Download Reducing surgical site infections-Understanding the risk factors

OR Excellence
Module 1:
Reducing Surgical Site Infections Understanding the Risk Factors
A Continuing Education Activity
Sponsored By
Grant Funds Provided By
Welcome to
OR EXCELLENCE
Module 1:
Reducing Surgical Site Infections Understanding the Risk Factors
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is intended for use as a stand alone self-study activity. We suggest you take the
following steps for successful completion:
1. Read the overview and objectives to ensure consistency with your own learning needs and objectives.
2. Review the content of the self-study activity, paying particular attention to those areas that reflect the
objectives.
3. Complete the Test Questions and compare your responses with the answers provided.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration form.
6. Pfiedler Enterprises will send certificate once the participant has completed all seven modules.
If you have any questions, please call: 720-748-6144.
CONTACT INFORMATION:
2101 S. Blackhawk Street, Suite 220
Aurora, CO 80014-1475
Phone: 720-748-6144
Fax: 720-748-6196
Website: www.pfiedlerenterprises.com
© Pfiedler Enterprises - all rights reserved 2011
OR EXCELLENCE
Module 1: Reducing Surgical Site Infections - Understanding the Risk Factors
OVERVIEW
Surgical site infections (SSIs) are an important and grave concern in health care today, as they are a significant source
of patient morbidity and mortality, extended hospital stays, and increased health care costs. Preventing the development
of a surgical site infection is a desired outcome for all surgical patients. Since all members of the surgical team share the
responsibility for achieving this outcome, they must understand the factors that increase a patient’s risk for SSIs, as well
as evidence-based strategies to reduce the patient’s risk. This continuing education activity will provide an overview of
the current impact and definition of SSIs, their causative agents, and associated risk analysis. Variables that increase a
patient’s risk for SSI will be reviewed. Process variables related to reducing the risk for SSI will be described. Measures
outlined in the Surgical Care Improvement Project (SCIP), specifically the CATS (clippers, antibiotics, temperature, sugar)
tool, will be discussed. Other professional recommendations will also be outlined.
LEARNER OBJECTIVES
Upon completion of this continuing education activity, the participant should be able to:
1. List the patient variables related to increased risk for surgical site infection.
2. List the process variables related to reducing the risk of surgical site infection.
3. Describe the Surgical Care Improvement Project (SCIP) measures to prevent SSI.
INTENDED AUDIENCE
This continuing education activity is intended for use by perioperative nurses, and other health care professionals who
are interested in learning more about the risk factors associated with surgical site infections and effective risk reduction
strategies.
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for
1.0 contact hour(s).
Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end.
Licensees must provide their license numbers for record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be retained in the participant’s
records for at least four (4) years as proof of attendance.
AST Credit for Surgical Technologists
This continuing education activity is approved by the Association of Surgical Technologists, Inc. for (1.0) CE credits for
continuing education in Surgical Technology.
RELEASE AND EXPIRATION DATE
This continuing education activity was planned and provided in accordance with accreditation criteria. This material was
originally produced in August 2011 and can no longer be used after August 2013 without being updated; therefore, this
continuing education activity expires in August 2013.
1
DISCLAIMER
Accredited status as a provider refers only to continuing nursing education activities and does not imply endorsement of any
products.
SUPPORT
Grant funds for the development of this activity were provided by 3M Healthcare.
PLANNING COMMITTEE
Judith Pfister, RN, BSN, MBA
Program Manager
Pfiedler Enterprises
Aurora, Colorado
Rose Moss, RN, MN, CNOR
Nurse Consultant
Moss Enterprises
Larkspur, Colorado
Chad Edmonson, CST
Certified Surgical Technologist
Skyridge Medical Center
Lone Tree, Colorado
EXPERT REVIEWERS
Elizabeth Deroian, RN, BA
Program Manager
Pfiedler Enterprises
Aurora, Colorado
Julia A. Kneedler, RN, EdD
Director of Education
Pfiedler Enterprises
Aurora, Colorado
Kristine L. Winters, RN, BSN
Consultant
Aurora, Colorado
2
DISCLOSURE
All planning committee members and expert reviewers participating in all continuing education activities sponsored by
Pfiedler Enterprises are expected to disclose any real or apparent financial affiliations related to the content of this activity. Detailed disclosure appears below.
