Postoperative Deep Surgical Site Infections in Orthopedic Surgeries

ISSUE: The Baltimore VA Medical Center, a 110-bed university-affiliated acute-care hospital, is a division of the VA Maryland Health Care System (VAMHCS). In reviewing surgical site infections (SSIs) following total hip replacement (THR) and total knee replacement (TKR) surgery, the infection rates exceeded the NNIS median rate. PROJECT: In March 2001, a multidisciplinary performance team was established to address the SSI rate in TKA and THR. There was a review of the CDC Guidelines for Prevention of SSI and the AORN Standards. Several joint replacements were observed, monitoring surgical technique and OR practices including dressing change technique on the surgical unit. Infections were reviewed for any commonalities or trends. Antibiotic prophylaxis was reviewed. Staffing was assessed. The team implemented the following actions: instituted pre-operative CHG baths for all patients undergoing joint replacement, developed an electronic CHG quick order template, required use of electric clippers for hair removal, conducted monitors for timing of prophylactic antibiotic administration, evaluated the OR air handling system, reviewed sterilization procedures including use of flash, scheduled education for SPD and housekeeping personnel, removed reusable props for positioning patients, established operating room rounds, and assessed staffing patterns for housekeeping and SPD. RESULTS: Infection rates were risk-adjusted for length of surgery, wound class, and ASA code. The overall risk-adjusted SSI rate prior to implementation of Best Practices was 11 per 100 procedures (6/54) for THR and 4.3 per 100 procedures (3/69) for TKR. After implementation the rates decreased to 0 for THR and to 4.2 for TKR. Antibiotic prophylaxis increased from 74% to 87%.