Surgical Products recently talked to Charles E. Edmiston Jr., PhD., CIC, Professor of Surgery & Hospital Epidemiologist – Department of Surgery at the Medical College of Wisconsin in Milwaukee about the importance of reducing surgical site infections and how the use of a surgical care bundle is aiming to improve patient care across the country.
Surgical Products: How did you come up with the idea for the surgical care bundle?
Edmiston: In 2009 I was asked to put together a presentation that was a reflection of my thoughts on the Surgical Care Improvement Project and what I thought was good and bad concerning that process initiative. Since 1985 in the Department of Surgery at the Medical College of Wisconsin we have been studying SSI risk reduction and I felt that SCIP, while a valuable initiative had too many gaps to fully be viewed as a comprehensive intervention. So using in-part our own research efforts and those of other key opinion leaders such as Maureen Spencer, we started developing the bundle concept. This thought process culminated in a paper that was published in 2011 in the journal Surgical Infections where we described several evidence-based initiatives that would appropriate bundle components.
SP: Why is it important to use a standardized regimen for the pre-admission shower using CHG?
Edmiston: The devil is always in the details” – I felt that we needed to approach the preadmission shower from a pharmacokinetic perspective. In other words develop a strategy by which we can achieve a maximal skin surface concentration of CHG that is sufficiently higher than the minimal inhibitory concentration (MIC) required to inhibit (or kill) Gram-positive and Gram-negative bacteria and therefore reduce the microbial burden on the skin prior to surgery.
When we look at the myriad factors that impact the risk of infection in the surgical patient population –patient characteristics such as length of preoperative stay, comorbidities and colonization with microorganisms, microbial factors such as virulence, antibiotic resistance and adherence and operative or environmental characteristics such as surgical technique and intraoperative contamination – it becomes clear that not all risk factors are modifiable.
However, one easily controllable factor that helps improve quality by eliminating variability is standardizing pre-admission skin cleansing protocols. Standardized pre-cleansing initiatives in total joint patients with CHG cleanses the night before and morning of surgery have been shown to significantly reduce the risk of SSI in orthopedic surgery, and in one study, by as much as 50 percent.
SP: Why is it important for CHG shower/cleansing to be a component of every surgical care bundle and used for all elective surgeries, not just orthopedic and cardiothoracic procedures?
Edmiston: Because if done correctly it can be a valuable risk-reduction strategy for all elective surgical procedures.
It is important to remember that SSIs are largely preventable. Recent studies suggest that as many as 60 percent of SSIs could be prevented using current evidence-based strategies designed to reduce the risk of infection. For the majority of SSIs, the primary source of contamination is the patient’s skin and CHG skin cleansing has applications for a wide range of surgical procedures. Our research has shown this standardized preadmission CHG cleansing regimen to be a safe and cost-effective risk reduction strategy that should be a component of every surgical care bundle and used for all elective surgeries, not just orthopedic or cardiothoracic procedures.
SP: What is the most dangerous component of surgical site infections? Why are SSIs so costly?
Edmiston: The human tragedy associated with many of these infections can be catastrophic for the patient, his (her) family and also the surgeon.
Last year an analysis of more than 54,000 patients who underwent surgery in 129 Veterans Affairs hospitals in 2010 revealed approximately 1,750 patients suffered SSIs, 0.8 percent of which were considered deep infections and 2.4 percent superficial infections. According to the findings, published in JAMA Surgery[ii], the average cost of caring for infected patients was $52,620 – approximately $21,000 more than the cost of caring for patients without infections. Patients who experienced infections after neurosurgery were the most expensive to care for, followed by those who had orthopedic, general, peripheral vascular and urologic surgeries performed. The relative costs for caring for patients with SSIs was 1.43 times greater overall.
SP: Talk about some of the feedback you received from your presentation at the fall meeting in Huntsville, Ala. What was the reaction you received from other medical professionals?
Edmiston: As a rule I always view my presentations as a first step in the process and I encourage members of the audience to contact me if they have additional questions or concerns. Therefore, I often have several emails waiting for me when I get home requesting additional information and data.
Dr. Edmiston currently consults with Clorox Healthcare surrounding the proper use of skin antiseptics.