It all seemed so easy

In 2010 an article was published in the New England Journal of Medicine, Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus .  Patients were screened for Staphylcoccus aureus ( including MRSA, methicillin resistant Staphylococcus aureus) and those that were positive underwent a 5 day perioperative decontamination procedure with chlorhexidine baths and an antibiotic, mupirocin, in the nose.  The results were impressive.  Before the intervention the infection rates were 7.7 % and after the intervention it was 3.4 %.  That is an impressive drop in surgical infections.

One of the orthopedic groups approached us (us being the hospital administration, pharmacy, nursing  and infection control, of which I am Chair) to implement the protocol in their patients, citing a similar study on an orthopedic population.  Great.  It should be an easy enough intervention.  I should have known better, of course, long experience has continually demonstrated that what appears to be simple never is.

First was the question as to whether the study was applicable to our patients.  Resources were going to be devoted to an intervention, so going forward we had to demonstrate that the bang would be worth the buck.  These are financially lean times, with cutbacks and declining reimbursement, so every expenditure of time and money needs to be justified.  In the bizarro accounting of health care, not every hospital administration will include money saved in the evaluation of interventions, only the money spent.   I work in a hospital system with a remarkably strong commitment to patient safety and quality, so there was little  worry on that point.

Still, our overall surgical infection rates are less than 1%, so we are doing better at baseline than NEJM study were at the end of the intervention.  When I see surgical infection rates going from 7.7 % to 3.4 %, I have to wonder if the benefit of the intervention is a surrogate for an issue with deeper problems with infection prevention at the hospital.  Maybe there was a a decrease in infections with decolonization because they were sloppy with the compliance with other, more basic, infection prevention strategies.   My system has been very aggressive applying SCIP interventions, a series of actions that, when consisting applied, result in a large drop in surgical infections.  Perhaps they are sloppy with their SCIP.  I have no way of knowing.

Also,  I can’t help but think there is a lower limit to the infection rates under which it will be impossible to go. As long as we operate on people we will always have some infections no matter what we do for prevention.  One of our surgeons had his only infection for the year in an emergency case on a 450 lb woman with a glucose of 600 and a 2 pack a day habit.  Even after a week in the hospital she still had dirt tattooed on her palms and feet.   I think zero infections should be our goal; I am not so sure that is realistic given the co-morbidities of some patients.  Could we go lower?

I also wondered if we had infections that would be amenable to surgical screening and decolonization.  Many of the orthopedic S. aureus infections are presenting late, 4 to 8 weeks post op.  Given the virulence of S. aureus, where people usually become symptomatic the day they acquire the bacteria, I suspect the infections we had been seeing in the orthopedic population are being acquired after discharge.  If so, we may make no impact on our infections by beating down the S. aureus in the peri-operative period.

Still, we had the occasional S. aureus infection, MRSA and MSSA, Staph colonization is a risk for subsequent infections, and the orthopedic group wanted to do something so it seemed reasonable. I can count on one hand the number of times a surgeon has been the one to ask for help in reducing infection; usually we take suggestions to them.  It was an opportunity I didn’t want to miss.  We had evidence, science even, to drive change.

At first it was suggested that we not bother to screen, but treat everyone.  Everyone has MRSA, right?  Wrong.  In Washington (in Oregon, we call it Washington, not Washington State) they mandate screening for all ICU admits, and we know that about 20% of patients have S. aureus in their nose, and about 2% have MRSA.  With mupirocin resistance already at 14%  in some parts of the US and chlorhexidine resistance being described, the last thing I wanted to do was increase the use of these drugs.  Resistance, said the Borg, is inevitable, or some such.

Cost-efficacy analysis, which make my head hurt, suggests we should treat everyone but the authors minimize the threat of future antibiotic resistance. In a world that is running out of antibiotics, I cannot be quite so cavalier on the issue. Use it and lose it.   We are already sliding into the post antibiotic era, and I don’t want to drive resistance any harder than necessary.

The next step was deciding was how patients would be screened.  A nasal swab misses 30% of MRSA carriers, and to maximize the yield would probably require a swab of the nose, throat, skin folds, arm pits and stool.  5 separate swabs would make it cost prohibitive ($120 each) but if you use one swab, in what order do you swab? Always end at the anus, that’s my rule.  And the PCR, polymerase chain reaction, is not approved for every body specimen.   So in the end we decided that the published data only screened with nasal swabs, so we would as well.  We may miss a few MRSA carriers but they would be rare; the perfect is the enemy of the good and reality requires compromise.

