Download Continuing the fight in reducing the risk of surgical site

Continuing the fight in reducing the risk of surgical site infections in
the perioperative environment
Leonard, L. (2016). Continuing the fight in reducing the risk of surgical site infections in the perioperative
environment. Journal of Perioperative Practice, Procurement Guide 05(02), 6-11.
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Download date:03. May. 2017
06
Journal of Perioperative Practice
PROCUREMENT GUIDE
May 2016
Volume 05 Issue 02
www.afpp.org.uk
Infection Prevention
Continuing the fight in reducing
the risk of surgical site infections
in the perioperative environment
Assessing risk has become part of the process of supporting patients and
maintaining safety in the healthcare setting. The risk of healthcare associated
infections (HCAIs) has long been well documented and surgical site infection (SSI)
is recognised as one of the most prevalent (Tanner & Khan 2008, Wilson 2013a).
SSIs arise when sufficient
microorganisms enter the surgical
site to overwhelm the host’s
natural defence mechanisms
(PHE 2014). In the UK, the Health
and Social Care Act 2008 Code
of Practice for the prevention
and control of HCAIs (DH 2015)
emphasises the responsibility of
care providers to make suitable
and sufficient assessment of
the risk to patients with respect
to HCAIs. The National Patient
Safety Agency (2004) also
highlighted the importance of risk
assessment when it published
“Seven Steps to Patient Safety”.
These steps included the need to
integrate risk-management activity
and implement solutions to
prevent harm. Throughout many
healthcare facilities, including the
perioperative area, many initiatives
have been taken to reduce the
harm arising as a result of HCAIs
and in particular SSIs.
In Scotland significant
improvements in reducing HCAIs
between 2003 and 2010 have
been reported (Wilson 2013b).
Public Health England (2015) also
reported a significant decrease in
SSI incidence occurring following
surgery for repair of neck of
femur, between 2008 and 2014,
and a decreasing trend for SSIs
following gastric surgery. However
the risks of SSIs are still a cause
for concern (Srejic 2015). Health
Protection Scotland (2013) and
The Northern Ireland (NI) Public
Health Agency (2014) report that
while significant advances in
infection control practices within
Health Protection
Scotland (2013)
and The Northern
Ireland (NI) Public
Health Agency
(2014) report that
while significant
advances in
infection control
practices within
operating rooms
have been made,
SSIs remain a
substantial cause
of morbidity and
mortality.
operating rooms have been made,
SSIs remain a substantial cause of
morbidity and mortality.
Richmond (2009) cautions
against complacency with regard
to infection control practice
within operating departments.
As part of the effort to reduce
risks, staff must be able to
identify and separate potential
sources of infection (Pyrek 2002).
Understanding the chain of
infection and how to implement
strategies to disrupt this chain
is imperative if the incidences
of SSIs are to be reduced. This
involves analysing how infectious
agents can be transmitted,
the susceptibility of patients to
infection and the implementing of
infection prevention and control
precautions while continuing
to provide for the individual’s
healthcare needs.
There are six links to the chain
including the causative agent,
the reservoir of infection, portal of
exit, mode of transmission, portal
of entry and the susceptible host
(Damani, 2010). At any time if a
link in this chain is broken then the
infection risk will be minimised.
Tanner and Khan (2008) and
Wilson (2013a) outline a number
of sources of SSI risks within
the perioperative area to include
the patient, the environment
and the staff. Particular factors
determining the infection risk in an
operating suite are the duration
and complexity of the surgical
procedure itself, the number of
people in contact throughout, the
patient’s state of health, such as
pre-existing immune deficient
conditions, and the nature of the
microorganism and its route of
transmission.
Not all the organisms cause
HCAIs but most often
responsible for SSIs are the
patient’s endogenous flora
and the bacteria most often
associated with SSIs are
Staphylococcus, Enterococcus
and Escherichia coli (Owens &
Stoessel 2008, Tanner & Khan
2008). According to Chen
et al (2013) staphylococcus
aureus is the most common
organism responsible for SSIs.
Staphylococcus aureus is a gram
positive bacteria and can be
frequently found as a commensal
organism on the surface of human
skin. Public Health England (2015)
reports that staphylococcus
aureus accounted for 13%
of inpatient SSIs in 2014/15
following a decreasing trend
from 2006. Methicillin-resistant
S. aureus (MRSA) accounted
for 25% of SSIs and had
decreased markedly since 2006.
However Enterobacteriaceae
SSIs increased from 2008 and
accounted for 25% in 2014.
