Institution of the Steiros Algorithm^® Outpatient Surgical Protocol Reduced Orthopedic Surgical Site Infections (SSI) Rates

Abstract

Background

Control of surgical site infections (SSI) is imperative for the safety of our patients. As orthopedic surgeons we strive to have the lowest infection rate possible for all our surgical procedures. this study evaluates the effects of a simple outpatient peri-operative patient cleaning protocol (The Steiros Algorithm^® Outpatient Surgery Protocol) on SSI rates.

Methods

We retrospectively reviewed the hospital's infection rate database for all procedures from July 2005 until February 2011 performed by one general orthopedic surgeon (PAW) within one hospital system. The Steiros Algorithm^® Outpatient Surgery Protocol was instituted on January 1^st, 2009. We calculated and compared the deep and superficial SSI rate for orthopedic surgeries performed before and after the Outpatient Protocol was instituted. All patients had a minimum of one-year follow-up data. Lowest previously published estimated costs for SSI were used for a cost analysis ($17,708).

Results

The July 1^st, 2005 through December 31^st, 2008 SSI rate was 1.0% (13/1292). From January 1^st, 2009 through February 28^th, 2011 the SSI rate was zero (0/875). the SSI rates decreased 100%. Due to the reduction in SSI, the hospital saved a minimum of $154,059 over a two year period.

Conclusions

In this retrospective review, the Steiros Algorithm^® Outpatient Surgery Protocol dramatically reduced the overall SSI rate to zero and saved money. We believe this is a simple, effective protocol that can be used for all orthopedic surgical procedures.

Introduction

Surgical site infections (SSI) are a serious complication of orthopedic surgeries,¹ with total joint arthroplasty surgical infection rates ranging from 0.2% for primary total hip arthroplasty to 1.5% for total knee arthroplasty.^2,3 Orthopedic SSI increase patient morbidity by lengthening hospital stays and increasing re-hospitalization and revision surgery rates.⁴ Identifying risk factors for infection and taking appropriate steps to remove the cause can reduce infection rates.^5,6 It has been demonstrated that carriers of Staphylococcus Aureus are more likely to acquire Staphylococcus Aureus SSIs than non-carriers.^7,8,9 As well, most nasal carriers also culture positive at more than one extra-nasal site.¹⁰ In addition, patient screening followed by preoperative decolonization with five days of nasal muciprocin and chlorhexidine showers has been shown to improve methicillin resistant Staphylococcus aureus (MRSA) infection rates.¹¹ We therefore hypothesized use of a peri-operative patient cleaning methodology (Steiros Algorithm^® Outpatient Surgery Protocol) would lower the overall infection rate in patients undergoing orthopedic surgery.

Methods

To test this hypothesis, we retrospectively studied all patients who had orthopedic surgery performed by one surgeon (PAW) in a single hospital system (Alegent Health, Omaha, Nebraska). The 1292 consecutive patients who underwent orthopedic surgery between July 1st, 2005 and December 31st, 2008 were the control group. The 875 consecutive patients who underwent procedures from January 1st, 2009 to February 31st, 2011 were the study group. The Steiros Algorithm^® Outpatient Surgery Protocol was instituted on January 1st, 2009. The algorithm is an add-on preoperative and postoperative patient decontamination protocol which reduces bacterial bioburden from the surgical patient (unpublished data).¹² The surgeon (PAW) asked all patients to buy the skin sanitizer/antiseptic (0.13% benzalkonium chloride with preservatives, Steirolotion^®, Germcure, Houma, Louisiana) preoperatively during the preoperative risk discussion and apply the product the night before and the morning of surgery. A patient handout (Figure 1) was given and reviewed by the surgery scheduler as well. She told the patients how to obtain the product from the local pharmacies or online and reviewed the one page protocol with the patients. The patient was told to bring the Steirolotion^® to the surgery to help verify compliance by the surgeon. However, no specific tracking or documentation of compliance was performed. Preoperatively, after patient positioning, the surgeon applied the Steirolotion^® to the operative site and surrounding skin and allowed it to dry. Routine operative prep and drape was then performed. Patients who had a cast or splint on applied the product everywhere possible, and the surgeon made a single application once the splint or cast was removed before surgery.

Figure 1.

Post-operatively, patients were told to apply the Steirolotion^® daily to the wound from the time the dressing was removed until the wound was healed (about 1–2 weeks). The surgeon (PAW) assessed all patients at the time of surgery and during follow-up appointments to identify any allergic reactions.