The next roadblock was coordination of care.  The nasal swab had to be collected within 30 days of the planned surgery.  Someone had to note if the swab was positive for MRSA or MSSA, call the patient and the pharmacy for a prescription of chlorhexidine and mupirocin and start the antibiotics a few days before surgery.  When  22 in 100 have a positive PCR , initially the test was missed since there was no one person responsible for acting on the result.  Most of the people who need a new joint are old and, by definition, not mobile and getting to the pharmacy was limited by both patient mobility and transportation.  Getting the prescription to the patient was difficult to do consistently, and transitioning the outpatient prescription to the inpatient setting was equally unreliable.  Patients were not bringing in their medications  (we did not want duplicate prescriptions) and physicians were not reordering the mupirocin/chlorhexidine, thinking the patients had brought their own.

To compound the problem, many patients had to pay out of pocket for the medications, and there are two formulations of the mupirocin, the much more expensive formulation made for use in the nose.  Of course. It is weird how, when nasal mupirocin use started to be common a new, and much more expensive, formulation became available.   We elected to go with the less expensive formulation as there is no evidence for increased efficacy of the expensive formulation.

Peri-operatively we had decided to give add, rather than substitute, vancomycin to the usual cefazolin if the patient had MRSA.  That was only 2% of the patients, rare enough to be missed.  Vancomycin has many characteristics that make it a lousy drug, and I did not want to lose the efficacy of the cefazolin for MSSA.  However, initially there was no single person responsible for noting that the patient was MRSA postive and changing the perioperative antibiotics.  All too often Vancomycin was either not given, or given too late to have effect.  Vancomycin, requiring an hour infusion instead of the IV push of cefazolin, needs more lead time to give and can throw a monkey wrench into the work flow of the OR if a case has to be delayed an hour or more to give an antibiotic.

It took well over six months of trial and error to work out the kinks in the protocol with one orthopedic group to apply the evidence and and get the process to run smoothly.  Murphy’s law states that if something can go wrong, it will.  I agree with the suggestion that Murphy was an optimist.

Despite all that work, for some patients the process is grinding to a halt from an unexpected source.  The swab for Staph costs about 120 dollars, and Medicare, which many joint patients are on, does not pay for screening.  For the first several months we (not me) received irate calls from patients about the charge, and now Medicare patients have to sign a waiver when they get tested understanding that the swab will not be covered by insurance and they will be responsible for the cost of the test.

Part of the issue with instituting the protocol is that there is no health care system: one group pays, one group runs the hospital and OR and a third group does the surgery.  It would, perhaps, been much smoother to implement if we were in a unified health care system.  I dream of universal health care where the system will be totally screwed up in one consistent way, rather than the hundreds of ways it is totally screwed up now.    I really want to sit on one of them there death panels.

Has it worked? Too early to say, and I hate to jinx myself, but in the nine months since the protocol was introduced, despite all the glitches, we have had no Staphylococcal infections in that orthopedic group. I am cautiously optimistic the effort has paid off.  We hope to spread the protocol to other orthopedic groups and high risk surgeries now that we have worked out the kinks. Of course I expect a whole new collection of complications.

I read papers all the time about this or that intervention improving patient outcomes.  Reading the papers it seems ever so simple to apply the results to the real world, but it takes an amazing amount of work by a large number of people to coordinate the care that even a simple intervention can entail.  In the end we (mostly everyone else except me) accomplished what we set up to do, only to be stopped short for a large number of patients by Medicare.

This is one of many quality initiatives at my institutions that have resulted in decreased morbidity and mortality.  Last time I wrote on the issue I looked to see if there had been similar initiatives in any of the SCAMs. What are chiropractors, acupuncturists, naturopaths and their fellow travelers doing to improve patient care? At the time I had found none. I would have thought chiropractors would be interested since one of the Never Events  is “Patient death or serious disability due to spinal manipulative therapy.”  In their world a never event  never happens, not an event that can haappen but never should.   A quick search of the Googles and Pubmeds finds…

Still nothing.  Must be nice to be perfect.  It results in a lot less work.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at