1. Have you (or your spouse/partner) had any personal financial relationship in the last 12 months with the manufacturer
of the products or services that will be presented in this continuing education activity (planner/reviewer) or in your
presentation (speaker/author)?
2. Type of affiliation/financial interest with name of corporate organization.
3. Will your presentation include discussion of any off-label or investigational drug or medical device?
Judith I. Pfister, RN, BSN, MBA
1.Yes
2. Co-owner of company that receives grant funds from 3M Healthcare.
3. No
Rose Moss, RN, MN, CNOR
1. No
2. None
3. No
Elizabeth Deroian, RN, BA
1.Yes
2. None
3. No
Julia A. Kneedler, RN, MS, EdD
1.Yes
2. Co-owner of company that receives grant funds from 3M Healthcare.
3. No
Chad Edmonson, CST
1. No
2. None
3. No
Kristine L. Winters, RN, BSN
1. No
2. None
3. No
3
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Phone: 720-748-6144
Email:
[email protected]
Postal Address: 2101 S. Blackhawk Street, Suite 220
Aurora, Colorado 80014
Website URL:
http://www.pfiedlerenterprises.com
4
INTRODUCTION
One of the expected outcomes for every surgical patient is that he/she is free from signs and symptoms of infection.1
Today, unfortunately, surgical site infections (SSIs) are common complications and represent one of the leading causes of
postoperative morbidity and mortality; they may also be associated with enormous additional costs for hospitals and health
care systems.2 Therefore, all members of the surgical team should understand the factors that increase a patient’s risk for
a surgical site infection and the evidence-based strategies to reduce the risk.
SSIs: TODAY’S REALITY
In order to appreciate the importance of implementing effective measures to reduce a patient’s risk for the development of a
surgical site infection, the impact of SSIs on the both the patient and the healthcare system must be reviewed.
In the United States, SSIs occur in 2% to 5% of patients undergoing inpatient surgery; approximately 500,000 SSIs occur
each year.3 In addition, each surgical site infection is associated with approximately 7 to 10 additional postoperative
hospital days. Patients with an SSI have a 2 to 11 times higher risk of death, compared to surgical patients without an SSI;
77% of deaths among patients with a surgical site infection are directly attributable to the SSI. While the attributable costs
of an SSI vary, depending on the type of operative procedure and the type of infecting pathogen, published estimates range
from $3,000 to $29,000; furthermore, SSIs are believed to account for up to $10 billion annually in healthcare expenditures.
These estimates are based on inpatient costs and do not account for the additional costs of rehospitalization, postdischarge outpatient expenses, and long term disabilities.
In July of 2008, the increased costs associated with SSIs were also addressed by the Centers for Medicare and Medicaid
Services (CMS) when it announced new Medicare and Medicaid payment and coverage policies to improve safety for
hospitalized patients.4 The Inpatient Prospective Payment System (IPPS) 2009 final rule expanded the list of certain
hospital-acquired conditions that have Medicare payment implications, as of October 1, 2008. At that time, the agency also
issued a letter to State Medicaid Directors outlining the authority of State Medicaid Agencies to deny payment for selected
hospital-acquired conditions. As a result, CMS no longer reimburses hospitals for the increased care that a patient needs
after an extreme medical error has occurred or for a condition that was not present on admission, but is subsequently
acquired during the course of the patient’s hospitalization. In addition, the patient is not responsible for the additional costs
and therefore cannot be billed. Initially, hospitals were not reimbursed for infections associated with vascular catheters and
coronary artery bypass graft surgery. As of October 1, 2008, hospitals were no longer reimbursed for surgical site infections
after selected elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity (see Table 1).
