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Institution of the Steiros Algorithm® Outpatient Surgical Protocol Reduced Orthopedic Surgical Site Infections (SSI) Rates By Paul Watson MD(a), Luke Watson MD(b) and Alfonso Torress-Cook Dr PH(b) a = Lakeside Orthopedics, Omaha, Nebraska b = Pacific Hospital of Long Beach, Long Beach, California Paper presented at Nebraska Orthopedic Society Annual Meeting, Lincoln, NE, April 2011 |
Abstract
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Introduction
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 patient peri-operative cleaning methodology (Steiros Algorithm® Outpatient Surgery Protocol) would lower the overall infection rate in patients undergoing orthopedic surgery. |
Methods
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and postoperative patient decontamination protocol which reduces bacterial bioburden from the surgical patient (unpublished data).(12) The surgeon (PAW) asked all patients to buy the skin sanitizer (0.13% benzalkonium chloride with preservatives, Steirolotion®, Germcure, Houma, Louisiana) pre-operatively during the pre-operative risk discussion and apply the product the night before and the morning of surgery. A patient handout 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. Pre-operatively, 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.
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.
preoperative antibiotic protocols and skin preparations were otherwise unchanged. Standard hospital protocol was a 4% chlorhexidine wipe in the pre-op 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 along with 3 month surgeon questionnaires. The number of total joint arthroplasties performed was included in the infection data. All superficial and deep infections were included. 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.
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 milligrams was administered to patients with a type I allergy to penicillin. |
Results
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). 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
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.(14) As well, Watson etal (unpublished data) found that the Sterios Algorithm® significantly reduced total joint arthroplasty and spinal fusion SSI by over 60%.(15) 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.
etal(16) pre-operatively 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 etal(17) also screened total joint arthroplasty patients pre-operatively 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.
we did not collect demographic or other patient-specific data, so selection bias is possible. This bias is mitigated by using patients whose surgeries were performed by a single surgeon from a stable population. Furthermore, the large numbers of patients should help reduce the risk of selection bias. Second, we did not track and verify compliance other than verifying the patient bought the product and brought it to surgery. Third, we did not culture patients after the decolonization protocol to verify decolonization of specific bacteria types pre-operatively. However, the dramatic reduction in infection rates suggests the decolonization was effective.
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).(13) This allows for much easier application and compliance for patients undergoing all orthopedic inpatient and outpatient surgeries.
Protocol dramatically reduced the orthopedic SSI rate and saved money. |
References
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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). (4,13) |
