Increased Use of Ambulatory Surgery Centers Demands SSI Prevention

Introduction

The use of ambulatory health care facilities for minor surgical procedures is projected to grow by at least 25% at ambulatory surgery centers (ASCs) and 18% at hospital outpatient departments and physician offices over the next 10 years.¹ ASCs have the most substantial projected increase due to patient savings. The average price of standard procedures performed in a hospital in 2019 was $7716, which is nearly 144% higher than the average price of the exact procedures performed in ASCs.² This savings is only valid if a surgical site infection (SSI) does not occur.

The CDC defines SSI as “infection related to an operative procedure that occurs at or near the surgical incision within 30 or 90 days of the procedure, depending on the type of procedure performed.”³ SSIs are a significant concern associated with every surgical procedure regardless of their complexity, as they may enact a considerable economic burden and increase morbidity and mortality rates. Outpatient SSIs can result in prolonged hospital stays that can last 7 to 10 days, resulting in $20,000 to $27,600 in costs per admission.⁴ The astronomical figures associated with an SSI provide a significant indication for prevention efforts. When considering approaches to SSI prevention, it is essential to address the variety of perioperative opportunities available to improve patient safety during outpatient procedures while acknowledging the multidisciplinary collaboration needed to implement multiple effective strategies simultaneously.

Every patient who enters a health care facility for a surgical procedure is at risk of developing an SSI. SSIs are among the most avoidable health care–associated infections but only with focused attention to all aspects of a surgical procedure. Delineating the 3 subsections of perioperative processes (pre-, intra-, and postoperative) emphasizes the importance of evidence-based guidelines in SSI prevention while incorporating the unique cross section of disciplines involved in executing surgical procedures even within ASCs.

Preoperative Strategies

Patient optimization

Several accepted risk factors for SSIs are based on the patient. These patient-related risk factors, whether modifiable or nonmodifiable, provide a solid foundation for addressing preoperative strategies to mitigate the burden of SSIs. Patient-related factors that influence the risk for SSIs include nonmodifiable variables, such as age or sex. There is evidence that supports the fact that older patients may have comorbidities that can increase their risk for SSIs due to reduced immune function.⁵

Also, specific factors related to sex, determined by a patient’s biological characteristics, might influence surgery type and frequency, resulting in an increased SSI risk. The modifiable lifestyle behaviors of patients, including substance use (ie, alcohol, tobacco, and illicit drug use), diet, and exercise, can actively contribute to the development of SSIs.⁶ Smoking, alcohol misuse, and obesity are known to have a grave impact on immune function, consequently also affecting the wounds associated with surgical procedures. The oxygen supply to tissues, which is necessary for healing, is impaired by smoking.⁷ The results of alcoholism are malnutrition and a weakened immune response, whereas obesity can also complicate the wound-healing process and increase the susceptibility of a patient to infections of the tissues.⁸ Identifying these risk factors in patients allows for appropriate care management throughout the procedure.

Antimicrobial prophylaxis

Preoperative antibiotics are justified when the risk of infection is high or if there is a high risk of adverse outcomes specific to the procedure being performed, as seen with cardiac procedures and/or implantation of a foreign device. The rationale behind antimicrobial prophylaxis hinges on its ability to prevent SSIs by reducing the microorganism burden that can occur at the surgical site during the operative procedure. Patients who receive prophylactic antibiotics within 1 to 2 hours before the initial incision of their procedure are at a decreased risk of developing an SSI compared with patients who receive antibiotics sooner or later than this time window.⁹ When antimicrobial prophylaxis is employed appropriately, there is an increased likelihood of preventing SSIs, morbidity, and mortality; reducing the duration and cost of health care; causing minimal adverse drug effects; and having minimal adverse effects on the microbial flora of the patient or the health care environment.¹⁰

Skin preparation

Contamination by instruments or room air is less likely to cause an SSI than the patient’s normal skin flora. Before a surgical procedure, skin preparation plays a vital role in reducing normal skin flora bioburden.¹¹ Because of its histologic structure, human skin cannot be sterilized even by intense disinfection; therefore, surgical skin preparation aims to reduce bacterial colonization.¹² The reduction of bacterial colonization depends primarily on concentration and exposure to the antiseptic agent, given that skin cannot be sterilized. This evidence suggests that surgical skin preparation should be optimized to minimize the intrusion of normal skin flora during procedures, but other strategies must also be considered.

