Taking the Lead to Prevent Surgical Site Infections and In-Hospital Adverse Events

By Amanda Decimo, MSN, MPH, CRNA, from the IARS, AUA and SOCCA 2019 Annual Meetings*

During the AUA Scientific Advisory Board Oral Session II, researchers Dustin Long, MD, University of Washington, and Ming Ann Sim, MBBS, National University Hospital Singapore, revealed their studies which present new ways to improve patient safety, and reduce and prevent surgical site infections and in-hospital adverse events.

Dustin Long, MD, University of Washington, received the Junior Faculty Research Award in Perioperative Medicine during the AUA Scientific Advisory Board Oral Session II on Thursday, May 16. Dr. Long shared his compelling study, Epidemiology of Surgical Site Infections (SSIs) in Spinal Fusion Surgery and Patterns of Discordance with Surgical Antibiotic Prophylaxis: A Retrospective Case-Level Analysis.

NSQIP data on adverse hospital outcomes show that healthcare-associated infections (HAIs) make up 52% of occurrences, with SSIs being the biggest subgroup. HAIs have diminished over the years with better surveillance and prevention, with one exception — SSIs. Incidence of surgical site infections remains constant across all surgical specialties. Spinal fusions have among the highest rates, which is concerning due to the amount of hardware in the spinal column.

Dr. Long teamed up with the infection control staff at Harborview Medical Center, examining data on the local microbiology of patients with SSIs after spinal fusion to target more effective infection prevention. The 328 reported SSIs were stratified by anatomic level of surgery. The unexpected discovery was a clear anatomical gradient for gram-negative, anaerobic infections; as incision sites moved from T4 down the lower back, gram-negative infections increased. These microorganisms don’t appear to be coming from the hospital environment, but the patient’s body. More concerning, the standard antibiotic prophylaxis of cefazolin in spinal fusion cases will not cover these organisms.

While the surgical response to these findings was to broaden prophylaxis across all cases to provide better gram-negative coverage, Dr. Long and his research team hope to develop a more targeted antibiotic prophylaxis. A multivariate model shows that female gender, duration of surgery, and incisions lower on the spine are independent predictors of infections that are resistant to first-line antibiotic prophylaxis. Another clinically relevant variable under investigation is the preoperative patient microbiome. A patient’s unique bacterial reservoir may play a significant part in the risk of SSI development.

Dr. Long hopes that future surgical antibiotic prophylaxis will target specific procedural factors and patient factors, including using patient microbiome information from preoperative cultures. We, as anesthesia providers, are in a unique position to take the lead in this patient safety initiative for prevention of surgical site infections.

Ming Ann Sim, MBBS, National University Hospital Singapore, received the Margaret Wood Resident Research Award for her study, Sustaining the Gains – A 6-year Follow-Through of the Impact of a Hospital Wide Patient Safety Strategy on Global and Anesthetic Patient Safety Outcomes.

In-hospital adverse events remain a challenge, with incidence rates of up to 17%. Half of these are preventable. Sim and her colleagues hope to achieve a sustainable, hospital-wide, patient safety initiative starting with hospital leadership down to buy-in at the staff level. The initiative included three phases: establishing patient safety goals, root cause analysis, and preparing for crisis through simulation training.

Phase I anesthesia department goals included zero occurrences of wrong blood, wrong drug, and wrong site (wrong drug administered intrathecally) administration. Dental trauma and PACU reintubation, more commonly occurring adverse events, were also included. Phase II included the development of departmental safety plans and internal review of adverse events. Finally, Phase III — preparing for crisis — involved identifying sentinel event categories: cannot intubate, cannot ventilate scenario; OR death; and anaphylaxis or hypoxia scenarios.   

Over the study period, N=955 adverse events were reported and analyzed. Hospital-wide incidence of adverse events decreased from 11.6% to 5.3%. Anesthesia department rates of adverse events decreased throughout the safety initiative, but without statistical significance. This may have been due to low event rate.

Dr. Sim’s work demonstrates how a hospital culture of safety and adverse outcomes can improve over time, through a hospital-wide safety initiative, integrated within leadership, but also at the staff level.  

Drs. Long and Sim’s e-Posters are available for viewing at https://tinyurl.com/AM19eposters.

*Coverage from the AUA SAB Oral Session II at the AUA 2019 Annual Meeting, moderated by Meghan Lane-Fall, MD