There are two identified
routes of transmission of such
microorganisms; through direct
contact, or through indirect
contact. Direct contact as the
name implies consists of bodily
contact with the bacteria and
a physical transfer from the
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08
Journal of Perioperative Practice
PROCUREMENT GUIDE
May 2016
Volume 05 Issue 02
www.afpp.org.uk
>> infected source to the host.
Indirect contact occurs when
an agent is carried from a
reservoir (the source of infection)
to a susceptible host without
direct contact with the source.
In the operating environment
there are many surfaces that
can be contaminated with
microorganisms such as
dressing trolleys, door handles,
keyboards, and soap dispensers
(Pellowe 2007). Microorganisms
can also be dispersed
from contact with unsterile
instruments, inadequately
decontaminated endoscopes
and surgical accessories.
Humphreys (2009) outlines
three broad classifications of
interventions in the control of
SSIs to include interventions
before surgery, during surgery
and following surgery. In
2014 NICE reviewed the 2008
Infection Prevention
infection control guidelines
based on the latest available
evidence and published
recommendations for clinical
practice for minimising risks
to patients. The key elements
of these revised guidelines are
summarised under the headings
of preoperative, intraoperative
and postoperative phases.
Although the 2008 NICE
guidelines recommended
topical skin decontamination
of staphylococcus aureus to
routinely prevent surgical site
infection the 2014 revised
guidelines recommend that in
the preoperative phase, patients
who are undergoing planned
surgery should be advised to
shower or bathe with soap on
the day before or day of surgery.
The removal of hair from the
area of the operative site has
been a tradition but NICE
(2014) does not recommend
the routine removal of hair.
This is in line with earlier
recommendations by Owens
and Stoessel (2008) who
suggest that hair removal
should be avoided unless
it might interfere with the
surgical procedure. Tanner
et al (2011) compared hair
removal (shaving, clipping,
or depilatory cream) with
no hair removal and found
no statistically significant
difference in SSI rates. In
cases where hair removal is
necessary the current NICE
recommendation is that this
should be done with single
use headed electric clippers
and should be performed
on the day of surgery. As
in previous guidance, and
guidance elsewhere, the use
of razors is advised against
due to the risk of small incisions
(Tanner & Khan 2008).
Although Kallen et al (2005)
have claimed a reduction
in SSI rates following nasal
mupirocin application, the NICE
2014 guidance recommends
against the routine use of
such antimicrobial nasal
decontamination preparations.
Anderson (2014) also highlights
that it is now recognised that
mechanical bowel preparation
do not reduce the risk of SSI,
this is reflected in the NICE
guidelines which advises
against the routine use of
mechanical bowel preparation.
The use of prophylaxis
antibiotics is also advised
against in routine clean nonprosthetic uncomplicated
surgery, but further detailed
guidance in the use of
antibiotics is given for various
types of surgery.
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09
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The current NICE guidelines
(2014) reiterate the importance
of hand decontamination,
recommending hand washing
with antiseptic surgical solutions
prior to the first operation and
use of either alcoholic hand rub
or antiseptic surgical solutions
before subsequent operations.
The recommendations also
suggest that skin at the surgical
site should be prepared using an
The removal of
hair from the area
of the operative
site has been
a tradition but
NICE (2014) does
not recommend
the routine
removal of hair.
antiseptic solution. Solutions
such as chlorhexidine gluconate
in a 2% solution are effective
against a wide variety of skinborne pathogens (Edmiston et
al 2013).
Gloves protect against contact
with infectious materials. NICE
recommend the consideration
of two pair of sterile gloves
when there is a high risk of
glove perforation. Cicconi
et al (2010) argue that this
practice reduces the risk of
occupational exposures for
healthcare workers and the risk
of SSIs for patients. Al Maqbali
(2014) reviewed a number of
trials which compared single
gloves with double gloves for
numbers of perforations. There
was some evidence that the
use of double gloving reduces
the risk of the innermost glove
being perforated. However as
Al Maqbali (2014) highlight the
longer duration of surgery, the
bacteria count on the hands of
surgical teams increases, as
does the number of perforations.
Once contaminated, gloves can
become a means for spreading
micro-organisms.
The way gloves are used can
influence the risk of infection
transmission. Incorrect use
of clinical gloves and failure
to change them between
procedures increases the risk
of cross-transmission (Loveday
et al 2014). Humphreys (2009)
highlighted how compliance
with preventative measures
and guidance is often poor.
