Surgical Site Surveillance: Quality Improvement or Waste of Time?

SURGICAL SITE II FECTION (SSI) IS A RELATIVELY INFREQUENT complication of surgery. yet it is a major medical problem because thousands of operations are done weekly across Canada. SSI has several possible outcomes. including the morbidity related to the infection per se. secondary complica tions such as ventral hernia and necrotizing soft tissue infection and, rarely, death. The prevention of SSI requires good judgement in patient selection and preparation, meticulous surgical technique and judicious use of prophylactic antimicrobial agents. For clean operations. infection rates as low as 1% have been reported (1). In the early 19th century infection at the operative sile was exceedingly common, and the results were usually disastrous; for example, limb amputation carried a mortality rate of 30 to 50%. Pasteur's work on the microbial cause of infection and the studies of Semmelweis and Lister led to tl1e use of antisepsis. then asepsis, in the operating theatre. After the discovery of safe general anesthesia in the 19th century. surgery performed at frantic speed to reduce the duration of pain gave way to the precepts of Halsted and other modern pioneers. who demonstrated that meticulous surgical technique improved the chance of a successful outcome. Clean surgical procedures had become safe. In the 1960s a similar but less dramatic decrease in infection rates was seen in clean contaminated operalions as prophylactic antimicrobial agents were successfully used. It is evident that past reductions in SSI rates have occurred not by gradual decrements but by relatively precipitous drops in response to important discoveries. Current SSI rates seem too low to be reduced drastically, but it is the aim of surgeons and infection control teams to continu e to decrease their incidence . Can 'zero infection· rates be achieved or has an irreducible minimum been reached? Most practitioners interested in infection control believe that efforts at quality improvement \vi ii continue to reduce SSI rates by the same mechanism as quality improvement programs used in industry: determination of incidences of failures followed by attempts to "do better nexi: time .. . Indeed, growing numbers of reported studies have shown that calculation of SSI rate and confidential reporting of those rates to individual surgeons lead to red uctions in subsequent rates of SSI (1,2). Such studies h ave become show-