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(Editor’s note: In this first part of a two-part series on infection control, we discuss how to control infections in the same-day surgery setting. In next month’s issue, we’ll discuss the importance of good preparation of the surgical site, we’ll tell you how to do informal education on a continuing basis, and we’ll tell you about a facility that achieves a 75% return rate on its physician surveys.)
It makes sense that the types of procedures performed in same-day surgery programs carry a lower risk of surgical site infections. Although the procedures generally are less complicated and require smaller incisions than inpatient surgical procedures, the lower risk of infection does not mean that same-day surgery staff can pay less attention to aseptic techniques, emphasize experts interviewed by Same-Day Surgery.
"We can be too lax in the outpatient setting," says Gordon Laing Telford, MD, FACS, professor of surgery at the Medical College of Wisconsin in Milwaukee. "Although there is a lower risk of surgical site infection, we should still be concerned about the risk that does exist."
A 10-year surveillance study of nosocomial infections conducted by the Centers for Disease Control and Prevention in Atlanta found that surgical wound infections dropped by 60% between 1990 and 1999. (To see results of the study, go to www.cdc.gov/mmwr/preview/mmwrhtml/mm4908a1.htm.)
"I’m not surprised at the decrease reported in the study," says Ellen O’Connor-Graham, RN, CNOR, chairman of the Ambulatory Surgery Specialty Assembly of the Association of periOperative Registered Nurses in Denver and a surgical nurse in the women’s operating room at Huntsville (AL) Hospital. "Because nosocomial infections are caused by airborne bacteria, the simple, proper use of a mask in the operating room has a great effect on the rate of that type of infection," she says. Following normal, aseptic procedures such as gloves, masks, hand washing, and draping are all important to preventing infections, O’Connor-Graham says.
"Many same-day surgery infections are the result of breaks in sterile technique such as a punctured glove or a dropped instrument that is flashed without being totally clean," she says.
A common cause of surgical site infections for same-day surgical procedures is skin bacteria, so site preparation is important, says Farrin A. Manian, MD, MPH, chief of infectious disease division at St. John’s Mercy Medical Center in St. Louis.
Evaluate the type of surgery to determine if prophylactic antibiotics are needed, Telford advises. "Most same-day surgery procedures are not as high risk for infection as colon surgery in the traditional operating room, but if you are performing a laparoscopic cholecystectomy, antibiotics are a good idea," he says. Other procedures that warrant prophylactic antibiotics include hernia repair and hemorrhoidectomy because of the area in which the surgeon is working, he adds.
There is a debate among surgeons as to the need for antibiotics, but Telford suggests that surgeons follow the standard of care for their community. Even if antibiotics are used, surgeons need to administer the antibiotics properly to achieve the best result, warns Telford. "The biggest mistake made with prophylactic antibiotics is giving the medication too soon," he says. The antibiotic should be given no more than 20-30 minutes prior to the incision to guarantee the best protection, he explains. "If the procedure is lengthy, a second dose should be given before the patient leaves the operating room," he adds.
Educating staff and monitoring infection rates are two other important aspects of protection against surgical site infections, says O’Connor-Graham. Education should be more than formal classroom teaching, she says. Informal education and reminders should continue in the operating room, she explains.
A good monitoring program also helps you identify areas in which you need to improve your procedures to protect against infection, says Manian. It is difficult to monitor same-day surgery infection rates because the patient won’t show signs of infection the day of surgery, and it becomes the surgeon’s responsibility to report infections to the same-day surgery program.
St. John’s has a program to monitor surgical site infections that has proven successful, says Manian. A 75% response rate to his hospital surgical site infection monitoring survey means that Manian knows what happens to at least 80% of the patients undergoing surgery, because the physicians most likely to respond are usually the busiest surgeons, he says. "An ongoing monitoring program is important because it gives you a chance to identify problems before they get out of hand," he explains. For example, if you typically have an infection rate of 1% or less, then it jumps to 4% one month, you know that it is time to dig further to find out what might cause the increase," he says.
While most same-day surgical site infections are minor in the eyes of the staff and surgeon as compared to peritonitis caused by a leak in the colon, you need to remember that any infection is upsetting to the patient, says Telford. "Think about infections from the patient’s perspective, and make sure you take every step to avoid them," he suggests.
For more information about prevention of surgical site infections, contact:
• Ellen O’Connor-Graham, RN, CNOR, 728 County Road, Scottsboro, AL 35768. E-mail: email@example.com.
• Gordon Laing Telford, MD, FACS, Professor of Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226. Telephone: (414) 454-5750. Fax: (414) 4554-0152. E-mail: firstname.lastname@example.org.
• Farrin A. Manian, MD, MPH, Chief of Infectious Disease Division, St. John’s Mercy Medical Center, 621 S. New Ballas Road, Tower B, Suite 3002, St. Louis, MO 63141. Telephone: (314) 569-6171.