Section 3: Background—Strategies to Prevent SSI

1. 
   Summary of existing guidelines, recommendations, and requirements
   1. 
      CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines
      1. 
         The most recently published guideline for prevention of SSIs was released in 1999 by Mangram et al. The CDC and HICPAC are currently working on an updated version of the guideline with a projected publication date in mid-2014.
         
      
      
   2. 
      National Institute for Health and Clinical Excellence (NICE)—United Kingdom
      1. 
         NICE published guidelines for the prevention and treatment of SSI in 2008.
         
      
      
   3. 
      Surgical Infection Prevention (SIP) Project
      1. 
         The Centers for Medicare & Medicaid Services (CMS) created the SIP project in 2002.
         1. 
            After review of published guidelines, an expert panel identified 3 performance measures for quality improvement related to antimicrobial prophylaxis:
            1. 
               Delivery of intravenous antimicrobial prophylaxis within 1 hour before incision (2 hours are allowed for the administration of vancomycin and fluoroquinolones).
               
            2. 
               Use of an antimicrobial prophylactic agent consistent with published guidelines.
               
            3. 
               Discontinuation of the prophylactic antimicrobial agent within 24 hours after surgery (discontinuation within 48 hours is allowable for cardiothoracic procedures in adult patients).
               
            
            
         2. 
            The SIP project focused on 7 procedures: abdominal hysterectomy, vaginal hysterectomy, hip arthroplasty, knee arthroplasty, cardiac surgery, vascular surgery, and colorectal surgery.
            
         3. 
            Many hospitals that implemented and improved compliance with SIP performance measures decreased their rates of SSI.
            
         
         
      
      
   4. 
      Surgical Care Improvement Project (SCIP)
      1. 
         The SCIP, a multiagency collaboration created in 2003, is an extension of SIP.
         
      2. 
         In addition to the 3 performance measures of SIP, the SCIP also focuses on 3 additional evidence-supported process measures to prevent SSIs and expanded the types of operations eligible for the performance measures.
         1. 
            Proper hair removal: no hair removal, although hair removal with clippers or the depilatory method is considered appropriate. Use of razors is considered inappropriate with exception of use on the scrotal area or on the scalp after a traumatic head injury. Because of near-universal compliance with this performance measure, CMS retired the measure in 2012.
            
         2. 
            Controlling blood glucose during the immediate postoperative period for cardiac surgery patients: controlled 6 am blood glucose (200 mg/dL or lower) on postoperative days 1 and 2, with the procedure day being postoperative day 0. In 2014, this measure will be revised to assess glucose control (180 mg/dL or lower) in cardiac surgery patients in the time frame of 18–24 hours after anesthesia end time.
            
         3. 
            Maintenance of perioperative normothermia in surgical patients who have anesthesia duration of at least 60 minutes.
            
         
         
      
      
   5. 
      Institute for Healthcare Improvement (IHI)
      1. 
         The IHI created a nationwide quality improvement project to improve outcomes in hospitalized patients.
         
      2. 
         The IHI recommends the same 6 preventive measures recommended by the SCIP and has included these in the 100,000 and 5 Million Lives Campaigns.
         
      
      
   6. 
      The Joint Commission National Patient Safety Goals
      1. 
         The Joint Commission's National Patient Safety Goal 07.05.01 includes several evidence-based practices for prevention of SSI.
         
      
      
   7. 
      Federal requirements
      1. 
         CMS
         1. 
            In accordance with the Deficit Reduction Act of 2005, hospitals that are paid by Medicare under the Acute Care Inpatient Prospective Payment System receive their full Medicare annual payment update only if they submit required quality measure information to CMS.
            
         2. 
            CMS now requires hospitals to submit data on 7 SCIP measures as a part of the Hospital Inpatient Quality Reporting (IQR) system. Three of these measures focus on prevention of SSI (antimicrobial prophylaxis provided within 1 hour of incision, antimicrobial selection, and cardiac surgery perioperative glucose control). In addition, CMS now requires hospitals to report SSI rates for patients undergoing abdominal hysterectomy and colorectal surgery through NHSN.
            
         3. 
            Actual rates of performance on SCIP measures now impacts hospital payment under the Value-Based Purchasing (VBP) program. Current benchmarks identified for the VBP score that is used to modify a hospital's base operating diagnosis-related group payment are at or near 100%.
            
         
         
      
      
   
   
2. 
   Infrastructure requirements
   1. 
      Trained personnel
      1. 
         Infection preventionists must (1) be specifically trained in methods of SSI surveillance, (2) have knowledge of and the ability to prospectively apply the CDC/NHSN definitions for SSI, (3) possess basic computer and mathematical skills, and (4) be adept at providing feedback and education to healthcare personnel when appropriate.
         
      
      
   2. 
      Education
      1. 
         Regularly provide education to surgeons and perioperative personnel through continuing education activities directed at minimizing perioperative SSI risk through implementation of recommended process measures.
         1. 
            Several educational components can be combined into concise, efficient, and effective recommendations that are easily understood and remembered.
            
         2. 
            Provide education regarding the outcomes associated with SSI, risks for SSI, and methods to reduce risk to all patients, patients' families, surgeons, and perioperative personnel.
            
         3. 
            Education for patients and patients' families is an effective method to reduce risk associated with intrinsic patient-related SSI risk factors.
            
         
         
      
      
   3. 
      Computer-assisted decision support and automated reminders
      1. 
         Several institutions have successfully employed computer-assisted decision support methodology to improve the rate of appropriate administration of antimicrobial prophylaxis (including redosing during prolonged cases).
         
      2. 
         Computer-assisted decision support, however, is potentially expensive, can be time-consuming to implement, and in a single study was reported to initially increase the rate of adverse drug reactions.
         
      3. 
         Institutions must appropriately validate computer-assisted decision support systems after implementation.
         
      
      
   4. 
      Utilization of automated data
      1. 
         Install information technology infrastructure to facilitate data transfer, receipt, and organization to aid with tracking of process and outcome measures.