New Study Provides Concrete Guidelines for Preventing Surgical Site Infections . . . Finally

Hallelujah! After reading Pam Belluck’s New York Times article on preventing hospital-acquired surgical site infections, I couldn’t help but cheer. The study published recently in the New England Journal of Medicine that focused on skin preparation brings us closer to answering a decades-old question: “Which product do we use to prep the skin before surgery?”

The seminal document, “Guideline for the Prevention of Surgical Site Infections,” published in 1999, noted the advantages of using chlorhexidine gluconate over iodophors (e.g., povidone-iodine or betadine) or alcohol-containing products. The guideline also noted that there had been no controlled studies to support recommending one skin preparation product over the others, so it was left to individual surgeons, OR teams and ICPs (Infection Control Preventionists) to implement whatever they thought best.

In the 2008, The Society for Healthcare Epidemiology of America (SHEA) published an updated guideline, “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals.” But, in this guideline, the issue of skin preparation remained unresolved, referring back to the 1999 guideline. Still no answers! What’s an ICP to do?

Then, in 2005, when the Centers for Medicare and Medicaid Services (CMS) began requiring hospitals to report two Surgical Care Improvement Project measures (antimicrobial prophylaxis provided within 1 hour before incision and discontinuation of antimicrobial prophylaxis within 24 hours after surgery), hopes were raised once again. Perhaps the catalyst needed to provide the answer was to somehow “reward for results.” But, again, we needed the science to support the practice before including such a measure in a “pay for performance” program.

Enter Dr. Darouiche, et al., and their landmark study, which concluded, “preoperative cleansing of the patient’s skin with chlorhexidine–alcohol is superior to cleansing with povidone–iodine for preventing surgical-site infection after clean-contaminated surgery.” Many thanks to everyone involved in this monumental effort. Marcia Patrick, who was quoted in the New York Times article, got it exactly right. This is going to be a huge help, not just to hospital ICPs, but to the patients, for whom these infections will be prevented. Now, if we can just adopt this practice into our everyday work!

Though frustrating and sad, history shows it often takes 20 years—a generation—to assimilate evidence-based practices in healthcare. Perhaps the next step is to include a skin preparation quality measure in the Surgical Care Improvement Project to facilitate the rapid adoption of this infection prevention strategy. After all, we tend pay attention to what’s important to the people at the top of the hospital chain and those who pay the bills. And as humans, we tend to do those things that are fun and rewarding. We’ve waited over a decade for the answer. We shouldn’t wait another two decades to implement this important infection prevention strategy for patients undergoing surgical procedures. As Dr. Wenzel said, “Everybody wins: patients, hospitals and payors.” But, this is only true if we follow through.