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Preventing Surgical
Site Infections
Objectives
• Review microbiology basics of bacteria
• Review infection control measures for
isolation patients
• Hand hygiene importance
• Surgical Site Infection(SSI) surveillance
• OR nurses role in SSI prevention
• Discuss cleaning and disinfecting
Staphylococcus aureus
• Gram-positive cocci, facultative anaerobe
• Frequently found as part of the normal skin flora and in
nasal passages
• Most common species to cause Staph infections –
successful at evading the immune system
• Often the cause of surgical site infections
• Spread of S. aureus is generally through human-tohuman contact
Streptococcus
• Gram Positive, non-spore forming.
• Group A Strep common in necrotizing fasciitis.
• Part of normal skin flora.
Most bacteria in the OR environment are shed from the
skin of perioperative personnel.
Enterococcus spp.
• Gram positive cocci, often occur in pairs or short
chains, facultative anaerobes
• Common organisms in the GI tract
• High level of intrinsic antibiotic resistance
• Found in SSI, UTI,
bacterial endocarditis
& septicemia.
• Vancomycin-Resistant
Enterococcus (VRE)
Escherichia coli
• Gram negative rod, facultative
anaerobe
• Harmless strains are part of GI
flora
• Responsible for ~90% of UTIs
Mycobacteruim Tuberculosis
• Non spore-forming bacillis
• Can infect almost any tissue
including skin, bone, lymph
nodes, intestine.
• Spread through upper
respiratory tract and dispersed
through the body by
macrophages.
• Patients without active
infection are not infectious
Multi-Drug Resistant Organisms
Gain resistance to antibiotics by:
• Mutations
• Sharing resistance genes
• Inherent resistance
Vancomycin-Resistant Enterococcus (VRE)
• VRE can be carried by healthy people
• The most commonly transmitted by the contaminated
hands of healthcare workers
• Can remain viable in the environment for extended periods
- Resistant to desiccation and temperature extremes
Patients actively colonized or
infected must be in contact
precautions
MRSA
• Any strain of Staphylococcus aureus that has developed
resistance to beta-lactam antibiotics
• Does not mean it is more virulent, however it is more
difficult to treat with standard antibiotics
• Healthcare provider-to-patient transfer is common,
especially when hand hygiene is poor
Patients actively colonized
or infected must be in
contact precautions
Colonized patients represent the major reservoir of MRSA
Infected
Colonized
Countries that actively seek out and isolate MRSA colonized
patients have very low rates of MRSA transmission
Creutzfeldt-Jakob Disease
• Transmissible spongiform
Encephalopathy
• Disease causing organism is
prion
• Can be hereditary or occur
spontaneously
• 1% of cases are transmitted
person-person, requires CNS tissue
contact for transmission.
• Resistant to conventional heat and
chemical methods of sterilization.
• Special sterilization practices or use of
disposable instruments a must.
Do all health care workers “carry” MRSA?
• 4-6% of HCW colonized w/MRSA (2014)
– As opposed to about 1% of general population
– Not colonized does not mean you can’t transmit
MRSA
– Nor does it mean you cannot become colonized
Chain of Infection
Causative Agent
Susceptible Host
MRSA
Surgical, dialysis,
cancer patient
Portal of Entry
Central line, wound,
ventilator
Reservoir
Skin, wound, urine
Portal of Exit
Mode of
Transmission
Hands, equipment
Secretions,
cough, drains
• The body’s defenses are compromised during
surgery
• External barriers- skin
• Inflammatory response
• Immune response
Environment of Care
An OR is more than just a room where everyone
has a cool hat.
• Surgical department is semi-restricted
• Scrubs, Hat, Booties
• An open OR is a restricted Environment
• scrubs, hat, mask, and Booties
• Temp 68-73 degrees
• Humidity 30-60%
• Smooth surfaces, easily wiped clean
Environment of Care ctd.
AIRFLOW
• OR suites arranged around a
sterile core
• Airflow from core to rooms to
hallways (positive air pressure in
OR relative to hallways)
• 15 air exchanges per hour
• Nurse controls movement
through and around the OR
• Best Practice: enter through
core when open.
Transmission-Based Precautions
• Contact
- Spread through direct or indirect contact
- MRSA, ESBL, VRE, C. diff., RSV, Shingles
- Place signs on OR doors, notify
housekeeping personnel.
