A Successful Multi-Disciplinary Approach to Decreasing Orthopedic Surgical Site Infections

Background: Joint replacement surgeries (arthroplasties) are increasing nationally and deep surgical site infections (D-SSI) after these procedures can cause substantial morbidity for patients, as well as additional healthcare costs. Minimizing orthopedic arthroplasty post-operative infections is an important goal for improving patient outcomes and enhancing patient safety. Our institution had rates of arthroplasty-associated D-SSI that were within the range of reported national benchmark 50^th percentile rates.

Objective: To improve outcomes and enhance patient safety, through a decrease in orthopedic D-SSI occurring within 30 days of joint replacement procedure. To standardize processes in the peri-operative care of orthopedic joint replacement surgical patients.                                                                                               

Methods: A multi-disciplinary working group was convened that included orthopedic surgeons, peri-operative nurses and managers, anesthesia, central processing, short procedure unit personnel, and Infection Prevention. The group analyzed a variety of processes, and institutional infection data. As a result the group implemented 4 initiatives in an effort to decrease orthopedic D-SSI. These initiatives included: 1) OR staff training on the basics of aseptic technique, maintaining sterility, and standardization of skin site preparation; 2) implementation of a chlorhexidine gluconate (CHG)-based skin antiseptic for skin site preparation; 3) patient education for CHG bathing prior to surgery; and 4) addition of vancomycin to the standard pre-operative antibiotic regimen along with optimizing timing of pre-operative antibiotics.

Results: Initiatives were phased in over 6 months. In the 12 months after implementation our institution observed a 66% reduction in hip arthroplasty D-SSI, and an 80% reduction in knee D-SSI. Results have been sustained for an additional 6 months since that time. Figure 1 depicts the decline in rates and numbers of hip arthroplasty D-SSI, along with the slope of the regression line (one-tailed p value = 0.0194).

Conclusions: We conclude that the multi-disciplinary initiatives are effective in decreasing orthopedic D-SSI, and as these initiatives became standard practices, low rates of infection have been successfully maintained.