The Elephant in the OR: Surgical Site Infection

Cool Photos from Depositphotos

By Dr. Anthony Senagore, Senior Medical Director, PolyPid Ltd. 

Patients and surgical teams independently travel a journey, meeting in the operating room (OR) with the shared goal of a successful procedure followed by rapid and complete recovery. In emergency surgery, the goal is to preserve life, in a planned surgery patients seek to address illness or impairments and improve quality of life. However, these desired outcomes may be drastically hindered or even result in mortality if an infection should develop. The moments leading up to any surgery, planned or otherwise, involve a host of procedural steps exclusively focused on preventing infection – chief among them surgical site infections (SSI).

SSIs are localized wound infections that develop from bacterial contamination of the exposed tissues during surgery.  SSI may manifest within the first 30 days of surgery and accounts for 40 percent of all nosocomial or hospital-acquired infections. Often resulting in significant and prolonged disability, increased risk of mortality, and hospital readmission.  As a result, SSIs costs $3.3 billion annually in related healthcare expenses. Although a wide range of interventions are included in today’s infection prevention protocols (i.e. surgical bundles), four percent of all surgical patients continue to suffer subsequent SSI. Thus, of the 30 million patients undergoing surgical procedures yearly in the US alone, 1.2 million patients will likely develop a surgical site infection. Unfortunately, patients who develop SSI are twice as likely to die as a result. 

The urgency to implement effective measures preventing SSIs weighs heavily on practitioners and hospital executives alike, prompting ongoing discussions and critical review of standard infection prevention protocols. In an effort to contain the growing rates of hospital acquired infections, the Centers for Medicare and Medicaid Services (CMS) implemented a reduction incentive program. The CMS program grades hospitals on hospital-acquired infection rates and related readmissions then determines the reimbursement penalties hospitals will incur. As physicians foster patient safety, hospital executives must confront the financial impact of SSIs and readmission to keep hospital systems financially stable. 

Bundles and Bundles of Protocols 

Infection prevention protocols have continued to evolve as our understanding of bacterial contamination advances. The evolution of these protocols premiered in the 1950s as a result of a nationwide epidemic, hospital-acquired S. aureus, now a well-known antibiotic-resistant bacteria. In time, the 1976 Study on the Efficacy of Nosocomial Infection Control (SENIC) revealed a 32 percent reduction of nosocomial infections indicated improvement. While promising, the 32 percent reduction in healthcare-acquired infections did not satisfy the disparity in infection prevention failures. 

Since then, global organizations collaborated to offer defining protocols to help reduce infection rates stemming from hospital care settings. In 2018, the World Health Organization (WHO) published guidelines for SSI prevention, highlighting various infection prevention bundles that could prove impactful. Comprising anywhere from three to 15 procedural steps, SSI bundles aim to target points of potential contamination throughout the perioperative process.

Here is a sample SSI bundle, primarily focused on the intraoperative phase:

• Administration of parenteral antibiotic prophylaxis
  • Antibiotic prophylaxis should be administered within 60 minutes prior to incision
  • Weight based dosing adjustments
  • Re-dosing is recommended for prolonged procedures and in patients with major blood loss or excessive burns
• Patients should be washed with soap or an antiseptic agent within a night prior to surgery
• Avoid hair removal: use electric clippers if necessary
• Use alcohol-based disinfectant for skin preparation in the operating room
• Maintain intraoperative glycemic control with target blood glucose levels < 200 mg/dL (in patients with and without diabetes)
• Maintain perioperative normothermia
• Administer increased fraction of inspired oxygen during surgery and after extubation in the immediate postoperative period in patients with normal pulmonary function

Despite these well-intentioned steps, the obstinate statistic endures with most of the near 30 interventions reporting moderate to low quality of efficacy. To contend with the scope of the issue, we must first address the greatest point of risk: the incisional site itself.  Successful SSI prevention hinges on the management of intraoperative risk. The bundled perioperative interventions fail to address the surgical site directly, leaving it vulnerable to contamination that may result in the onset of an SSI. 

Looking Back to See Ahead

A hospital’s OR should provide surgeons and clinical teams the tools to effectuate the task at hand, with straightforward measures that safeguard patients. Towards this effort, we must simplify infection prevention. To begin, adjudicating ineffective interventions and antiquated protocols can relieve unnecessary spending and pave way for innovative solutions. Moreover, investing in research and modern innovation stands to bridge gaps between clinician and executive approaches while resolving failures in preventing infection. Although responsibility may dictate the approach, agencies seeking to withhold reimbursement for HAIs and surgeons who desire to see their efforts resolved in a healthy, functioning patient are on the same side.  

The priority of healthcare professionals is promoting patient health and safety. Infections resulting from a healthcare setting pose and undermining risk with dire consequences. Reducing procedural steps and increasing infection prevention measures directly at the surgical site, provides patients the best chance for full recovery. Leveraging progressive use of antimicrobials provides hope of true resolution in the not-so-distant future and innovation in this area is generating significant traction. As medicine continues to evolve, we can expect to see a paradigm shift in infection prevention standards as we embrace simplicity to bolster efficacy for improved patient outcomes.

About Dr. Anthony Senagore

Anthony J. Senagore, M.D., is a colorectal surgeon with a long track record of academic surgery practice and significant experience in healthcare start-up companies. He currently serves as the Senior Medical Director of PolyPid. In previous positions, he has served as Professor of Surgery at several prestigious academic medical centers, including University of Texas Medical Branch at Galveston, Central Michigan University College of Medicine, the University of Southern California, Keck School of Medicine, Cleveland Clinic Foundation, and Spectrum Health/Michigan State University. Dr. Senagore has experience with payment policy and health care economics with service on the AMA/CMA Relative Value Update Committee for 16 years and as Chair of the Practicing Physicians Advisory Committee for the Centers for Medicaid Services. In addition, Dr. Senagore has edited five textbooks in colon and rectal surgery and authored over 230 peer-reviewed publications and 25 textbook chapters.