title: A surgical site infection cluster: the process and outcome of an investigation--the impact of an alcohol-based surgical antisepsis product and human behavior.
abstract: BACKGROUND
  The institution of a process used to successfully execute a perioperative antibiotic administration system is but 1 component of preventing postoperative infections. Continued surveillance of infections is an important part of the process of decreasing postoperative infections. We recently experienced an increase in the number of postoperative infections in our patients. Using standard infection control methods of outbreak investigation, we tracked multiple variables to search for a common cause. We describe herein the process by which Quality Improvement methodology was used to investigate and manage this surgical site infection (SSI) cluster.
  
  
  METHODS
  As part of routine surveillance for SSI, the infection control division seeks out evidence of postoperative infections. Patients were defined as having an SSI according to National Healthcare Safety Network SSI criteria. SSI data are reviewed monthly and aggregated on a quarterly basis. The SSI rate was above our usual level for 3 consecutive quarters of 2007. This increase in the infection rate led to an internal outbreak investigation, termed a "cluster investigation." This investigation comprised multiple concurrent methods including manual chart review of all cases; review of microbiological data; and inspection of operating rooms, instrument processing facilities, and storage areas.
  
  
  RESULTS
  During 3 quarters, a trend emerged in our general surgical population that demonstrated that 4 surgical types had a sustained increase in SSI. The institutional antibiotic protocol was appropriate for prevention of the majority of these SSIs. As part of the investigation, direct observation of hand hygiene and surgical hand antisepsis technique was undertaken. At this time, there were 2 types of surgical hand preparation being used, at the discretion of the clinician: either a "standard" scrub with an antimicrobial soap or the application of a chlorhexidine gluconate and alcohol-based surgical hand antisepsis product. Observers noted improper use of this alcohol-based surgical hand antiseptic. This product was withdrawn from our operating rooms, and the SSI rate markedly decreased in the following 2 quarters.
  
  
  CONCLUSIONS
  In conclusion, we report the results of a quality improvement process that investigated a 3-quarter increase in our SSI rate. An investigation was undertaken, and it was thought that the (mis)use of an alcohol-based hand antiseptic product was associated with the increased infection rate. Removing this product, along with reemphasizing the importance of infection control, was associated with a decrease in the infection rate to a level at or below our historical rate.
authors.affiliation: Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Haessler
authors.forename: Neil Roy
authors.initials: NR
authors.lastname: Connelly
authors.forename: Gary
authors.initials: G
authors.lastname: Kanter
authors.forename: Jan
authors.initials: J
authors.lastname: Fitzgerald
authors.forename: Mary Ellen
authors.initials: ME
authors.lastname: Scales
authors.forename: Anneta
authors.initials: A
authors.lastname: Golubchik
authors.forename: Michael
authors.initials: M
authors.lastname: Albert
authors.forename: Charles
authors.initials: C
authors.lastname: Gibson
mesh_terms: D000046:Academic Medical Centers; D000891:Anti-Infective Agents, Local / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis; D001519:Behavior; D004196:Disease Outbreaks; D000431:Ethanol / Q000627:therapeutic use*; D006801:Humans; D009511:New England; D009873:Operating Rooms; D011785:Quality Assurance, Health Care; D013242:Sterilization; D013525:Surgical Instruments; D013514:Surgical Procedures, Operative; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D014193:Trauma Centers; D016896:Treatment Outcome
chemical_list: D000891:Anti-Infective Agents, Local; D000431:Ethanol