Obesity is an increasingly common medical condition in the Western world, leading to a rapidly growing subset of high-risk surgical patients.1 Obesity has long been reported to be a risk factor for perioperative surgical site infection (SSI) because it is the result of a disruption of energy balance that leads to weight gain and metabolic disturbances, which, in turn, can cause tissue stress and dysfunction. More specifically, obesity can negatively affect immunity by creating alterations in lymphoid tissue integrity and shifts in leukocyte populations and inflammatory phenotypes.2 Therefore, obesity can increase a patient’s risk for SSI, which can significantly affect length of hospital stay and health care costs.
Identification of the problem
South Miami Hospital, FL, is a 453-bed, not-for-profit community hospital. It is the only hospital within the Baptist Health South Florida system that performs bariatric surgery, and it is a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence. The infection control team has always been vigilant with regard to safeguarding against SSI, and the surgeons who practice at South Miami have always taken pride in their proactive approach to the prevention of SSI.
Between July 2014 and June 2015, surgeons at South Miami Hospital performed 255 bariatric operations, including sleeve gastrectomy and Roux-en-Y gastric bypass. South Miami Hospital was identified as having six SSI events, as well as four “needs improvement” ratings as defined by MBSAQIP categories. These results were significantly higher than the hospital’s previous scores.
The South Miami Hospital performance improvement steering council established a bariatric interdisciplinary committee subgroup to address the SSI scores on the quarterly report from the MBSAQIP. The committee comprised all bariatric surgeons, leadership, nursing staff (including clinical nurse educators), infection control practitioners, and pharmacy staff.
Quality improvement activity
The project began with a brainstorming session. We addressed all aspects of care that can lead to SSI, such as preoperative hair removal, preoperative bathing, antibiotic administration, skin-prepping agents, number of people involved in the operation, preoperative Hgb A1C levels, and types of surgical dressings used.
After an analysis of all contributing factors to SSI and our compliance with efforts to mitigate those complications, we decided to focus on preoperative patient skin antisepsis. Compliance with skin antisepsis guidelines is paramount in the prevention of SSIs. The Association of periOperative Registered Nurses endorses preoperative bathing the night before and the morning of an operation as a means of preventing SSIs.3
All bariatric surgeons agreed to standardize their practices, and guidelines were established regarding the types of skin-prepping agents that should be used. Patient and staff education were of vital importance in this endeavor.
The skin-prepping agent used for patient preoperative bathing/showering was 4 percent chlorhexidine gluconate (CHG)—an approved antimicrobial agent. When applied, the mechanical friction and rinsing removes transient skin microbes. CHG also provides persistent activity, which continues to reduce the level of the patient’s skin flora.4 Immobile patients on the nursing units who were unable to shower were provided with a bath-in-a-bag, which contained a 2 percent CHG component.
The preoperative testing unit nurses were responsible for instructing all patients to shower the night before and on the morning of an operation with the 4 percent CHG solution. The preoperative unit nurses were responsible for ensuring that all patients were compliant. Additionally, the preoperative unit nurses gave the patients 2 percent CHG cloths to use on the patients’ abdomens immediately before an operation. This measure would further enhance the removal of any microbes caused by clothing that the patients wore before the procedure.
The operating room nurses used the skin-prepping agent ChloraPrep on all patients, unless there were any contraindications. The nurses received in-service education regarding the proper use of ChloraPrep, which is composed of 2 percent CHG and 70 percent isopropyl alcohol. Isopropyl alcohol is one of the most effective antiseptic agents available, and alcohol-based solutions that contain CHG have sustained any durable antimicrobial activity that lasts long after the alcohol has evaporated.5
Additional costs were incurred as a result of this endeavor. The cost of the 2 percent CHG cloths used by patients immediately before surgery was $5.50 per wipe. This item is not patient chargeable; therefore, the hospital incurred the additional costs.
Results and lessons learned
These quality improvement activities were implemented in October 2015. On our following quarterly report (July 1, 2015, to June 30, 2016), we had only one SSI and one “needs improvement” rating as defined by MBSAQIP. The “needs improvement” event occurred in the sleeve gastrectomy category, out of a total of 245 cases. Also noted were three “exemplaries” in the sleeve gastrectomy category. Skin prep was an easy solution to a complex issue.
No barriers presented themselves in the completion of this project. The entire team worked together cohesively and was optimistic about the results. The cost analysis regarding patient decreased length of stay is ongoing as of press time.
Institutions that are seeking to decrease their SSI rates in bariatric surgery patients should implement the following recommendations:
- Engage all stakeholders and develop a multidisciplinary team
- Standardize best practices as defined in current literature
- Evaluate the implementation process continuously and make adjustments as necessary
- Conduct team meetings at least on a quarterly basis, and more often if needed
- Review the results of the project and strive to maintain the improvement
- Gupta A, Schweitzer MA, Steele KE, Lidor AO, Lyn-Sue J. Surgical site infection in the morbidly obese patient: A review. Bariatric Times. June 11, 2008. Available at: http://bariatrictimes.com/surgical-site-infection-in-the-morbidly-obese-patient-a-review/. Accessed November 27, 2017.
- Andersen CJ, Murphy KE, Fernandez ML. Impact of obesity and metabolic syndrome on immunity. Adv Nutr. 2016;7(1):66-75.
- Association of periOperative Registered Nurses. Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice, 2017 Edition. Denver, CO: AORN, Inc.; 2017.
- Rothrock JC. Preoperative skin cleansing with chlorhexidine gluconate. Medscape. News & perspectives. March 11, 2010. Available at: www.medscape.com/viewarticle/717993. Accessed November 27, 2017.
- Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: Which agent is best? Rev Urol. 2009;11(4):190-195.