Background

There is an increasing rate of surgical site infections (SSIs) in the US, with the Center for Disease Control (CDC) reporting a 3% increase reported from 2021 to 2022 (1). SSIs are the costliest hospital acquired condition (HAC). The cost is driven by increases in length of stay, emergency room visits, and readmissions. The CDC mandates reporting and surveillance of SSI in colorectal and hysterectomy patients. As 60% of SSIs are deemed preventable, they are a target for pay for performance (2).

The standardized infection ratio (SIR) for an institution is defined as the rate of reported hospital acquired infections (HAI) over predicted rates of infections. There are modifiable and nonmodifiable factors used in calculating the SIR for an institution. Modifiable factors include weight, diabetic glucose control, skin colonization, smoking cessation, alcohol consumption, and chronic liver disease. Non modifiable factors include age, previous radiation, and gender. The calculated SIR also includes surgical factors such as surgical approach and duration of operation.

Prevention Bundle

A challenge for anesthesia providers is that we have a huge impact on the potential for SSIs, but this is often thought to be the concern of surgeons. As our involvement in patient care, we usually do not personally feel connected to SSIs as they occur, as the discovery is often remote from the perioperative period. In addition, many factors are associated with SSIs. There are patient factors, institutional factors, and personnel factors (Table 1). However, focusing on controlling this bundle can improve outcomes by controlling the modifiable factors. An example of the Bundle that we focus on at Froedtert is seen in Table 2.

The anesthesiologist’s role is focused on usually shared preoperative and intraoperative factors. Ensuring that a patient has received the correct antibiotic prophylaxis on time, maintains intraoperative normothermia, avoidance of unnecessary transfusion, appropriate fluid management, and plasma glucose management are the focus of the perioperative team (2, 3). Ensuring that the patient has appropriate decolonization of their skin and has met their preoperative optimization targets is shared between surgeons, perioperative physicians, as well as the patient.  Targeting the “bundle” of care is the responsibility of the perioperative care team. Following the metrics as they are measurable, hardwiring management and tips for care, and feedback of data to the providers and staff drives improvement and can decrease SSI rates (4, 5).

More subtle and difficult to measure is the strict adherence to antiseptic process. This is often difficult to measure, outside of auditing provider’s activity, which is an expensive and challenging endeavor (Figure 1). Anesthesia providers have a unique role in protection of patients from infection. Known pathogens, such as MRSA, gram-negative bacteria, and multidrug resistant organisms have been found on operating room (OR) surfaces including anesthesia work areas and are an opportunity for transmission to patients without careful attention (6). Placement of contaminated airway equipment on an anesthesia machine after use adjacent to medication syringes, and uncapped syringes increase the risk of contamination and transmission of infective organisms to patients (7). Hand hygiene should be done before aseptic tasks, before touching anesthesia carts, after removing gloves, and when entering and exiting an OR room.  Limiting OR traffic has also been identified as a modifiable risk factor, as it disturbs airflow (8). This must be a focus of providers. Inclusion of appropriate work design that decreases the transmission of organisms to patients is the responsibility of all providers, but for anesthesia providers who must be the protectors of our most vulnerable patients, it is essential.

References

Table 2.

1. American Society of Anesthesiologists. (2021). ​ASA physical status classification system. Asahq.org. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
2. Burlingame, B., Davidson, J., Denholm, B., Fearon, M. C., Giarrizzo-Wilson, S., Johnstone, E. M., Link, T., Ogg, M. J., Spruce, L., Spry, C., Van Wicklin, S. A., & Wood, A. (2018). Guidelines for perioperative practice (R. Conner, Ed.). Association of Perioperative Regiestered Nurses.
3. Berríos-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R., Reinke, C. E., Morgan, S., Solomkin, J. S., Mazuski, J. E., Dellinger, E. P., Itani, K. M. F., Berbari, E. F., Segreti, J., Parvizi, J., Blanchard, J., Allen, G., Kluytmans, J. A. J. W., Donlan, R., & Schecter, W. P. (2017). Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surgery, 152(8), 784. https://doi.org/10.1001/jamasurg.2017.0904
4. Edmiston, C. E., Borlaug, G., Davis, J. P., Gould, J. C., Roskos, M., & Seabrook, G. R. (2017). The Wisconsin Department of Health Services, Division of Public Health supplemental guidance for the prevention of surgical site infections: An evidence-based perspective. https://www.dhs.wisconsin.gov/publications/p01715.pdf
5. Olexia, D., Bunnell, K., Kennedy, P., & Wainaina, J. N. (2021). Froedtert Health antimicrobial stewardship guideline: Perioperative antibiotic prophylaxis. Froedtert & the Medical College of Wisconsin. http://intranet.froedtert.com/upload/docs/Froedtert%20Hospital/Departments/Pharmacy/DZ/Periop%20Abx%20PPX%20guideline%201.7.21.pdf
6. Tartari, E., Weterings, V., Gastmeier, P., Rodríguez Baño, J., Widmer, A., Kluytmans, J., & Voss, A. (2017). Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrobial Resistance & Infection Control, 6(1). https://doi.org/10.1186/s13756-017-0202-3
7. World Health Organization. (2018). Global guidelines for the prevention of surgical site infection (2nd ed.). World Health Organization. https://www.who.int/publications/i/item/global-guidelines-for-the-prevention-of-surgical-site-infection-2nd-ed

Figure 1.