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Hospital Harm: Post Procedural Infections

A Post Procedure infection is associated with a medical or surgical procedure and results from colonization with a bacterial load greater than the capability of the immune system to manage. These infections can significantly increase cost, morbidity and even mortality.

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

To prevent post procedural infections and deaths in hospitalized patients by reliably implementing evidence-based procedural care for all patients undergoing invasive procedures.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Surgical site infections (SSIs) are infections of the incision, or organ, or space that occur after surgery. Surgical patients initially seen with more complex comorbidities and the emergence of antimicrobial-resistant pathogens increase the cost and challenge of treating SSIs. The prevention of SSI is increasingly important as the number of surgical procedures performed … continues to rise. It has been estimated that approximately half of SSIs are preventable by application of evidence-based strategies (Berríos-Torres et al., 2017). SSIs affect up to one-third of patients who have undergone a surgical procedure (World Health Organization, 2018). Surgical site infections are a frequent cause of morbidity following surgical procedures and have also been shown to increase mortality, readmission rates, length of stay, and costs for patients who incur them. (Cataife et al., 2014).

The pooled incidence of SSIs in low- and middle-income countries is 11.8 per 100 surgical procedures. Although it is much lower in high-income countries, it remains the second most frequent type of healthcare-associated infections (HAI) in Europe and the United States of America (USA). The highest cumulative incidence was for colon surgery with 9.5 per cent episodes per 100 operations, followed by 3.5 per cent for coronary artery bypass graft, 2.9 per cent for caesarean section, 1.4 per cent for cholecystectomy, 1.0 per cent for hip prosthesis, 0.8 per cent for laminectomy and 0.75 per cent for knee prosthesis (WHO, 2018).

Many factors in a patient's journey through surgery have been identified as contributing to the risk of SSI. The prevention of these infections is complex and requires the integration of a range of measures before, during and after surgery (WHO, 2018).

Importance to Patients and Families

Skin is a natural barrier against infection. Even with many precautions and protocols to prevent infection in place, any surgery that causes a break in the skin can lead to an infection (Johns Hopkins Medicine, n.d.). When patients get an infection following surgery or procedure, it delays healing, extends the patient's length of stay and increases their risk for harm and readmission. By implementing the appropriate interventions, patients are safer and go home sooner (Institute for Healthcare Improvement, n.d.).

Most patients who have surgery do well, but about three out of every 100 surgery patients get an infection. This can lead to other problems such as a longer hospital stay and rarely, an infection-related death (IHI, 2012).

Patients and carers should be given information and advice on how to care for their wound after discharge, how to recognize a surgical site infection, and who to contact if they are concerned (NICE, 2019).

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Post Procedural Infections, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category:

  • B14: Post Procedural Infections

Concept: Infections associated with a medical or surgical procedure.

Notes: This clinical group may include inflammatory reactions in the absence of infection.

Success Stories

HSO Leading Practices Library

Healthcare associated infections are considered a serious threat to the hospitalized patient's safety. Among surgical site infections, those related to orthopaedic procedures are considered severe and can increase morbidity-mortality rates. Factors in the preoperative, intraoperative, and postoperative periods that can help prevent orthopaedic infections include good preoperative skin care, optimal care during the operative phase, high rates of hand hygiene compliance throughout the continuum of care, stringent aseptic technique with postoperative dressing changes and the reduction of any incision site complications such as blisters. In the pre-operative period, the goal is effective skin preparation to reduce the resident microbial count and is achieved by having patients shower using Chlorhexidine 2 per cent, eliminating shaving, and screening for antibiotic resistant organisms such as MRSA. In the operative phase, the administration and timing of prophylactic antibiotics are crucial to the reduction of infection rates. Timing was improved by having Nurses start the infusion when the previous patient leaves the OR. The dose of the antibiotic Ancef was increased from 1 to 2 gms, and antibiotic impregnated cement (methyl methacrylate) was introduced. Perioperative normothermia has been shown to help decrease infections in orthopaedic patients so all patients are provided with warming blankets. Hand Hygiene is considered the single most important way to reduce nosocomial infections. Holland Centre compliances rates went from 28 per cent in 2008 to 85 per cent in 2012 with education, increased access to hand wash stations and products at Point-of-Care. We also now have full compliance with staff not wearing hand or arm jewelry and not eating and drinking in the nursing stations. These two factors are known to decrease infection rates. The introduction of a new wound care product and protocol, reduced the need for dressing changes, allowed greater flexibility for patients mobilizing and showering after surgery, and reduced blistering around the wound. The Holland Centre performs over 2,100 Total Joint procedures annually. A comprehensive process is in place to monitor and report infection rates for 12 months following surgery. In 2011/12 surgical infection rate in total hip and knee replacement patients was 0.00 per cent (compared to the National Healthcare Safety Network (NHSN) target rates of 0.75 per cent for hips and 0.68 per cent for knees). Preliminary data for 2012/13 shows that the program has sustained a 0.00 per cent infection rate for both hip and knee patients. We continually strive to improve practice throughout the entire process in order to eliminate surgical site infections in our patient population.

Best Practice in Infection Prevention and Control in a Surgical Patient Population (Health Standards Organization, 2013)

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References

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