During the study period, all standard hospital infection control protocols, preoperative antibiotic protocols and skin preparations were otherwise unchanged. Standard hospital protocol was a 4% chlorhexidine wipe in the preop surgical area prior to surgery. As well, chlorhexidine gluconate 2% with 70% ethyl alcohol (Chloraprep) was used for all preoperative skin preparation unless patients were allergic. All data was collected via the hospital infection control database using the standard hospital infection surveillance system. The hospital infection control practitioners review and investigate culture laboratory data, return to surgery data and monthly physician questionnaires during the postoperative period for one year in patients with implants and for 3 months in patients without implants. This includes data from all eleven regional hospitals in the system. The number of total joint arthroplasties performed was included in the infection data. All superficial and deep infections were included as based on the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions for these conditions.¹³ All patients were followed for a minimum of one year. We did not collect demographic or any other patient specific data. For this reason, the study did not require approval by the Institutional Review Board.

All patients received peri-operative antibiotic prophylaxis according to the hospital protocol. The standard regimen was cefazolin 1 gram administered within 60 minutes before surgery followed by 1 gram every 8 hours for 24 hours if an inpatient. Alternatively, vancomycin 1 gram or clindamycin 600 miligrams was administered to patients with a type I allergy to penicillin. We calculated and compared the SSI rate for orthopedic surgeries performed before and after the algorithm was instituted. The Pearson chi square with a two tailed fisher exact test was used to determine the p value.

The lowest previously published estimated direct costs for orthopedic SSI were used for analysis of potential cost savings ($17,708 per average orthopedic infection).^4,14

Results

From July 1st, 2005 through December 31st, 2008, the SSI rates were 1.0% (13/1292). From January 1st, 2009 through February 31st, 2011, the SSI rates were zero (0/875).

The SSI rates decreased 100% (P=0.0026). Overall, 35% of the surgeries were inpatient and 65% were outpatient surgeries. 10% were total knee or total hip arthroplasties. During the study period (2009–2011) the number of total hip and knee arthroplasties (137) were greater than during the control period (80). No allergic reactions were noted at the time of surgery or during the postoperative application period. Due to the reduction in SSI, our cost estimate indicates the hospital saved $154,059 over a 26 month period.

Discussion

The Steiros Algorithm^® is a global environmental cleaning protocol for hospitals which reduces all forms of hospital acquired infections. Watson etal (unpublished data) found that the Sterios Algorithm^®, an inpatient hospital cleaning protocol, dramatically reduced hospital acquired methicillin resistant Staphylococcus aureus (MRSA) rates to almost zero (0.11/1000 discharges) and saved the hospital almost $5,000 dollars per bed per year.¹⁵

As well, Watson etal (unpublished data) found that the Sterios Algorithm^® significantly reduced total joint arthroplasty and spinal fusion SSI by over 60%.¹⁶ The data from this study shows that the Steiros Algorithm^® Outpatient Surgery Protocol is a very safe, effective and simple way to reduce orthopedic SSI by reducing the bioburden on the skin of surgical patients.

Previous preoperative protocols have been used to reduce SSI. Bode et al.¹⁷ preoperatively did a nasal rapid screening MRSA test and treated MRSA carriers with five days of twice daily nasal muciprocin and chlorhexidine 4% baths prior to surgery and lowered the general surgical infection rate from 7.7% to 3.4%. Rao etal¹⁸ also screened total joint arthroplasty patients preoperatively for S. aureus by nasal swab cultures. S. aureus carriers were decolonized with mupirocin ointment to the nares twice daily and chlorhexidine baths once daily for 5 days before surgery. He reduced the infection rate from 2.6% to 1.5%. The Steiros Algorithm^® compares very favorably with these studies with a zero overall (deep and superficial) infection rate.

Our study had several limitations. First, the study was not randomized and we did not collect demographic or other patient-specific data, so selection bias is possible. Using patients whose surgeries were performed by a single surgeon from a stable population mitigates this bias. Furthermore, the large numbers of patients should help reduce the risk of selection bias. Second, we did not track and verify compliance other than the surgeon asking the patient if they used the product and brought it to surgery. The surgeon (PAW) applied the antiseptic in the immediate preoperative period 100% of the time. Third, we did not culture patients after the decolonization protocol to verify decolonization of specific bacteria types preoperatively. However, the dramatic reduction in infection rates suggests the decolonization was effective.

The algorithm uses a simple patient cleaning protocol that any surgeon can institute in their practice without hospital dependence or involvement. A low cost ($11.99 on line price), alcohol free preoperative biocide is applied, avoiding antibiotics that promote resistant organisms. As well the significant costs involved with MRSA screening, muciprocin prescription and chlorhexidine baths are avoided (up to $300).¹⁴ This allows for much easier application and compliance for patients undergoing all orthopedic inpatient and outpatient surgeries.

In summary, institution of the Steiros Algorithm^® Outpatient Surgery Protocol dramatically reduced the orthopedic SSI rate and saved money.