Reducing infection rates through perioperative glycemic control – how sweet it is

Abstract

Surgical site infections (SSI) are a morbid and costly complication, making it an attractive target for quality improvement efforts. The cost of a single organ space infection after hysterectomy approaches $20,000, and in the US annual expenditures to manage SSIs are estimated to be between $3.5 and $10 billion [ 1 Bakkum-Gamez J.N. Dowdy S.C. Borah B.J. et al. Predictors and costs of surgical site infections in patients with endometrial cancer. Gynecol Oncol. 2013; 130: 100-106 Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar , 2 Stone P.W. Hedblom E.C. Murphy D.M. Miller S.B. The economic impact of infection control: making the business case for increased infection control resources. Am J Infect Control. 2005; 33: 542-547 Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar ]. SSI’s may also have devastating consequences for patients. Among postoperative mortalities that include a diagnosis of surgical site infection, 77% are directly attributed to the infection [ [3] Anderson D.J. Podgorny K, Berrı´os-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014; 35: 605-627 Crossref PubMed Scopus (713) Google Scholar ], and for patients with ovarian cancer, SSI increases the risk of death by 50% [ [4] Tran C.W. McGree M.E. Weaver A.L. et al. Surgical site infection after primary surgery for epithelial ovarian cancer: predictors and impact on survival. Gynecol Oncol. 2015; 136: 278-284 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar ]. Fortunately, nearly 60% of SSIs are preventable by following evidence-based guidelines [ [3] Anderson D.J. Podgorny K, Berrı´os-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014; 35: 605-627 Crossref PubMed Scopus (713) Google Scholar ], and future evolutions in our care pathways may prove that to be an underestimate. Prior successful efforts in gynecologic oncology and other surgical specialties have resulted in reductions of 50 to 80%, with absolute rates of SSI under 0.5% depending on case mix [ 5 Johnson M.P. Kim S.J. Langstraat C.L. Jain S. Habermann E.B. Wentink J.E. Grubbs P.L. Nehring S.A. Weaver A.L. McGree M.E. Cima R.R. Dowdy S.C. Bakkum-Gamez J.N. Using Bundled Interventions to Reduce Surgical Site Infection After Major Gynecologic Cancer Surgery. Obstet Gynecol. 2016 Jun; 127: 1135-1144 Crossref PubMed Scopus (72) Google Scholar , 6 Cima R. Dankbar E. Lovely J. Pendlimari R. Aronhalt K. Nehring S. Hyke R. Tyndale D. Rogers J. Quast L; Colorectal Surgical Site Infection Reduction Team. Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program--driven multidisciplinary single-institution experience. J Am Coll Surg. 2013 Jan; 216: 23-33 Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar , 7 Taylor J.S. Marten C.A. Munsell M.F. Sun C.C. Potts K.A. Burzawa J.K. Nick A.M. Meyer L.A. Myers K. Bodurka D.C. Aloia T.A. Levenback C.F. Lairson D.R. Schmeler K.M. The DISINFECT Initiative: Decreasing the Incidence of Surgical INFECTions in Gynecologic Oncology. Ann Surg Oncol. 2017 Feb; 24: 362-368 Crossref PubMed Scopus (22) Google Scholar ]. Most of these initiatives have targeted process-related rather than patient-related factors, including adherence to SCIP guidelines for preoperative antibiotic administration, use of a chlorhexidine-isopropyl alcohol skin prep, maintaining normothermia, and the use of fresh closing pans. As reported in this issue of Gynecologic Oncology, Hopkins and colleagues from the University of Ottawa had incorporated most of these practices into their perioperative management schema. Therefore, in order to reduce SSI they addressed a deceptively difficult subject, namely perioperative hyperglycemia [ [8] Hopkins, et al. (Current study) Google Scholar ]. Their referral to discharge glycemic control initiative standardized processes in the perioperative period and ultimately led to a 55% reduction in surgical site infection, an impressive result by itself. However, a number of aspects of this investigation and study design are deserving of emphasis, and as such should be used as a model for quality improvement elsewhere.