SSIs: a call for zero tolerance

With the introduction of the new operating framework, whereby hospitals will no longer be paid for all unnecessary readmissions within 30 days,1 it is estimated that up to £1.5 billion of NHS funding could be affected, based on 2009 figures of a re-admission rate of 6.7%, resulting in the cost of unnecessary readmissions falling back onto Hospital Trusts.2 The framework states that “there is now an intention to ensure that hospitals are responsible for patients for the 30 days after discharge. If a patient is readmitted within that time, the hospital will not receive any further payment for the additional treatment... This will improve quality and performance and shift the focus to the outcome for the patient.”1 Studies have shown that 14% of re-admissions are caused by a Hospital Associated Infection (HAI),3 with surgical site infections (SSIs) being the most common HAI that causes readmission.3 One in seven of all HAIs are SSIs.4 SSIs represent a considerable burden to healthcare,5 and are among the most serious and costly hospital infections, affecting 1 in 20 patients who undergo surgery.6 Infected patients are also twice as likely to die following surgery,7 they cost almost three times more to treat than uninfected patients8 and stay at least twice as long in hospital.9 Despite being one of the most preventable infections,5 SSIs have received little attention, which has led to a group of key experts urging UK hospitals to take SSIs more seriously and to take action to minimise this costly and largely preventable problem. A report produced by the group and funded by CareFusion, highlights the physical and financial burden of SSIs on both the patient and the healthcare system and calls for every hospital to review its current practice in relation to the prevention of SSIs. Mr Shyam Kolvekar, cardiothoracic surgeon and co-author of the Under the Knife report said: “SSIs are dangerous healthcare associated infections (HCAIs) that affect a large number of patients yet little is known about the true rates of infection. Surveillance of SSIs are not mandatory and the problem has been relatively neglected compared to attempts to tackle the prevention and control of other HCAIs, MRSA and Clostridium difficile. Every hospital should be made accountable for their current SSI rates and how they plan to lower them, something that is relatively low in cost to do and can be done using simple evidence-based approaches.” The report also identifies that SSIs impose a substantial burden on NHS budgets, being estimated to cost, on average, £3,500 per infection, costing the NHS up to £700 million per year.

A preventable HCAI

The good news is that the majority of SSIs are preventable. The patient’s own skin is the source of the pathogens responsible for most SSIs10, 11 so a few basic, but essential evidence-based practices prior to and during surgery can significantly reduce SSI rates and, by doing so, improve patient safety, unblock beds, reduce readmissions and save the NHS a substantial amount of money. The Health Protection Agency (HPA) has recently reported that staphylococci are by far the most common cause of SSIs in the UK, accounting for almost 50% of the micro-organisms responsible for SSIs.12 Staphylococcus aureus, which is a normal component of human nasal microflora, can lead to serious invasive infections such as septic arthritis, osteomyelitis, pneumonia, mediastinitis, meningitis, septicaemia and endocarditis. Staphyloccus epidermidis, the most common organism found on the skin, has emerged as a frequent cause of HCAIs and is particularly pathogenic in immunocompromised individuals. Since skin-dwelling bacteria such as staphylococci are an important cause of SSIs – even in patients undergoing contaminated procedures such as colorectal surgery – it is imperative that skin antisepsis is optimised before surgery.13 Studies have demonstrated that the incidence of SSIs varies widely between hospitals and between surgeons,14,15 suggesting that working practices play a critical role in the prevention of these infections. Surgical teams that are equipped with their post-operative infection data are often able to reduce their SSI rates,16 suggesting that more could be done to improve infection control in routine surgical practice. Unfortunately, many UK hospitals do not routinely collect SSI data or provide feedback on SSI rates to the surgical staff, so vital opportunities are being missed to monitor infection rates and assess the outcomes of any changes to infection control practices.