-Don’t forget PACU
-Terminal clean after case.
“When transport or movement in any healthcare setting is necessary, ensure
that infected or colonized areas of the patient's body are contained and
covered.”- CDC
Transmission-Based Precautions
• Droplet
- Airborne particles larger than 5 microns do
not remain suspended in the air for long
periods
- 3 foot rule, mask patient (unless intubated)
- Bacterial meningitis, influenza, B. pertussis
-Use door signs and terminal clean room
-Transport same as contact precaution but
with surgical mask on the patient.
-Don’t forget PACU
Airborne Precautions
If an OR must be positively pressurized to protect our
patients, how do we handle TB patients?
– Gold Standard is a negative pressure anteroom
If that isn’t available…
– Intubate/Extubate in a negative pressure room and
transport using a ventilator with HEPA filter.
What if it’s an Airway case?
– Wear N95 mask while in the OR
– Keep OR closed for min 28 minutes following case
– Keep doors closed during case
– Supplemental air cleaning with portable HEPA
– Don’t forget…
Contact Enteric
-Hand washing on room egress with soap and water.
May use alcohol based hand sanitizer on entry.
-All environmental cleaning to be done with bleach
based products.
-Must be transferred or discharged and room
terminally cleaned with bleach before resolution of
contact enteric precautions.
-C diff, norovirus.
Hand Hygiene
•
Hands contaminated with transient bacteria
are a primary means for transmission leading to infection.
Transient flora are microorganisms that colonize the
superficial layers of the skin. These are acquired by HCW while
caring for patients and from coming into contact with
contaminated surfaces where patients reside.
•
Hands with broken skin are more susceptible to
becoming colonized with transient bacteria, including
MDROs.
An outbreak involved a cardiac surgeon’s infected
fingernail. When cultured, it grew Psuedomonas aeruginos. Two
patients treated by the surgeon developed a surgical site infection
with the same strain of P. aueruginosa. (AORN Guidelines 2012)
Hand Hygiene
• Short fingernails are a must. Longer nails have
increased bacterial load, are harder to keep clean.
• No Artificial nails of any kind
• No fingernail polish, gel nails or overlays.
• Chipped nail polish harbor bacteria and can cause
gloves to rip.
• No rings! There is a strong link between wearing rings
and hand contamination. (AORN Guidelines, 2012)
Hand Hygiene
• Skin irritation, dermatitis from frequent hand
washing is common. Use plenty of lotion to
keep skin intact. ONLY use hospital provided
lotion.
• If you have cuts, abrasions, weeping
dermatitis on exposed skin you should NOT be
providing direct patient care. You are at risk
for acquiring and transmitting infection.
Surgical Hand Antisepsis
Persistent antimicrobial activity is important
Alcohol has no persistent effect, CHG is most effective
Remove all jewelry
Remove all debris from under fingernails under
running water
Scrub hands and forearms for the recommended time
(3-5 minutes, depending on product guidelines)
Scrubs longer than the manufacturers guidelines are
unnecessary
HAND HYGIENE
THE SINGLE MOST IMPORTANT MEASURE TO PREVENT THE
TRANSMISSION OF INFECTION
Partnering to Heal | HHS.gov
Break?
Surgical Site Infections (SSIs)
Surgical Site Infections…
Account for14-16% of all nosocomial infections among
hospitalized patients
Account for 38% of nosocomial infections among surgical
patients
Occur in 2-5% of extra-abdominal
operations, and 20% of intraabdominal operations
Cost an average of $25,546 per
affected patient
Are preventable!
Patient
• Diabetes
• Morbid obesity
• Nicotine use
• Steroid use
• Malnutrition
• Prolonged preoperative hospital stay
• Comorbidities
• Perioperative transfusion
• Immunosuppressive therapy, neutropenia
Factors
Surgical Site Infection Surveillance
•
•
•
•
•
•
•
•
Total knee replacements
Total hip replacements
Laminectomy
Fusion
All cardiac with open chest
C-section
Colectomy
Abdominal hysterectomy
Defining Surgical Site Infections
RUBOR, CALOR, TUMOR, DOLOR. FLUOR ET
Superficial Incisional SSI
• Occurs within 30 days of surgery
• Involves skin or subcutaneous tissue
• Patient has at least one of the following:
i. Purulent Drainage
ii. Identified organisms
iii. Pain/tenderness, edema, redness or heat
iv. Opened by the surgeon , and culture positive or not
cultured
v. Diagnosed by the surgeon or attending physician
Deep Incisional SSI
• Occurs within 30 or 90 days after surgical procedure
AND
• Involves deep soft tissues (fascial and muscle layers)
AND
• Patient has at least one of the following:
i.
ii.
iii.
iv.
