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Practice development Innovations
Reducing surgical site infection in a
hospital in Singapore
Surgical site infection (SSI) is preventable and achieving zero SSI rates
for every clean operation should be the goal of all surgeons. This paper
describes one hospital’s strategy for reducing SSIs, enhancing the care of
patients and promoting a culture of patient safety. All clean and cleanAuthors.
Liau Kui-Hin, contaminated elective gastrointestinal and hernia operations were managed
Khin Thanda Aung using four specific interventions. SSI rates were compared to historical data.
Useful links and
further reading
Surgical Site Wounds and Suprasorb® X+PHMB:
Infection, prevention and treatment
References
1. Lee C, Ooi S, Tay E, Low A,
Teo S, Lau C, Tai B, Lim I, Lam
S, Lim I. Shortening of median
door-to-balloon time in primary
percutaneous coronary intervention
in Singapore by simple and
inexpensive operational measures:
clinical practice improvement
program. J Intervent Cardiol 2008;
21(5): 414–23.
2. Balthazar ER, Colt JD, Nichols
RL. Preoperative hair removal:
a random prospective study of
shaving versus clipping. South Med J
1982, 75(7): 799–801.
2. Seropian R, Reynolds BM. Wound
infections after preoperative
depilatory versus razor preparation.
Am J Surg 1971; 121(3): 251–4.
9
INTRODUCTION
The authors’ hospital has 1,440 beds, making
it the second largest public acute care
hospital with specialty centres in Singapore.
The clinicians’ expertise is well-supported
by state-of-the-art facilities and medical
equipment. The surgical department
is composed of upper gastrointestinal,
hepatobiliary, colorectal, vascular, urology
and trauma teams, each performing a wide
range of surgical operations [Fig 1].
Although there is evidence on preventing
surgical site infection (SSI) dating back to the
1970s, these practices were not standardised in
the hospital.
In 2006, the authors implemented an SSI
prevention project to improve the surgical
infection rate on elective gastrointestinal
and hernia operations in the hospital.
STRATEGY FOR CHANGE
The Clinical Practice Improvement Program
(CPIP) is a training programme for clinical
leaders aimed at improving the quality of
health care. It was developed by Wilson and
Harrison and was first implemented in New
South Wales, Australia, in 1999[1].
The hospital adopted this programme and
has used the CPIP to train clinicians since early
2000. During the planning stage of the CPIP
project, the team brainstormed all the risk
factors for SSI.
The risk factors were categorised and
summarised in a fish-bone diagram [Fig 2]. All
the staff involved in the project were given
the opportunity to vote on the top risk factors.
Staff participation in voting encourages
a deeper sense of project ownership and
improves motivation. A Pareto chart was
Wounds International Vol 2 | Issue 1 | ©Wounds International 2011
then used to identify and prioritise the most
important risk factors for intervention
planning [Fig 3]:
n
Skin preparation
n
Prophylactic antibiotic regimen
n
Routine glucose monitoring
n
Postoperative core temperature
monitoring.
IDENTIFIED INFECTION
PROBLEMS
Before the SSI project, surgical site hair
was removed with a razor by the operating
room attendants soon after anaesthesia had
been administered. However, this practice is
associated with increased SSI rate due to the
potential for micro-injuries to the skin, which
can predispose the skin to contamination
and infection[2, 3].
In addition, there was no standard
prophylactic antibiotic guideline in the
hospital. This meant that the choice of
prophylactic antibiotic was guided by the
preference of the surgeons. The timing
of prophylactic antibiotic administration
was also variable. As a way of combating
these inconsistencies, the following new
interventions were standardised and
implemented.
Skin preparation
Firstly, razors were replaced by electric
clippers when performing preoperative hair
removal. This is because shaving by razors
was a known risk factor for SSI[2,3]. Posters
were used to remind staff to use clippers
in the operating room, operating room
attendants were trained to use clippers,
Practice development
Page points
1. Surgeons, pharmacists and
the infection control team
were all involved in developing
a standardised prophylactic
antibiotic guideline
2. Where surgery was scheduled to last
for more than four hours or where the
estimated blood loss was expected
to exceed one litre, a repeat dose of
antibiotics was administered
and patients were instructed not to shave
themselves preoperatively.
All razors were removed from operating
rooms and the team worked with the
purchasing department to provide a
continuous supply of clippers.
Prophylactic antibiotic regimen
Surgeons, pharmacists and the infection
control team were all involved in
developing a standardised prophylactic
antibiotic guideline that was consistent
with international recommendations[4,
5]
. The guideline specifically stated
that antibiotics must be administrated
within 30 minutes of a surgical incision
as per the recognised evidence-based
practice for SSI prevention[6]. Classen et al
convincingly demonstrated that the SSI rate
is at its lowest point when antimicrobial
prophylaxis is administered within the first
hour of anaesthesia induction [6].
