On October 1, the Centers for Medicare and Medicaid Services (CMS) instituted their new policy to stop reimbursing organizations for defined preventable never events. These are events that should never occur in the healthcare setting.
Several events have significant implications in the surgical setting: retained objects, blood incompatibility, pressure ulcers, vascular catheter-associated infections, and surgical site infections (SSIs) associated with specific procedures. What does this initiative mean to the institution, the OR staff, and our patients?
A reason to crack down
It's estimated that there're 500,000 to 750,000 individuals infected with SSIs per year. Mediastinitis related to Staphylococcus aureus can cost organizations up to $50,000 additional dollars.1 SSIs increase the likelihood of a prolonged hospital stay and patients are more likely to need intensive care. The mortality rate of patients with a SSI doubles.2
Not a black and white issue
The intent of CMS's initiative is to promote patient safety and is written in a straightforward and uncomplicated language. However, though some preventable events such as retained objects are clearly defined, SSIs are more imprecise. The American Society of Microbiology, in a letter to CMS, commented on the new initiative and repo rted that the "documentation of hospital-acquired infections (HAI) is an imperfect process."3 Guidelines for defining HAI may differ depending on institutional lab findings and different professional organization guidelines.3 It's possible that patients with an infection could be admitted with no symptoms, only to display symptoms later during their hospital stay.
In addition, some patients may be more at risk for developing an SSI. Obesity, vascular disease, or diabetes are examples of comorbidities that make some patients more susceptible to SSIs. It's feasible for a patient to still end up with a SSI even if all surgical asepsis guidelines or techniques are followed.
Methods such as maintaining patient normothermia and administering antibiotics within an hour of incision are proven to reduce SSIs. Many of the sterile-technique practices and guidelines we conduct every day are not as well defined. Questions of how long instruments can be left unused on a sterile field before the incision, adhering to proper dress codes, decreasing traffic during the surgical procedure, or controlling the number of personnel in the OR are just some of the measures we implement in an effort to reduce the chance of infection, but aren't well researched if researched at all.
We know these guidelines and others when practiced in their entirety help to reduce the infection rate and when these practices are lax, the SSI rate increases. But to isolate one practice from another as a primary source of contamination is difficult. These intangible practices may be at the core of determining whether a patient ends up with a SSI or not. This might be the point where perioperative nurses will have a unique opportunity to impact practice. Our knowledge and promotion of sterile techniques is where we demonstrate our distinct value in attaining positive patient outcomes. OR
Elizabeth M. Thompson, RN, CNOR, MSN
Editor-in-Chief, Nursing Education Specialist, Mayo Clinic, Rochester, Minn. [email protected]
REFERENCES