Ambulatory Care Perspective: A Multidisciplinary Approach to Preventing Surgical Site Infections

Surgical site infections are hospital-associated infections (HAIs), defined as an infection occurring at the incision, organ, or space in which surgery took place. National guidelines exist for the prevention of surgical site infections (SSI); however, SSIs still account for 20% of all HAIs (NHSN, 2022) and ranked as the 4th largest contributor to harm caused in the national pediatric hospital quality network (SPS, 2021). Moreover, SSIs are the costliest HAIs, averaging approximately $10,000-25,000 per infection, which drastically can increase to > $90,000 for implant surgeries (JAMA, 2017).
Like other HAIs, prevention and education is key. Often, there is a large focus on the inpatient setting to prevent HAIs due to numerous risk factors present at the time of hospitalization and surgery; yet many surgical patients start in the ambulatory care setting (Prin et al., 2017). There is an opportunity to target preoperative interventions in the outpatient setting. These silos within the system may be a contributing factor to prevention optimization.
At our pediatric health system, we identified an opportunity for improvement to target the ambulatory care setting and enhance existing processes. A hospital-based surgical site infection task force was previously established and focused on learned opportunities from swarming or reviewing cases after the patient developed an infection at the surgical site. Ambulatory care did not have a seat at the “table.” Most patients came through the ambulatory care setting preoperatively, and an opportunity to provide education could have existed. Furthermore, without collaboration within the health system, identified action items may or may not have resulted in loop closure for improvement in the outpatient setting.
SSI task force membership was evaluated, and the orthopaedic clinical nurse manager was added to the multidisciplinary team including infection prevention, infectious disease, surgical quality, inpatient leaders, and front-line staff. This specific membership addition opened communication on a weekly basis for surgical patients flowing between the ambulatory and acute care settings. Not only were potential contributing factors to SSIs identified during case review, additional opportunities for improvement to increase prevention strategies emerged.
Tools were created for ambulatory care surgical divisions by pulling pertinent ambulatory care SSI prevention bundle information from our evidence-based policy utilizing CDC and SPS guidelines. These resources, partnered with targeted staff education and rounding from the perioperative quality specialist, increased awareness of preoperative SSI prevention education for patients and families. The ambulatory care team recognized the need to revise an existing preoperative SSI prevention educational flyer provided to surgical patients and families during ambulatory care visits. The document was sent to the task force for revisions, resulting in an enhancement through the prevision of a QR code with video instruction to match the written instructions.
The evolution and inclusiveness of the SSI task force targeted SSI prevention from all aspects of care. In addition to the ambulatory care interventions, hospital- and surgical-based interventions were implemented in plan-do-study-act fashion. Through collaboration of the multidisciplinary team, the pediatric SPS, or solution for patient safety, SSI rate (per 100 procedures) decreased from 2.57 (2020 centerline) to 1.75 (2021 centerline), resulting in a 32% reduction.