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66 Executive Briefing Sponsored by: A Recipe for SSI Reduction: Bundling Evidence-Based Interventions to Lower Risk, Improve Patient Outcomes In December 1999, the Institute of Medicine published, To Err is Human: Building a Safer Health System, a report which stunned the American healthcare industry with its estimate that prevent- able adverse events are a leading cause of death in the U.S., claiming up to 98,000 lives each year. 1 One adverse event type has garnered the attention of health- care leaders: surgical site infections. In the U.S., it has been shown that up to 60 percent are preventable 2,3 despite evi- dence-based strategies for prevention have been available for many years through global initiatives. Concerted efforts by healthcare professionals have produced positive results. According to the CDC, hospitals reported a 17 percent decrease in SSIs related to 10 select procedures be- tween 2008 and 2014. 4 Despite this progress, SSIs remain the most common, costly healthcare-acquired infection 5-7 , with an estimated 160,000– 300,000 SSIs occurring in the U.S. each year. 8,9 SSIs can cost up to an additional $60,000 per incident. 10 SSIs are a complex problem … SSIs are a complex issue, in part, because the risk of acquiring an SSI depends upon a number of patient and process factors. "Any surgery that causes a break in the skin can lead to a post-op- erative infection," said Michele Hulse-Stevens, MD, medical di- rector with 3M Health Care. "The majority of SSIs come from bacteria already on the patient. There are many patient-related factors that are known to increase the risk of SSI, including med- ical conditions such as diabetes, high blood pressure or heart disease, being elderly or overweight, and smoking." According to the CDC, there are three major variables that con- tribute to the risk of SSIs: 11 1. Number of bacteria 2. Virulence of bacteria 3. Patient risk factors The problem of SSIs is a complex and significant one that can- not be solved by a single solution. Although the major variables are not easily controllable, the risk of SSIs can be minimized by evidence-based best practices related to the number of bacte- ria and select patient risk factors. … requiring a new approach A wave of surgical innovation — inspired in large part by the To Err is Human report — has spurred a significant acceleration in the development of new healthcare technologies and research. Along with these advances comes the challenge of staying cur- rent on published research and evaluating the science behind the findings. Evidence-based medicine, defined as "a system- atic approach to clinical problem solving which allows the in- tegration of the best available research evidence with clinical expertise and patient values," 12 offers clinicians a way to stay informed using standardized, evidence-based protocols. Rath- er than relying on previously accepted facts or anecdotal expe- rience, clinicians have access to data vetted and agreed upon by peers for use in evidence-based guidelines. Multifaceted prevention efforts Applied to the CDC's three variables that contribute to SSI risk, reduction efforts have been most successful when used in "bundles" — a set of evidence-based practices that, when per- formed collectively and reliably, have been proven to improve patient outcomes. 13 In the case of SSIs, each of the bundled in- terventions contributes to the overall goal of SSI risk reduction in different ways. "The perioperative care of the surgical patient is designed to address modifiable risks," said Dr. Stevens. "Interventions such as methicillin-resistant Staphylococcus aureus decolonization, preoperative bathing and prewarming for the maintenance of core body temperature are all components of a strategy that can improve patient outcomes." Below are just a few examples of interventions with compelling supporting evidence that can be included as part of a success- ful SSI prevention bundles. Nasal decolonization, patient bathing More than 80 percent of infections from Staphylococcus au- reus, the leading cause of SSIs, come from a patient's own nasal flora, making this a major concern. 14-16 Providers frequently ad- dress nasal colonization with a five-day regimen of the antibiot- ic mupirocin. However, poor patient compliance and antibiotic resistance can make this treatment less effective. "Having patients bathe, shower or use chlorhexidine gluconate wipes at least the night before and the morning of surgery will help reduce bacteria on the body prior to entering the hospi- tal for surgery," said Ellen Anderson Manz, MSN, RN, technical service manager with 3M Health Care. "Decolonizing the nares preoperatively also helps reduce the risk of SSIs when part of a comprehensive preoperative protocol." 17,18 An antiseptic solution provides an alternative to the traditional antibiotic approach. 3M™ Skin and Nasal Antiseptic can ad- dress nasal carriage of S. aureus safely and effectively and is supported by an increasing amount of clinical evidence. This simple, one-time application reduces nasal bacteria, including S. aureus, by 99.5 percent in just one hour and maintains this reduction for at least 12 hours. 19