Several variables in operating room preparation and patient care have been evaluated for their roles in the pathogenesis of SSI. Once surgical intervention is planned, the appropriate evidence-based steps must be taken to minimize risk of developing an infection.

Prior to bringing the patient to the operating room, the appropriate antibiotics must be selected and given. Most patients undergoing orthopedic surgery will receive adequate prophylaxis with a first-generation cephalosporin (cefazolin) or vancomycin if patients have a penicillin allergy or other documented adverse reaction to penicillins and/or sulfa drugs (Classen, Pavel Prokuski, Hill, Burnett) [135–138]. Antibiotics should be continued for less than 24 h postoperatively but have not shown increased benefit when given for a longer duration [139]. Antibiotics should be redosed intraoperatively if surgery lasts longer than 3–4 h [2]. Hair removal has shown no benefit in infection prevention, and the studies available for review are of poor quality [140].

Factors believed to contribute to infection inside the operating room can be difficult to control for, at times, and studying these factors is oftentimes unethical. Infection prevention in the operating room begins from the second the patient is brought back to the operating room with standard precautions including handwashing between patients and use of gloves. One frequent source of infectious organisms is the patient’s own skin flora. Prevention with adequate skin prep has been studied. A pre-scrub is helpful to mechanically remove bacteria from the skin, as well as to debride any sloughing skin or debris. With regard to formal skin prep, some studies support the use of 2% chlorhexidine gluconate and alcohol solutions as compared to povidone-iodine or alcohol, whereas others show no difference in infection rates [124, 141–143]. In one meta-analysis, chlorhexidine preparation was associated with significantly fewer SSIs and fewer positive skin culture results, and switching to chlorhexidine even led to a cost savings of approximately $400,000/year [144]. Another study showed that ChloraPrep (chlorhexidine and alcohol) was most effective for eliminating bacteria preoperatively in foot and ankle surgery [145]. Available hand antiseptic agents for surgical team scrubbing include alcohol rubs with or without additives, chlorhexidine gluconate, iodine/iodophors, and phenol compounds. Results of studies comparing various agents are variable based on the study, but a recent Cochrane review demonstrated no difference in infection rates but did show a decreased bacterial load on hands with CHG [146]. Other practices such as irrigation with antibiotics or other additives, irrigating with high-pressure systems, using special iodine-impregnated drapes may or may not decrease bacterial burden and reduce infection rates [2].

Meticulous surgical technique should be emphasized and clearly shows benefit in diminishing bacterial load in surgical wounds. Maintaining hemostasis, preventing hypothermia, gentle handling of tissues, removing devitalized tissues, and appropriately using drains and other foreign bodies are all techniques that should occur. Considering the association of surgical time with development of surgical site infection, surgical skill and experience plays a role in decreasing surgical times [147]. While vancomycin powder has demonstrated some effectiveness in the spine surgery literature, there is no clear benefit in orthopedic surgical wounds otherwise [148]. At the conclusion of surgery, a sterile dressing must be applied to incisions prior to removal of sterile drapes.

Environmental and equipment factors can also contribute to infection rates. Proper cleaning of operating room surfaces, gowning and gloving with sterile supplies, and careful sterile draping technique should be routined in all cases [140]. Operating room traffic is a factor that has been clearly associated with increased infection rates in the literature and therefore should be kept to a minimum [140, 149–151]. In orthopedic surgery, double gloving is recommended. All members of the surgical team should be aware of appropriate antiseptic technique s and should be aware of activity in the operating room to minimize missed contamination events. Instruments should all be sterilized with a full cycle of sterilization in the sterile processing department, and flash sterilization should be avoided [124, 152].

As discussed earlier, less than 24 h of perioperative prophylactic antibiotics is considered standard in most major orthopedic surgical procedures, based on available literature demonstrating clear benefit with reduction in postoperative surgical site infection . Careful wound management at follow-up should be encouraged to monitor for any early signs of infection or breakdown. Soft tissues should be monitored for development of hematoma, especially in patients who are on anticoagulation for any reason. Sterile dressings should remain in place for a few days postoperatively to allow bridging tissue to form as a barrier to infection and any wound examinations or dressing changes should be preceded by handwashing and glove use. Prolonged soaking in water should be avoided for a few weeks after surgery. Sutures and staples should be removed only after the incision has healed fully, to prevent dehiscence.

