematically review approaches to cleaning hospital room surfaces to prevent HAIs, a review later published in the Annals of Internal Medicine.
This latest work is more than five years in the making, and early signals suggest it may have great impact. The level of interest from peers – more than 1/2 million views, 75,000 downloads, and the most “tweeted,” “posted,” and “blogged” about JAMA Surgery article in history – gives the team hope that this momentum will continue, and the findings will inform surgical practice at the national and international level.
“Clinical practice and quality measures are informed by guidelines,” Umscheid says. “This is about ensuring all patients in all hospitals receive the best evidence-based care available.”