Where surgery was scheduled to last for more
than four hours or where the estimated blood
loss was expected to exceed one litre, a repeat
dose of antibiotics was administered as extensive
blood loss can dilute the prophylactic antibiotics
serum concentration and impair immunity.
The guideline was circulated to all
operating room staff and anaesthetists to
encourage compliance. Notices, proforma,
checklists and posters describing the
prophylactic antibiotic guideline were used
as reminders. The proforma and checklists
served to prompt clinicians and track their
compliance to the protocol as they signed
off when action was taken. The antibiotic
dosage was adjusted according to the
patient’s body weight. Medications were
stocked in the hospital according to the
standard drugs inventory.
Routine glucose monitoring
A mandatory glucose monitoring regimen
was introduced for diabetic patients. Post
Anaesthesia Care Unit (PACU) and ward
nursing officers were responsible for
monitoring and controlling diabetic patients’
postoperative blood glucose levels at sixhourly intervals to ensure that they were
kept below 11.1mmol/l.
Postoperative core temperature
monitoring
A target of keeping patients’ postoperative
core body temperature within the range of
36–38°C was set. Maintaining normothermia
has many benefits and has been shown to
reduce the risk of complications and cost.
Perioperative unplanned hypothermia is a
References
4. American Society of Healthsystem Pharmacists [ASHP]
Commission on Therapeutics.
ASHP therapeutic guidelines
on antimicrobial prophylaxis in
surgery. Clin Pharm 1992, 11(6):
483–513.
5. Waddell TK, Rotstein OD:
Antimicrobial prophylaxis
in surgery. Committee on
Antimicrobial Agents, Canadian
Infectious Disease Society. CMAJ
1994, 151(7): 925–31.
6. Classen DC, Evans RS, Pestotnik
SL, Horn SD, Menlove RL, Burke
JP. The timing of prophylactic
administration of antibiotics
and the risk of surgical-wound
infection. N Engl J Med 1992,
326(5): 281–6.
7. Melling A, Ali B, Scott E, Leaper D.
Effects of preoperative warming
on the incidence of wound
infection after clean surgery:
a randomised controlled trial.
Lancet 2001; 358(9285): 876–880.
11
Figure 1 – The authors’ team performing surgery in the operating room.
Wounds International Vol 2 | Issue 1 | ©Wounds International 2011
Reducing surgical site infection in a hospital in Singapore
Environment
Equipment
 Skill-mix
 nurse
 Physiotherapy
 Other patients
 Aseptic technique
 Cross-infection
 Attire
 Sequential compression device
 Drainage systems
(closed or open)
Infection
Sterilisation 
Surgical technique 
Operating time 
Drains 
Urinary catheter 
Clipping 
Temp monitoring 
Glucose monitoring 
Hair removal 
Prophylactic antibiotics 
 Selection
 Expectations
 Compliance
 Confusion
 Pressure ulcer
 Nutritional status
Patients
 Blood loss
 Drainage systems
 Storage of equipment
 Post-operative haematoma
 Dressings (time and type)
 Epidural insertion
1.
Unplanned hypothermia
increases the likelihood of
postoperative myocardial
infarction, admission to
intensive care units and
mortality rates
2.
Warmed intravenous (IV)
fluids, increased ambient
temperature in theatre and
the use of blankets during
surgical procedures can also
maintain normothermia
Practice development
 OT traffic/attire
 Post-operative, ie recannulation
 High-dependency unit
 Pre-operative, ie showers
Page points
Staff
Procedure
Figure 2 – Diagram demonstrating the risk factors for SSI.
RESULTS
risk factor for SSI and it correlates with the
occurrence of SSI[7, 8].
Unplanned hypothermia also increases
the likelihood of postoperative myocardial
infarction, admission to intensive care units
and mortality rates. Warmed intravenous
(IV) fluids, increased ambient temperature
in the hospital’s operating room and the
use of warming blankets during surgical
procedures can also maintain normothermia
in patients.
80
70
60
50
40
30
20
10
0
82%
92%
With the bundle of interventions described
above, the hospital’s overall SSI rate was
reduced year on year at the following rates:
n
3.1%in2005
n
0.7%in2006
n
0.4%in2007
n
1.1%in2008
n
1.2%in2009.
When compared with data from the
US’s National Nosocomial Infections
97%
98%
99%
100%
58%
tic
lac ics
y
h
t
p
Pro ntibio
a
e
cos
Glu oring
t
ni
mo
r
Hai al
ov
rem
re
atu
per toring
m
Te oni
m
ng
rati e
Ope tim
ptic
Ase ique
hn
tec
Figure 3 – Pareto chart demonstrating the most important risk factors for intervention planning.
c
traffi
T
O
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
References
8. Kurz A, Sessler D, Lenhardt R.
Perioperative normothermia to
reduce the incidence of surgicalwound infection and shorten
hospitalization. New Eng J Med
1996; 334(19): 1209.