Intraoperative Strategies

Intraoperative interventions for reducing SSIs are primarily focused on skin decontamination for patients and health care workers, using barriers to prevent the movement of microorganisms into incisions and optimizing the patient’s bodily functions to improve recovery.¹³

Skin antisepsis

The patients’ skin is disinfected in the procedure room using antiseptic solutions such as povidone‐iodine or chlorhexidine at varying concentrations. The aim of these skin antiseptic agents for patients is to reduce the risk of SSIs by reducing the number of microorganisms on the skin.¹³ The CDC recommends that surgical personnel perform surgical hand/forearm antisepsis according to the product manufacturer’s recommendations and remove debris from underneath fingernails using a nail cleaner under running water. Surgical hand antisepsis using an antimicrobial soap or an alcohol-based hand rub with persistent activity is also recommended. Health care workers have multiple opportunities to practice hand hygiene during perioperative patient care.

Surgical drapes

In addition to preparing a patient’s skin for surgery, sterile drapes are used as a barrier to protect the patient from their skin flora and contamination from the surgical team members and environment.¹⁴ Before a surgical incision, sterile drapes can be placed onto the patient’s decontaminated skin. The Association of Surgical Technologists (AST) has developed the AST Standards of Practice for Surgical Drapes to support health care facilities in reinforcing best practices related to surgical drapes.¹⁴

Surgical attire

Various coverings worn during a procedure are designed to act as a barrier between the environment and the patient’s wound to maintain a sterile procedural field, such as masks that aim to contain any droplets being expelled by the surgical staff.¹³ Shoe coverings aim to limit the transfer of external material in and out of the procedure room. Gowns cover the designated attire of the surgical staff and can be removed when contaminated and replaced. Surgical staff wear disposable gloves during surgery to prevent the transfer of microorganisms from the staff member’s skin to the patient’s skin or surgical incision.

Patient homeostasis

During the surgical procedure, the patient’s bodily functions must be optimized to promote recovery and reduce the risk of SSI.¹³ Under general anesthesia, the risk of perioperative hypothermia increases because the body finds it more difficult to regulate temperature in these conditions. Instituting appropriate warming methods to maintain body temperature and prevent the development of perioperative hypothermia, which can prevent postoperative outcomes, to include an SSI. Also, during surgical procedures requiring general anesthesia, the patient is intubated and supplied with oxygen to maintain adequate oxygen perfusion to all tissues; however, if oxygenation is not at optimal levels during surgery, there is an increased risk of an SSI.¹⁵ Strict glycemic control using medications to maintain glucose levels during surgery can reduce the risk of surgical complications, including infection.¹⁶

Postoperative Strategies

Wound care

Surgical wound and incision management in the postoperative period is imperative to prevent complications, including SSI and wound dehiscence (wound source). Appropriate cleansing, skin care, and moisture management should be an essential part of surgical patients’ postoperative care plans. Regular dressing changes and monitoring for signs of infection are pivotal during this period in preventing SSIs.¹⁷

Early mobilization

Encouraging mobilization during the postoperative period supports blood circulation and reduces the risk of infection.¹⁸ When patients are mobile, blood can circulate and deliver oxygen and nutrients to the wound site, supporting healing and reducing the chance of infection. Early mobilization can also have broader benefits for patients, including reduced risk of complications such as pneumonia and blood clots and faster recovery times.¹⁹

Multidisciplinary collaboration

In ASCs, the heterogeneity in procedures, roles of the patient care team, and patient populations makes it difficult to define the most appropriate structure or model for optimal team-based health care. Because many factors increase patients’ risk of SSI along the surgical pathway, engaging all the health care workers within the ASC is crucial. Implementing multidisciplinary strategies in SSI prevention must be consistently applied, responsive to the individual patient’s needs, and supported by the health care organization.²⁰

Conclusion

Successful implementation of these perioperative strategies could be attributed to increasing awareness of the individual measures but, most importantly, to the patient care team’s adherence to these measures.²⁰ Preventing SSI is a complex endeavor requiring a multidisciplinary approach. A cultural shift acknowledging appropriate perioperative strategies that capitalize on the expertise of various groups, including the patient, can make SSI prevention measures effective and achievable.