A Regulation and Quality
Improvement Authority (RQIA)
2014 report of theatre practice
in Northern Ireland Healthcare
Trusts, found poor practice in
the use of gloves with some
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Hand hygiene is the cornerstone
of infection control and in
both the preoperative and the
intraoperative phase. Widespread
guidance is available for the
moments when hand hygiene
should be performed and these
include before performing
invasive procedures and between
procedures on the same patient
where soiling of hands is likely
to cause cross-contamination of
body sites.
Infection Prevention
>>
10
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PROCUREMENT GUIDE
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>> staff failing to wash hands
before or after donning gloves,
and excessive use of gloves
when there was no identifiable
clinical need (RQIA 2014).
If gloves become torn or
heavily soiled and additional
patient care tasks must be
performed, then change the
gloves before starting the next
task. Gloves should always
be changed after use on each
patient and be discarded in
the appropriate receptacle.
Hand decontamination should
also occur immediately after
removing gloves.
The use of physical barriers,
including incise drapes and
sterile gowns, to reduce SSI
is a long-standing practice in
the operating environment.
The use of surgical incise
drapes to protect the wound
Infection Prevention
from organisms is one strategy
used to prevent SSIs. They are
considered to provide a sterile
barrier to bacteria migrating
to the wound and creating an
SSI (Evans 2012). However
there have been conflicting
conclusions regarding their
value with regard to reduction
of SSIs. Webster and Alghamdi
(2013) caution that there are
conflicting results from nonrandomised studies about
the efficacy of this approach,
and that no systematic review
has been conducted to date
to guide clinical practice.
The antimicrobial efficacy
of an iodine-impregnated
incise drape against MRSA
was evaluated in Casey et al
( 2015) who found that the
iodine impregnated drape
demonstrated high antimicrobial
activity. The current NICE
guidelines recommend against
the use of non-iodophor
impregnated incise drapes for
routine surgery. However the
effectiveness of the use of such
drapes may be affected by
drape lift or drape pull-back from
the wound edge allowing skin
organisms to contaminate the
wound (Evans 2012).
SSIs have been seen as a key
performance indicator in the
delivery of high quality care and
will continue to be so. Adherence
to the NICE guidance and to
the latest evidence will help to
minimise the risks. Ongoing
surveillance and review of
practice will play an important
role in this fight but individual
practitioners must also reflect
on their own practice and
identify risks of infections in the
perioperative environment.
References
Al Maqbali M 2014 Using
double gloves in surgical
procedures: a literature review
British Journal of Nursing 23
(21) 1117 -1122
Anderson DJ 2014 Prevention
of surgical site infection:
beyond SCIP AORN Journal 99
(2) 315-319
Casey AL, Karpanen TJ,
Nightingale P, Conway BR,
Elliott TSJ 2015 Antimicrobial
activity and skin permeation
of iodine present in an
iodine-impregnated surgical
incise drape The Journal of
Antimicrobial Chemotherapy
70 (8) 2255-60
Chen A, Wessel C, Rao N
2013 Staphylococcus Aureus
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11
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Screening and Decolonization
in Orthopaedic Surgery and
Reduction of Surgical Site
Infections Clinical Orthopaedics
and Related Research 471 (7)
2383-2399
Cicconi L, Claypool M,
Stevens W 2010 Prevention of
Transmissible Infections in the
Perioperative Setting AORN
Journal 92 (5) 519-527
Damani N 2012 Manual of
Infection Prevention and Control
Oxford University Press: Oxford
Department of Health 2015
The Health and Social Care
Act 2008: code of practice on
the prevention and control of
infections and related guidance
[online] https://www.gov.uk/
government/uploads/system/
uploads/attachment_data/
file/449049/Code_of_
practice_280715_acc.pdf
[Accessed April 2016]
Edmiston CE, Bruden B,
Rucinski M, Henen C, Graham
MB, Lewis 2013 Reducing the
risk of surgical site infections:
does chlorhexidine gluconate
provide a risk reduction benefit?
American Journal of Infection
Control 41 (5 Suppl) 49-55
Evans RP 2012 Incise drape
adhesion and the adherence
to principles of surgical site
infection prevention Journal
of Bone and Joint Surgery
94 (13) [online] http://jbjs.
org/content/94/13/e99.long
[Accessed April 2016]
Gillespie BM, Kang E, Roberts
S, Lin F, Morley N, Finigan T,
Homer A, Chaboyer W 2015
Reducing the risk of surgical site
infection using a multidisciplinary
approach: an integrative review
Journal of Multidisciplinary
Healthcare 8 473–487
Health Protection Scotland 2013
Surgical Site infection surveillance
protocol 6th edition NHS National
Services Scotland [online]
http://www.documents.hps.scot.
