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Riverside County Regional Med Center drastically cuts infection rates

When Jake Ainsworth sought help for a torn ligament in his left knee he never expected that the outpatient exploratory surgery he underwent would devolve into a medical nightmare.

"Within hours, it started to get infected," says Ainsworth. "By the next morning, I was in excruciating pain, and by that evening, I was in the emergency ward...My knee will never be the same."

The procedure introduced staph bacteria into Ainsworth's knee. Treatment for the resulting infection included four surgeries that left the Ventura County physical education teacher mostly bedridden for six months, in physical therapy for many more months, and in pain through all of it.

 "It was devastating," he says. "There didn’t seem to be any hope."

Ainsworth, 67, is among the tens of thousands of Americans who become ill each year with mostly preventable surgical site infections (SSIs) that cost several billion dollars and are the second most common health care-acquired infections (HAI's) nationwide, according to the California Department of Public Health. 

Still, Ainsworth is among the lucky ones. While most SSI's are treatable with antibiotics, experts have found that about three percent of patients die from them.

"It's a huge burden on our health system," says Dr. Michael Bell, deputy director of Health Care Quality Promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta. "And then from the suffering perspective, when you think about the individual who wanted to get better and then being afflicted by an infection, that's a big issue as well." 

But things are starting to change.

Infection rates - once kept private by hospitals - are now public record in 32 states, California included. 

This new transparency - which in California includes an interactive map for consumers - coupled with Medicare now docking payments to hospitals that don’t meet quality measures - is prompting innovation at many hospitals with high infection rates. Among them:  Riverside County Regional Med Center in the City of Moreno Valley, which until recently had a rate of surgical site infections that was far above the national norm. 

"We were not getting the results," says  Dr. Arnold Tabuenca, surgeon and Chief Medical Officer at the hospital.  "We were having like three times more infections."

One of the steps the hospital took: to more closely monitor routine tasks, such as how surgeons wash their hands before operating. And, more importantly, hospital management directed staff to develop an expanded list of anti-infection measures.

"It's better for patients and its better for us as well because I'm not going to expend a lot of unnecessary resources if I do it right the first time," says Annette Greenwood, Chief Operating Officer for the county run hospital. "And that's just better business for a hospital."

Among the many new protocols: keep operating room temperature and humidity at levels that minimize bacterial growth and limit traffic in and out of operating rooms – which can be challenging for a teaching hospital like this one, says Louise O’Rourke, a registered nurse who works in the medical center's surgery department. 

"It's kind of a crowd control methodology," she says. "Who needs to be here? If you’re not needed… don’t come in." 

That’s because air that flows in and out of an operating room when the doors are opened and shut creates an almost imperceptible turbulence that can kick up dirt, skin particles and other things that might infect a patient’s wound.  And that’s why everyone who spends time in the operating room is asked to wear long sleeves to cover as much exposed skin as possible. 

"There is a skin shedding that happens to everyone, every day," says O'Rourke. "So the moment we walk into the room if we’re not completely covered we have shedding that can be sucked into the patient’s surgical site.” 

Patients, too, play an important role in minimizing infections. For instance, smokers are encouraged to stop for 30 days before surgery, as there is evidence indicating that tobacco use may increase the risk of infection. Patients are also taught how to manage blood sugar levels, which could also contribute to infection risk, Trabuenca says.  If their blood sugar level is too high on the day of surgery, their procedure is postponed.

"Even in those emergency surgeries where a patient comes in with their blood sugar high, we have devices in the OR that measures their blood sugar every hour and adjusts the amount of medication, hourly, to keep the levels under better control," says Trabuenca. 

Fueling these changes  is collaboration among members of the entire surgical team. 

"We’re all reminding each other, 'hey did you change your scrubs? You were on the floor, can you go change them?'" O'Rourke says. "It's a a more collaborative attitude," she adds, not "punitive" or "angry."

Everyone who works with patients is expected to keep an eye on whether the hospital's anti-infection protocols are being followed.

"The greatest challenge is encouraging nursing personnel or an assistant to stop something that is being done wrong, even if the most important surgeon in the hospital is doing it," Trabuenca says. "The era when the surgeon was a superstar and everyone needed to serve that person is gone."

And so far, the plan at Riverside County Regional Medical Center  seems to be working.

Surgical site infections have plummeted about 76 percent since 2010, from unacceptable to slightly below national and state surgical site infection rates. 

Hospital officials say there is plenty more room - and plenty more plans - for improvement, but the medical center’s achievements are getting noticed. 

The hospital this past fall  won a 2013  statewide innovation award from the California State Association of Counties, as well as an invitation to share its new protocols with the American College of Surgeons in Washington DC. 

"Improvement is sometimes a very complex, complicated process," said Dr. Clifford Ko,  director of the Division of Research and Optimal Patient Care at the American College of Surgeons. "And so anytime a hospital is able to improve on something like SSI, we like to learn from them and see what they did and share their successes and their experiences with everyone else."