The Michigan Value Collaborative (MVC) and the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) held a recent workgroup focused on surgical site infections (SSI) related to joint replacement. Hospitals met to discuss some of the root causes for these infections and initiatives they have implemented to help reduce them.
Below is one of the presented slides that exhibits the proportion of readmissions due to SSI’s for MVC/MARCQI hospitals based on MVC claims data:
Although many of the hospitals have done extensive analysis and in-depth review of pre-, intra- and post-operative joint conditions, few specific root causes for surgical site infections have been identified. However, major focus areas for hospital-led initiatives that have been identified are:
- Improving the general health of the patient especially in terms of reducing the body mass index (BMI);
- Improving hemoglobin A1C for diabetics;
- Improving albumin levels; and
- Tobacco cessation
One hospital recently began an initiative aimed at helping patients become healthier and ultimately maintain an optimal weight for joint-replacement surgery. Referrals for the program come from surgeons prior to the surgery. The initiative includes a weight loss clinic and classes, which offers a refund of the cost of the program if the patient is successful in losing weight before surgery.
Most hospitals are following the Joint Commission recommendations from the Surgical Infection project (SIP) and the Surgical Care Improvement Project (SCIP). However, there are some differences in the identification and treatment of staphylococcus aureus carriers with some hospitals universally treating all joint replacement candidates and some only treating those identified as carriers through a nasal swab. Although this workgroup only focused on SSIs related to elective joint replacement, it was mentioned that some hospitals are treating their trauma cases for staphylococcus aureus as well, while others are looking at this potential.
Other topics that prompted discussion among the group were wound closure and whether different types of closure affected SSI rates along with the type of dressing being used and the length of time the dressing stayed intact over the wound. There was some variety among surgeons and hospitals, however many are using a moisture-impervious silver based dressing that remains on for about seven days. Despite what may be considered a more expensive dressing being used the benefits of keeping the wound covered and out of contact with potentially infectious elements, i.e. pets, clothes, bed linen etc. outweigh these added costs. In addition, when comparisons were made between these dressings and changing a dressing daily the difference in cost was negligible.
Finally, patient education was a major talking point during the workgroup. All hospitals agreed that having the patient’s cooperation is a significant factor in reducing SSI. Some hospitals have produced videos for patient viewing pre-operatively while others have an educational sheet that they provide to the patient before the surgery. Some discussion focused on the amount of information that the patients are expected to retain and ways hospitals are sharing reminders using booklets, pamphlets, a coach that is known to the patient or being seen by a discharge planner.
The Coordinating Center has put together a pre-, intra and post-operative check list of things to consider to potentially help reduce SSI, as well as a hygiene at home sheet for patients. These can be found in the resource tab on the registry along with information from our other workgroups.
If you have identified any specific root causes or have a new initiative aimed at reducing surgical site infections, then we would love to hear from you. Please contact Deb Evans (firstname.lastname@example.org) or Abeer Yassine (email@example.com) to share your story. Preference