Some studies have associated postoperative blood transfusion with increased rates of SSI [153, 154]. Glycemic control should be emphasized postoperatively with close monitoring of finger-stick blood glucose levels and appropriate treatment. Physical therapy and balance training should be initiated early to minimize risks of falls [2].

In addition to surgical site infection, other infectious processes that geriatric patients are susceptible to in the postoperative period should be avoided as best as possible. With prolonged bedrest and respiratory splinting secondary to surgical and fracture pain, patients are susceptible to pneumonia. Any atypical postoperative fevers in combination with respiratory symptoms such as productive cough and dyspnea should be evaluated with a chest X-ray and cultures as indicated. Incentive spirometry should be encouraged to minimized development of atelectasis. Perioperative Foley catheter use should be discontinued as soon as possible to minimize risk of urinary tract infection. In patients who require antibiotics for longer than the typical 24 h duration, antibiotic associated colitis and Clostridium difficile infections are of particular concern. The development of any type of infection in the postoperative period can be a devastating complication that can severely impact the outcome of surgical intervention and patient recovery.

In an ongoing effort to improve functional outcomes and decrease costs associated with hip fractures in the growing elderly population, physicians and researchers need to critically assess the current available evidence and studies on quality improvement. The literature needs to evaluate outcome measures that accurately reflect true patient results in order for the data to be useful in shaping improvement strategies. While clinicians focus on improving patient outcomes, hospital administration uses patient outcome data to screen for inefficiencies that can be improved with process adjustments. This, in turn, leads to cost savings, through value analysis. In this respect, clinicians tend to define health measures in line with the International Classification of Functioning, Disability and Health and health-related quality of life definitions. Administrators, from a business perspective, focus more on the cost-to-benefit analyses related to health-care and patient outcomes, as the result of the health-economic pressures of an aging population. Therefore, improving the outcomes we measure in collecting data with regard to geriatric hip fractures can lead to better quality research and improved quality of care.

Most of the research available for review currently evaluates patient outcomes with two types of measures: performance-based measures and subjective patient self-reported measures. The properties that characterize effective outcome measures are reliability, validity, sensitivity to change, and responsiveness [155]. Latham et al. have shown that both types demonstrate validity and sensitivity when improvement in function is a primary endpoint [156]. Therefore, in addition to complication rates and mortality, the measures discussed above can be useful in analyzing patient data, and subjective patient results can be used in outcomes analysis.

In evaluating the usefulness of quality improvement interventions, such as the institution of a geriatric fracture center care model, appropriate outcomes must be used to identify strengths and weaknesses of such programs. A recent literature review reported the most frequently used clinical outcomes in evaluating these care models as in-hospital mortality, length of stay, time to surgery, place of residence, and complication rates [157]. The most common patient-reported outcomes were activities of daily living and mobility scores. The authors of that study reported what they felt to be the most useful outcome parameters and the assessment tools best suited to evaluate each parameter [157]. Regardless of what researchers feel are the best measures to use, there must be an agreement on which parameters should be analyzed, so that conclusions can be drawn across many different centers in many different geographical regions and internationally [158]. In order to build support for changing the established paradigm in geriatric fracture management, the evidence must be concrete in support of new, more efficient care models.

The Joint Commission has developed a disease-specific care certification to evaluate health-care agencies that provide care for patients with specific medical problems. With respect to orthopedic care, they provide certifications that represent an approved level of quality of care for problems ranging from low back pain to fragility fracture, hip fracture, and osteoporosis [159]. The commission suggests that certification not only standardizes care but also provides an objective assessment of clinical care of specific disease processes. Certification is obtained through site visits and program reviews to identify revisions to current program structures and ensure that clinical practice guidelines are followed to maximize highlighted performance measures. Certification benefits hospitals by facilitating marketing and improving community confidence in hospital care.