Surgical site infections (SSIs) are one of the most common complications of surgical procedures. At Discovery NP Legal Consultants, we understand that Surgical Site Infections (SSIs) are a major complication of surgical procedures. These infections can range from mild to severe and can lead to significant damages up to and including wrongful death if the infection manages to get into the bloodstream. SSIs can be a direct and proximate result of simply a compromised immune system, which makes for a solid defense in cases where an SSI complication occurs. However, because many standards of care are in place to prevent infection, infection can also be established as proximally caused by a variety of healthcare negligence factors, including poor surgical technique or contamination of the surgical site.
Certainly, patients are warned about the risks of infection upon obtaining informed consent for any invasive procedure. Nevertheless, this does not excuse failure to meet the standards of care for its prevention. Nor does it excuse failure to recognize and swiftly act on signs of infection when they appear, which delay can negatively impact outcomes. When surgical error occurs, there must be accountability.
Standards of Care for Prevention of Surgical Site Infections
Preventing SSIs involves standards of care adhered to before, during, and after surgery, while management of a surgical site infection involves prompt recognition of its signs and symptoms, accurate diagnosis and proper application of evidence-based empiric treatment. In this article, we will explore the causes, symptoms, standards of care for the prevention of, and the responsible management–as well as mismanagement of surgical site infections to help attorneys who are evaluating cases of medical negligence involving surgical site infections to properly analyze the variables and factors that play into standard of care breaches and causation.
Causes of Surgical Infections
Surgical site infections (SSIs) can be caused by a variety of factors. These factors can be pre-operative, intraoperative, and postoperative.
Preoperative Factors
Prior to surgery, in the operating room, the medical staff must re-create a new sterile environment for each surgical procedure in order to prevent the spread of microbes and reduce the risk of infection. Fast-paced high-pressure operating rooms may cut corners in order to put through more cases in a day. This failure to attend to detail in the name of revenue can have deadly consequences.
The standard of care is that the surgeon and surgical staff wash their hands with special soap for a minimum of 120 seconds and up to 6 minutes, with special attention to fingernails and the webs between the fingers. All drapes are sterilized and even the gloves the surgical team dons are sterile and theoretically never before touched by a contaminated person or object.
Standard of care in the operating room workflow also includes a thorough cleaning of the surgical site with an antiseptic solution. All tools are autoclaved to kill microbes.
Information about any pre-existing conditions that decrease immunity is collected on admit and relayed to the surgical team. The patients are also often provided with pre-operative antibiotics and screened for antibiotic-resistant bacteria. Failure to adhere to these guidelines in whole or in part can, and likely will lead to healthcare-associated infection that can have catastrophic or deadly consequences.
Intraoperative Factors
Intraoperative factors such as poor surgical technique, intra-procedural contamination of the surgical site, and the use of improperly sterilized surgical instruments can also contribute to the development of SSIs. Contamination can be as simple as a surgeon or scrub tech wiping the sweat off his or her forehead with the back of their glove. Such careless contamination will not necessarily be found in the medical record, but could have far reaching surgical complications and negatively impact patient safety. Attorneys must rely on expert consultants who can read between the lines and ask the right questions of the staff to get the admissions needed to prove negligence in hospital-acquired infections cases.
Postoperative Care Factors
Postoperative factors such as poor wound care, compromised immune systems, and prolonged hospital stays can also increase the risk of SSIs. While the patient is convalescing in the hospital setting, it is the responsibility of the hospital staff to monitor the status of the wound; not simply the dressing. Nursing notes may indicate that the patient reports tenderness in the region of the wound, and the nursing staff repeatedly indicates that the “dressing is dry and intact”. What a non-nurse reviewer may not observe is the failure of the nursing staff to comment on the approximation of the edges of the wound and the absence of redness and drainage, the omission of which often signals that the nurse never removed the dressing, as would be standard of care. Failure of the nursing staff to routinely–and in response to complaints–visually inspect the wound directly as per hospital protocol and–where more rigorous– as per doctor’s order, can lead to a delay in diagnosis of a pervasive infection that may ultimately migrate systemically and result in sepsis and even death. Such tactless care is a violation of medical ethics and not conducive to infection prevention.
Antibiotics
Not all antibiotics are created equal. The wrong antibiotics prescribed by a provider acting imprudently or unreasonably can actually worsen the outcome. Initial antibiotic therapy is determined empirically. Empiric antibiotic therapy is the practice of algorithmically treating suspected bacterial infections before laboratory test results are available, using a broad-spectrum antibiotic that has known effectiveness against the most common causative organisms based on the location and nature of the wound/entry point.