Table 1 – Hospital-Acquired Conditions: Surgical Site Infections
(for which CMS no longer pays higher reimbursement)5
Mediastinitis after coronary artery bypass graft
Associated with certain orthopedic procedures involving the spine, neck, shoulder, elbow
Associated with certain bariatric surgical procedures for obesity, specifically laparoscopic gastric
bypass, gastroenterostomy, laparoscopic gastric restrictive surgery
The 2011 update to the CMS hospital IPPS rule included new reporting provisions for SSIs through the Centers for Disease
Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).6 CMS has published a final rule that will
require reporting SSIs through the CDC’s National Healthcare Safety Network (NHSN); this reporting will be a part of the
CMS Hospital Inpatient Quality Reporting Program. Reporting for SSIs will be clarified in a future regulation; however, data
collection is to begin with January 2, 2012 discharges for FY 2014 Medicare payment determination. As a result, Medicare
payments to hospitals will be tied to how well the facility protects patients from SSIs. This means that patients will be able
to determine how health care facilities are doing in regards to preventing SSIs; furthermore, hospitals and other health care
facilities will be incentivized to implement effective prevention strategies.
5
COMMON PATHOGENS THAT CAUSE SSIs
The source of microbial contamination of the surgical site may be either the endogenous microorganisms (i.e., the bacteria
from the patient’s own skin, mucous membranes, or hollow viscera) or exogenous microorganisms (i.e., the microorganisms
from health-care personnel, the environment, surgical instruments and other materials).7 When introduced into body tissues
by surgery or through medical devices and surgical instruments, the pathogenic potential of endogenous microorganisms
increases. However, for most SSIs, the source of pathogens is the patient’s endogenous flora.8
The pathogens most often associated with SSIs are Staphylococcus aureus, coagulase-negative staphylococcus, and
enterococcus; Table 1 below lists the distribution of the top ranking pathogens that cause SSIs. Alarmingly, more and more
SSIs are due to antibiotic-resistant microorganisms, such as methicillin-resistant Staphylococcus aureus (MRSA).9 In fact, in
the study below, 49% of the S. aureus infections were MRSA.10
Table 1 - Distribution of Top Ranking Pathogens Causing SSIs
(January 2006 - October 2007)10
Pathogen
6
SSI
Staphylococcus aureus
30.01%
Coagulase Negative Staph (CNS)
13.74%
Enterococcus spp.
11.21%
Pseudomonas aeruginosa
5.55%
Eschericia coli
9.55%
Acinetobacter baumannii
0.60%
Enterobacter spp.
4.17%
Candida spp.
2.07%
DEFINITION AND CLASSIFICATION OF SSIs
For purposes of standardized reporting, SSIs have been defined and classified as superficial incisional SSIs, deep
incisional SSIs, and organ/space SSIs (see Table2 for the complete definitions and Figure 1 for a graphic illustration). 11
Table 2 - Definition of SSIs
Superficial Incisional SSI
• Infection occurs within 30 days of the operation.
• Infection involves only skin or subcutaneous tissue.
• At least 1 of the following:
− Purulent drainage,
− Positive culture from the incision,
− At least 1 symptom of infection (pain or tenderness, localized swelling, redness, heat) and incision is opened by surgeon, unless incision is culture-negative, or
− Diagnosis of SSI by surgeon or attending physician.
Deep Incisional SSI
• Infection within 30 days of the operation if no implant is left in place or within 1 year if implant is in
place and the infection appears to be related to the operation.
• Infection involves deep soft tissues.