9. NNIS. System Report: Data
summary from January 1992
through June 2004, issued
October 2004. Am J Infect Control
2004; 32(8): 470–85.
10. Edmiston CE, Seabrook GR,
Goheen MP, Krepel CJ, Johnson
CP, Lewis BD, Brown KR,
Towne JB. Bacterial adherence
to surgical sutures: can
antibacterial-coated sutures
reduce the risk of microbial
contamination? J Am Coll Surg
2006; 203(4): 481–9.
www.woundsinternational.com
12
Practice development Innovations
Surveillance (NNIS)[9] records, the hospital’s
SSI rates were lower than the NNIS mean SSI
rate of 3.4% for gastrointestinal and hernia
operations. (The NNIS is a collaborative
surveillance system that collects data on
nosocomial infections. The data is reported
voluntarily by participating hospitals to
estimate the magnitude of the nosocomial
infection problem in the US and to monitor
trends in infections and risk factors.)
GENERAL POSTOPERATIVE
WOUND MANAGEMENT
References
11. Rozzelle CJ, Leonardo J, Li
V. Antimicrobial suture wound
closure for cerebrospinal fluid shunt
surgery: a prospective, doubleReferences
blinded, randomized controlled
trial. J Neurosurg Pediatr 2008; 2(2):
4. ?????????????3.
111–17.
12. Fleck T, Moidl R, Blacky A,
Fleck M, Wolner E, Grabenwoger
M, Wisser W. Triclosan-coated
sutures for the reduction of sternal
wound infections: economic
considerations. Ann Thorac Surg
2007; 84(1): 232–6.
13
The postoperative care bundle is part of
the comprehensive wound management
programme that has the aim of reducing
SSI in the hospital. The following routine
practices are also employed by the surgery
department:
n
The routine laparotomy wound closure
involves mass closure of the wound
with PDS™ II (polydioxanone) suture
(Ethicon), a monofilament absorbable
suture. Subcuticular skin closure is
applied where aesthetics is an overriding
consideration
n
For clean and clean contaminated
wounds, the skin is apposed with either
metal staples (Proximate® Plus [Ethicon]
or Appose™ [Covidien]) or absorbable
staples (Insorb® [Incisive Surgical]).
Absorbable staples are preferred
to metal staples for skin apposition
because of their superior aesthetic
outcome. Additionally, they obviate
the risk of suture track infection and
inflammation. More studies are needed
to investigate the impact of absorbable
staples in SSI reduction
n
Early suture removal is preferred for
interrupted wound closure. Sutures and
staples are removed on the eighth day
postoperatively
n
Dressing using chlorhexidine
and normal saline for wound cleansing is
advised. In the authors’ hospital all laparotomy wounds are covered
with Opsite® Post-Op (Smith & Nephew)
before the reversal of anaesthesia. The dressing is left on for 48–72 hours postoperatively unless it becomes
soiled or soaked with blood. Thereafter,
the dressing is removed for wound
inspection and the wound is exposed. If the wound is clean, any further cleaning is performed Wounds International Vol 2 | Issue 1 | ©Wounds International 2011
n
with normal saline
If a deep SSI is suspected, Kaltostat®
(ConvaTec) or hydrogel dressings
are recommended. Clinicians in the
authors’ hospital are not currently using
antimicrobial dressings as antimicrobial
products are being progressively
introduced. However, the hospital is in
the midst of converting from the PDS II
suture (mentioned above) to the PDS™ II
Plus antibacterial suture (Ethicon), which
is impregnated with triclosan. The use of
antimicrobial dressings will probably be
the next phase.
THE FUTURE
The main focus for future implementation is to
produce a guideline for the use of antibioticimpregnated sutures. Preliminary data
demonstrates a reduction in SSI rates
with the use of antibacterial-coated sutures for
surgical wound closure. For instance,
in vitro studies using triclosan-coated
sutures demonstrate a considerable reduction
in bacterial adherence to the sutures[10].
The triclosan-coated suture was
also reported to be effective in reducing
cerebrospinal fluid shunt infection[11] as
well as sternal wound infection[12]. The
authors remain to be convinced of the use
of the antibacterial-coated suture
in abdominal wound closure as there is
limited data in the current studies. In light
of this, the authors’ team is planning to
conduct a randomised controlled trial
to answer this question before
full implementation.
AUTHOR DETAILS
Dr Liau, Kui-Hin, FRCS, FAMS, is Director
and Senior Consultant Surgeon, Nexus
Surgical Associates, Mount Elizabeth Medical
Centre and Hospital, Singapore (position
when article was written — Deputy Head of
Department of Surgery and Senior Consultant
and Chief of Hepatobiliary and Pancreatic
Surgery Unit, Tan Tock Seng Hospital,
Singapore)
Khin Thanda Aung, is Research Assistant,
Department of Surgery, Tan Tock Seng
Hospital, Singapore.