Infection control is one of the most important goals pre, intra and post operatively. One of the driving forces behind the new new procedures I have developed over the past 9 years has been mitigation of surgical risk. Many of these risks can be managed with advanced fixation techniques, new surgical techniques and sophisticated equipment. But there is one risk factor that will always loom in every surgeons mind… infection.
Infection occurs because of bacterial colonization that exponentially replicates to levels that cause tissue damage and potentially dangerous bone infection. To reduce this potential growth, surgeons employ many standard protocols. Some of these include pre-operative scrub of the surgical site as well as the surgeon’s hands. The use of autoclaved (sterilized) instrumentation and sterile operating room drapes and dressings is also standard procedure.
Post operative infection control is just as important. This is achieved with oral antibiotics that inhibit bacterial growth while your skin is healing. Once the skin has healed, the risk for infection decreases dramatically since the portal for infection has been closed. This however is not the case for procedures that require fixation devices that pierce the skin (like K-Wires, External Fixators and such). In these situations infection control must be continued until the hardware is removed and the entrance sites are healed. This is also why all of the procedure I have designed have eliminated the need for external fixation.
But obtaining the holy grail in infection rate (< 1%) is a lot more challenging than that! As part of our mission to provide the highest level care available in foot surgery, I have incorporated protocols that exceed the standards of most hospitals and surgery centers across the country, so we can meet this exceptional level of care.
Part of maintaining an excellent track record of infection free surgeries is exposing our facility to the demanding standards placed by the largest and most respected accrediting body in the country, the Joint Commission (commonly referred to as JCAHO). This process requires that we maintain logs and implement infection control protocols that are mandated by the CDC (Centers for Disease Control) and WHO (World Health Organization). JCAHO accreditation is the norm in most hospitals across the United States however, so I decided to “super-size” our protocols.
To achieve this lofty goal, I made a decision early in our practice to reduce the size of the patient flow as well as the staff in contact with maintaining these protocols. This way instead of employing what’s found in most facilities (4+ people) in charge of instrument management, and sterilization processes, it’s just my surgical tech and myself. In this model there is tight control of what happens in preparation for each case and quality control can be micro managed.
Another simple factor is volume. We’ve all learned the correlation between volume and quality: Q = 1/V. As volume increases (the practice sees more patients per day) quality becomes compromised. In a perfect world this can be circumvented, but unfortunately that isn’t a reality yet. This is why we limit our patient volume so we can maintain the same level of excellence for every case.
I’ll discuss the relevance of a small volume practice in a future article and how it relates to our practice philosophy and ethos.
The surgical scrub has been shown to be one of the key components of infection control. To increase your chances of success, in late 2009 I began to implement the “double scrub”. With this protocol, we perform an initial pre-operative surgical scrub using Chlorhexidine Gluconate (Hibiclens). This antiseptic has been shown effectivity against Gram positive as well as Gram negative microbes, and is the scrub of choice for most plastic surgeons. Once the initial scrub is performed, the local anesthetic block is performed. This prevents entrance of bacteria into the sterile compartments of the foot. For more information on Hibiclens visit http://www.hibigeebies.com.
The second scrub is performed immediately before the procedure is performed. This scrub utilizes DuraPrep by 3M. DuraPrep has been shown to kill all major pathogens in one minute. Keep in mind, this is performed after an thorough Hibiclens scrub so not many bugs are able to survive the first scrub, and if they do… we’ll knock them out with the second scrub!
Although this increases costs, my philosophy is how you we put a price on your well being? You can learn more about DuraPrep here: http://solutions.3m.com
One of the things that always bothered me about hospital based surgeries is the known infection rates in hospitals. Nosocomial infections (hospital bourn infections) have been discussed in almost every respected medical journal. Long protocols and algorithms have been described to control this menacing and rapidly increasing phenomenon.
So how did we manage this problem? It was simple… we invested in our own premium surgical facility, and restricted access to only non-infected patients. This way, there just isn’t a chance that our O.R. can be contaminated with the scary bugs you hear about on the news. It also allowed us to bypass the complex bureaucracy found in larger institutions and implement changes rapidly to benefit our patient population.
This is not to say that all hospitals are dirty environments. Some of the finest facilities in the country like Cedars-Sinai medical center and UCLA hospital maintain some of the lowest infection rates, but the risk is still there since patients go in and out of these facilities with a variety of serious infections.
Having had the privilege of training in diabetic wound care and limb salvage at the Northridge Hospital Wound Care Center, I had a first hand experience of the rapidly growing field of wound care. The technology in this area of medicine has evolved exponentially since I matriculated in my program. One of the great yields of this science has been the use of Silver in wound management and infection control. Silver has found it’s way into a variety of wound products.
As another first, in 2009 we began a universal protocol of using Maxorb Extra Ag+ dressings on EVERY surgical patient. This advanced Calcium Alginate dressing not only absorbs drainage from the incisions keeping them dry (thus inhospitable to infection) but also delivers Silver ions to the incision site to kill any developing colonization process. Once again, another expensive but important protocol we use to maintain our incredibly low infection rate. You can read more about Maxorb Extra Ag+ here: http://www.medline.com/wound-skin-care/maxorb-extra-ag/
Steri-strips are used to further maintain the incision and reduce the tension so that the plastic surgical closure can heal without scarring. When 3M released their antimicrobial steri-strips… it was a no brainer!
Even with all of the above measures, infection control has to be a top priority inside and after surgery. That why every surgery is flushed with copious amounts of a Bacitracin Saline solution. One of the simplest formulas for infection control is taught to every first year resident: “the solution to pollution, is dilution!”
After surgery, every patient is given oral antibiotics to manage bacterial growth. Combine everything we’ve talked about with a pre-emptive first week dressing change, and we can proudly report a less than 1% infection rate for two years in a row! Despite this achievement, part of our commitment to you is to continuously raise the bar and set the standard for modern foot surgery.
Dr. Ali Sadrieh