• At least 1 of the following:
− Purulent drainage from the deep incision but not from organs/spaces associated with the surgical site,
− Spontaneous dehiscence of deep incision or deliberate opening by a surgeon when the patient
has at least 1 symptom of infection (fever, localized pain, or tenderness), unless site is culturenegative,
− Abscess or other evidence of infection involving the deep incision found on direct examination,
during reoperation, or by histopathology or radiography, or
− Diagnosis of SSI by surgeon or attending physician.
Organ/Space SSI
• Infection within 30 days of the operation if no implant is left in place or within 1 year if implant is in
place and the infection appears to be related to the operation.
• Infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which
was opened or manipulated during an operation.
• At least 1 of the following:
− Purulent drainage from drain placed into the organ/space,
− Positive culture of fluid or tissue from the organ/space,
− Abscess or other evidence of infection involving the deep incision found on direct examination,
during reoperation, or by histopathology or radiography, or
− Diagnosis of SSI by surgeon or attending physician.
7
Figure 1 – Surgical Site Infections
SSI RISK ANALYSIS
The development of a surgical site infection is a complex biologic process, occurring within a framework of multiple
variables; this makes the identification of individual causes problematic. Further complicating the issue is that
comparatively little research pertaining to prevention is available; therefore, the variability of each process must be
considered in the development of preventive strategies.
Microbial contamination of the surgical site is a necessary precursor of an SSI; the risk of an SSI can be conceptualized
according to the following formula: 12
Process Variability
↓
Dose of Bacterial Contamination x Virulence
(Resistance)
____________________________________________________ Resistance of the Host (Patient)
↑
Patient Variability
8
=
SSI Risk
WOUND CLASSIFICATION
Another important factor in determining a patient’s risk for developing a surgical site infection is the classification of the
surgical wound. The CDC recommends four surgical wound classifications: clean, clean contaminated, contaminated, and
dirty or infected wounds (see Table 3).13
Table 3 – Surgical Wound Classification
Wound Class
Class I / Clean
Description
An uninfected operative wound in which no inflammation
is encountered and the respiratory, alimentary, genital, or
uninfected
urinary tract is not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage.
Operative
incisional wounds that follow nonpenetrating (blunt) trauma
should be included in this category if they meet the criteria.
Class II / Clean-Contaminated
An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions
and without unusual contamination. Specifically, operations
involving the biliary tract, appendix, vagina, and oropharynx
are included in this category, provided no evidence of infection
or major break in technique is encountered.
Class III / Contaminated
Open, fresh, accidental wounds. In addition, operations with
major breaks in sterile technique (e.g., open cardiac massage)
or gross spillage from the gastrointestinal tract, and incisions
in which acute, nonpurulent inflammation is encountered are
included
in this category.
Class IV / Dirty-Infected
Old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infection or perforated
viscera. This definition suggests that the organisms causing
postoperative infection were present in the operative field
before the operation.
This classification system reflects the probability of SSI and thus enables the perioperative team to take appropriate
preventive measures. 14 In addition, the Association of periOperative Registered Nurses’ (AORN) Recommended Practices
for Documentation of Perioperative Nursing Care include that wound classification is documented in the patient’s record.15
Patient Variables16
In looking at the risk analysis formula, patient variability, i.e. resistance of the host, plays a role in the development of an
SSI. Factors that increase a patient’s risk for developing a surgical site infection include:
●●
Age;
●●
Compromised immune system;
●●
Diabetes;
●●
A remote site infection that is not treated prior to surgery;
●●
Nicotine use;
9
●●
Nutritional status;
●●
Prolonged preoperative stay;
●●
Obesity;
●●
Steroid use;
●●
Duration of surgery; and
●●
Nasal carriage of S. aureus.
These factors are useful in two ways; first, they allow stratification of surgical procedures, making surveillance data more
comprehensible and secondly, knowledge of certain risk factors prior to certain operations may allow for targeted prevention
measures. For example, for a patient who is known to have a remote site infection, the surgical team may delay the
procedure until after the infection has resolved, in order to decrease the patient’s risk for a surgical site infection.