nhs.uk/hai/sshaip/guidelines/
ssi/ssi-protocol-6th-edn/
Infection Prevention
SSI-Protocol-6th-Edition.pdf
[Accessed April 2016]
Humphreys H 2009 Preventing
surgical site infection. Where
now? Journal of Hospital
Infection 73 (4) 316-322
Kallen AJ, Wilson CT, Larson RJ
2005 Perioperative intranasal
mupirocin for the prevention
of surgical-site infections:
systematic review of the
literature and meta-analysis
Infection Control Hospital
Epidemiology 26 (12) 916–922
Loveday HP, Lynam S, Singleton
J, Wilson J 2014 Clinical glove
use: healthcare workers’ actions
and perceptions Journal of
Hospital Infection 86 (2)110-116
National Patient Safety Agency
2004 Seven steps to patient
safety [online]
http://www.nrls.npsa.nhs.uk/
EasySiteWeb/getresource.
axd?AssetID=59971&
[Accessed April 2016]
National Institute for Health and
Care Excellence 2014 Surgical
site infections: prevention and
treatment [CG74} (revised)
[online] https://www.nice.org.uk/
guidance/cg74 [Accessed April
2016]
Owens CD, Stoessel K 2008
Surgical site infections:
epidemiology, microbiology and
prevention Journal of Hospital
Infection 70 (Suppl 2) 3-10
Pellowe C 2007 Standard
Principles: Hospital
Environmental Hygiene and
Hand Hygiene Nursing Times
103 (26) [online]
http://www.nursingtimes.
net/nursing-practice/clinicalzones/infection-control/
standard-principles-hospitalenvironmental-hygiene-andhand-hygiene/291499.article
[Accessed April 2016]
Public Health Agency (Northern
Ireland) 2014 Surgical site
infection surveillance protocol
[online] http://www.publichealth.
hscni.net/sites/default/files/
directorates/files/Generic_
SSI%20MANUAL_v2014_1.pdf
[Accessed April 2016]
Public Health England 2014
Surgical site infection (SSI:
guidance, data and analysis)
[online] https://www.gov.
uk/government/collections/
surgical-site-infection-ssiguidance-data-and-analysis
[Accessed April 2016]
Public Health England
2015 Surgical site infections
surveillance: NHS hospitals
in England, 2014/15 London,
Public Health England
[online] https://www.gov.uk/
government/publications/
surgical-site-infections-ssisurveillance-nhs-hospitals-inengland [Accessed April 2016]
Pyrek K 2002 Breaking the
Chain of Infection Infection
Control Today [online]
http://www.
infectioncontroltoday.com/
articles/2002/07/breakingthe-chain-of-infection.aspx
[Accessed April 2016]
Regulation and Quality
Improvement Authority 2014
Review of theatre practice in
Health and Social Care Trusts in
Northern Ireland [online]
http://www.rqia.org.uk/
cms_resources/RQIA_Theatre_
Overview_Report_Final_Web_
Version_ISBN.pdf [Accessed
April 2016]
Richmond S 2009 Minimising
the risk of infection in the
operating department: a
review for practice Journal of
Perioperative Practice 19 (4)
142-146
Srejic E 2015 Standard
Precautions the Cornerstone
of Effective Care Infection
Control Today [online] http://
www.infectioncontroltoday.
com/articles/2015/04/
standard-precautions-thecornerstone-of-effective-care.
aspx [Accessed April 2016]
Tanner J, Khan D 2008
Surgical site infection,
preoperative body washing
and hair removal Journal of
Perioperative Practice 18 (6)
232-242
Tanner J, Norrie P, Melen
K 2011 Preoperative hair
removal to reduce surgical site
infection Cochrane Database
of Systematic Reviews
Nov 9 (11) CD004122. doi:
10.1002/14651858.CD004122.
pub4.
Todar K 2014 Online Textbook
of Bacteriology: Staphylococcus
aureus and Staphylococcal
Disease [online] http://
textbookofbacteriology.net/
staph.html [Accessed April 2016]
Webster J, Alghaamdi A 2014
Use of plastic adhesive drapes
during surgery for preventing
surgical site infection Cochrane
Database of Systematic
Reviews, 2013, Issue 1
Wilson, J 2013a Surgical site
infection: the principles and
practice of surveillance: part 2:
analyzing and interpreting data
Journal of Infection Prevention
14 (6)198-202
Wilson J 2013b Surgical
site infection surveillance: a
Scottish perspective (20032010) Journal of infection
prevention 14 (1) 20-25
Laurence Leonard
Lecturer, School of Nursing
and Midwifery, Queens
University Belfast