Purulent drainage
Incision spontaneously dehisces or is opened by surgeon and is
culture positive or not cultured, and the patient has fever or
pain/tenderness
Abscess found on direct exam, during re-op, or by examination by
histopathology or radiology
Diagnosis by surgeon or attending physician
Organ/Space SSI
• Occurs within 30-90days of surgery
• Involves any part of the body (excluding
skin, fascia, or muscle layers)
• One of the following symptoms:
i.
ii.
iii.
iv.
Purulent drainage
Incision spontaneously dehisces or is opened by
surgeon and is culture positive or not cultured,
and the patient has fever or pain/tenderness
Abscess found on direct exam, during re-op, or by
examination by histopathology or radiology
Diagnosis by surgeon or attending physician
And meets at least one criteria for site below.
Code
Site
Code
Site
BONE
Osteomyelitis
MED
Mediastinitis
BRST
Breast abscess or mastitis
MEN
Meningitis or ventriculitis
CARD
Myocarditis or pericarditis
ORAL
Oral cavity (mouth, tongue,
or gums)
DISC
Disc space
OUTI
Other infections of the
urinary tract
EAR
Ear, mastoid
OREP
EMET
Endometritis
ENDO
Endocarditis
Other infections of
the male or female
reproductive tract
EYE
Eye, other than conjunctivitis
PJI
Periprosthetic Joint Infection
GIT
GI tract
SINU
Sinusitis
HEP
Hepatitis
SA
JNT
Joint or bursa
Spinal abscess without
meningitis
IAB
Intraabdominal, not specified
UR
Upper respiratory tract
IC
Intracranial, brain abscess or
dura
VASC
Arterial or venous infection
LUNG
Other infections of the
respiratory tract
VCUF
Vaginal cuff
Preoperative Prevention Strategies
SCIP (Surgical Care Improvement Project)
Measures to Prevent Infections:
FYI….100% compliance with SCIP measures is essential
for complete re-imbursement by CMS
•Administer the appropriate prophylactic antibiotic within
one hour prior to surgical incision for included surgeries
•CABG, Cardiac or Vascular procedures
•Hip/Knee Arthroplasty
•Colon
•Hysterectomy
•Discontinue prophylactic antibiotics within 24 hr of
surgery end time (48hours for cardiac patients).
Perioperative Prevention Strategies
SCIP (Surgical Care Improvement Project)
Measures to Prevent Infections:
• Glucose Control
• Control serum glucose in cardiac surgery
patients < 200mg/dl @ 0600 post-operative days
1 and 2
• Hair Removal
• Use national guideline approved method for
surgical site hair removal
• Avoid shaving with razors
• Use clippers
Preoperative Prevention Strategies
SCIP (Surgical Care Improvement Project)
Measures to Prevent Infections:
• Ensuring Normothermia
Perioperative hypothermia occurs when a patient’s core
body temp falls below 36 C and is associated with
increased SSIs, longer hospital stays, and other negative
outcomes
Use warming devices to ensure patient
temp >36 C in or near the OR and upon arrival to
PACU
• Foley Catheter Removal
Urinary catheter removed on Postoperative Day 1
(POD 1) or Postoperative Day 2 (POD 2) with day of
surgery being day one
Cleaning and Disinfecting
“The responsibility for verifying a clean surgical
environment rests with perioperative nurses.”
•OR RN should assess the environment frequently
for cleanliness and take action where needed
•All flat surfaces should be damp dusted before the
first scheduled procedure of the day
•OR suites should be cleaned after each procedure
•Damaged or worn coverings need to be discarded
and replaced
•Patient transport devices, including straps and
attachments need to be cleaned after each use
Remember that you are the
patient’s advocate!
It’s your job to ensure the team is
adhering to aseptic practices, and
that you safeguard your patients privacy
and ensure their safety.
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