A wound culture is a laboratory test in which a sample of pus or drainage from a wound is taken using a large cotton swab. The collected material is spread on a petri dish and “cultured” to identify any potentially infectious agents or organisms. This test takes between 24 and 48 hours to result. Performing a culture must be done by a provider’s order. Failing to order a culture when a patient is not responding to empiric treatment is a missed standard of care. Failing to acknowledge results of a culture that should inform an adjustment in therapy is an egregious and easily verifiable error in clinical judgment.
Culturing a wound allows the provider to identify the precise bacteria or microbe responsible for the infection so that the prescribing provider can ensure that the antibiotics prescribed are appropriate and effective against it. Missing the opportunity to culture a wound can contribute to the microbes antibiotic resistance, and drastically impact the patient’s chances of an uncomplicated recovery. Left unchecked by the right antibiotic, bacteria can become a superbug and wreak havoc on the host.
Follow-up
Upon discharge, the medical staff is responsible to educate the patient about the signs and symptoms of a local SSI, and of a systemic infection,. The staff must also be trained to respond appropriately to the patient’s reports or concerns should the patient call the on-call provider or surgeon to report them. The staff is also responsible for setting up a follow-up appointment to visually inspect the healing surgical site, identify complications and appropriately treat or refer. Staff or surgeons may be held liable for failling to recommend that the patient be seen when the patient calls in with complaints of a fever, chills, suspicious drainage, redness, warmth or tenderness at the surgical site.
Symptoms of Surgical Infections
Infection is one of many surgical risk factors. Healthcare providers are trained to be wary of presentations that might signify post-operative infection. One of the primary purposes of post-operative monitoring and follow-up visits is to evaluate for the presence of infection, so when a healthcare provider misses those signs, thereby delaying treatment, they can and should be held legally accountable–informed consent and known risks notwithstanding!
The symptoms of surgical site infections (SSIs) can vary depending on the severity and location of the infection. Common symptoms may include redness, swelling, warmth, and pain at the surgical site. Patients may also experience fever, chills, and pus-like drainage from the wound. This is why it is so critical that medical malpractice attorneys consider hiring a nurse consultant to examine the medical records of inpatient surgical cases to see how the nursing staff were documenting the appearance of the wound itself; not just the dressing–if they were even documenting it! In more severe cases, patients may experience nausea, vomiting, fatigue, and dizziness. Some of these symptoms could signify an impending sepsis. If healthcare providers note these complaints without appropriate notification of the surgeon/attending or without consideration for accompanying changes in vitals signs, their lack of prudent and reasonable response should be called to accountability. Plaintiff attorneys should engage a medical consulting expert to identify documentation of complaints and findings versus the appropriateness of the healthcare team’s recorded responses.
Management of Surgical Infections
The management of surgical site infections (SSIs) depends on the location of the surgical site, the severity of the infection, the causative organism, co-morbidity considerations (including medication allergies), and local or systemic involvement.
Management Of Mild Infections
Mild infections can often be treated with oral antibiotics, while more severe infections may require IV antibiotics (i.e. hospitalization), or even additional interventions such as surgical debridement. Therapies and resources available to medical facilities may include an inpatient or outpatient wound care treatment plan and placement of drains. The involvement of the Infectious Disease specialty team, where available, is advised.
Management Of Aggressive local Infections
Aggressive local infections should be monitored at appropriate intervals outpatient, or even inpatient if appropriate to quickly recognize migration to the bloodstream which can lead to death. An astute medical team should also recognize and act quickly when the need arises to transfer to an interfacility or interfacility higher level of care.
Proper wound care and close monitoring by trained nursing staff are also essential components of SSI management. An attorney reviewing and critiquing all aspects of care related to the preventability of an infection in an injured party, its prompt recognition, and appropriate, timely management would do well to retain a consultant with both provider and nursing clinical background, who can identify all contributory factors.
Conclusion
Surgical site infections are a significant complication of surgical procedures that can lead to significant damages, prolonged hospital stays, additional procedures, lost wages, or even wrongful death. . Prevention of SSIs involves strict adherence to evidence-based standards of care before, during, and after surgery. Management of SSI involves prompt diagnosis and appropriate and timely treatment. The perioperative personnel should be educated in these issues, well-trained and alert to the risks to avoid liability for damages caused by preventable SSI. Contact us today for more information.