References

1. Taylor DL III. Planning for surgery’s future: ambulatory surgery centers expected to skyrocket. OR Management News. January 1, 2024. Accessed January 25, 2025. https://www.ormanagement.net/Opinion/Article/12-23/Planning-for-Surgerys-Future-Ambulatory-Surgery-Centers-Expected-to-Skyrocket/72398
2. Lagasse J. Shifting common outpatient procedures to ASCs shows cost savings. Healthcare Finance. September 9, 2021. Accessed January 25, 2025. https://www.healthcarefinancenews.com/news/shifting-common-outpatient-procedures-ascs-can-save-consumers-more-680-procedure
3. Surgical Site Infection Event (SSI). CDC. January 2025. Accessed January 25, 2025. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf
4. Broex ECJ, van Asselt ADI, Bruggeman CA, van Tiel FH. Surgical site infections: how high are the costs? J Hosp Infect. 2009;72(3):193-201. doi:10.1016/j.jhin.2009.03.020
5. Bucataru A, Balasoiu M, Ghenea AE, et al. Factors contributing to surgical site infections: a comprehensive systematic review of etiology and risk factors. Clin Pract. 2023;14(1):52-68. doi:10.3390/clinpract14010006
6. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224(1):59-74. doi:10.1016/j.jamcollsurg.2016.10.029
7. Kean J. The effects of smoking on the wound healing process. J Wound Care. 2010;19(1):5-8. doi:10.12968/jowc.2010.19.1.46092
8. Trevejo-Nunez G, Kolls JK, de Wit M. Alcohol use as a risk factor in infections and healing: a clinician’s perspective. Alcohol Res. 2015;37(2):177-184.
9. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-286. doi:10.1056/NEJM199201303260501
10. Voit SB, Todd JK, Nelson B, Nyquist AC. Electronic surveillance system for monitoring surgical antimicrobial prophylaxis. Pediatrics. 2005;116(6):1317-1322. doi:10.1542/peds.2004-1969
11. Mastrocola M, Matziolis G, Böhle S, Lindemann C, Schlattmann P, Eijer H. Meta-analysis of the efficacy of preoperative skin preparation with alcoholic chlorhexidine compared to povidone iodine in orthopedic surgery. Sci Rep. 2021;11(1):18634. doi:10.1038/s41598-021-97838-8
12. Wilson SE. Microbial sealing: a new approach to reducing contamination. J Hosp Infect. 2008;70(suppl 2):11-14. doi:10.1016/S0195-6701(08)60018-3
13. Liu Z, Dumville JC, Norman G, et al. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2018;2(2):CD012653. doi:10.1002/14651858.CD012653.pub2
14. AST Standards of Practice for Surgical Drapes. Association of Surgical Technologists. Accessed January 25, 2025. https://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard_Surgical_Drapes.pdf
15. Al-Niaimi A, Safdar N. Supplemental perioperative oxygen for reducing surgical site infection: a meta-analysis. J Eval Clin Pract. 2009;15(2):360-365. doi:10.1111/j.1365-2753.2008.01016.x
16. Ljungqvist O, Nygren J, Soop M, Thorell A. Metabolic perioperative management: novel concepts. Curr Opin Crit Care. 2005;11(4):295-299. doi:10.1097/01.ccx.0000166395.65764.71
17. Post-operative surgical wound management: key wound treatment considerations. WoundSource. September 26, 2018. Accessed January 25, 2025. https://www.woundsource.com/blog/post-operative-surgical-wound-management-key-wound-treatment-considerations
18. Rarani SA, Kramer A. Three steps to reduction surgical site infection: presentation of a comprehensive model. GMS Hyg Infect Control. 2023;18:17. doi:10.3205/dgkh000443
19. Castellà L, Sopena N, Rodriguez-Montserrat D, et al. Intervention to reduce the incidence of surgical site infection in spine surgery. Am J Infect Control. 2020;48(5):550-554. doi:10.1016/j.ajic.2019.09.007
20. Gillespie BM, Kang E, Roberts S, et al. Reducing the risk of surgical site infection using a multidisciplinary approach: an integrative review. J Multidiscip Healthc. 2015;8:473-487. doi:10.2147/JMDH.S73565