PROCESS VARIABILITY
There is also variability in several processes that can play a part in the development of an SSI. In this module we will give
an overview of the many process variables, which will be covered more in depth in subsequent modules.
SCIP Measures – CATS
The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving
surgical care by significantly reducing surgical complications.17 It has identified four key measures designed to reduce
surgical site infections based on the acronym, CATS:18
●●
Clippers
o Hair removal–if hair must be removed from the surgical site, clippers are the best option. Never use a razor.
„„
„„
The AORN Recommended Practices for Preoperative Patient Skin Antisepsis state that hair at the
surgical site should be left in place, i.e., not removed, whenever possible, as studies have demonstrated
that preoperative shaving of the surgical site increases the risk of SSI. Removing hair at the surgical
site abrades the skin surface and enhances microbial growth. Depilatory creams may cause skin
reactions in some patients; these creams may, however, be used for hair removal if skin testing is
performed without tissue irritation.
Other recommended changes for improvement include:
●●
●●
●●
●●
●●
●●
●●
10
Remove all razors from the operating room (OR) and supply areas;
Perform hair removal when necessary with clippers right before surgery;
Establish a protocol for when and how to remove hair in affected areas;
Provide patient education and materials on appropriate hair removal techniques so that he/she
does not shave the surgical area at home;
Avoid shaving heart surgery patients for electrocardiogram (EKG) conducted shortly before
surgery; and
Hair removal should take place outside the OR suite.
Antibiotics
o Prophylactic antibiotics – antibiotics consistent with national guidelines should be administered within one
hour of incision time and discontinued within 24 hours, in most cases.
„„
It is estimated that 40–60% of all SSIs are preventable with the appropriate use of prophylactic
antibiotics; furthermore, overuse, under use, improper timing, and misuse of antibiotics occurs in 25–
50% of operations. A large number of hospitalized patients develop infections caused by Clostridium
difficile;16% of this type of infection in surgical patients can be attributed to inappropriate antibiotic
prophylaxis alone. Inappropriate use of broad spectrum antibiotics or prolonged courses of prophylactic
antibiotics puts all patients at even greater health risks due to the development of antibiotic-resistant
pathogens. Changes for improvement in prophylactic antibiotic administration include:
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
●●
Designate responsibility and accountability for preoperative prophylactic antibiotic administration
(e.g., preoperative nurse, circulating nurse, anesthesiologist) connected to a key point in process;
Standardize the administration process to occur with commonly performed activities within one
hour prior to incision;
Through the use of antibiotic standing orders specific to surgical site, administer prophylactic
antibiotics according to guidelines based on local consensus;
Make the agreed-upon antibiotics available in the OR;
Standardize the medication delivery process to ensure timely delivery of preoperative antibiotics to
the holding area;
Provide visible reminders or checklists to give antibiotics for each patient (e.g., a brightly colored
sticker);
Ensure systematic documentation of antibiotic administration on every patient chart, whether paper
or electronic;
Develop system in which the antibiotic is hanging at the head of patient’s bed, ready for
administration;
Design protocols to deliver the antibiotic to OR with patient;
Educate all involved members of the OR staff regarding the importance of and rationale for
antibiotic timing, selection, and duration;
Provide feedback monthly on prophylaxis compliance and infection data;
Involve the pharmacy staff to ensure timing, selection, and duration are maintained;
Institute a computerized physician order entry system with procedure-specific fields for antibiotic
timing, selection, and duration;
Improve screening for allergies to beta lactam antibiotics to eliminate false positives;
Consider weight-based antibiotic dosing (i.e., higher dose for larger patients). While this may be
cumbersome, the facility may want to increase cephalosporins from 1 to 2 grams for all patients,
since there are minor issues regarding toxicity; and
Re-dose antibiotics for longer procedures (e.g., after 3 hours for short half-life cephalosporin).
Temperature
o Normothermia–SCIP Infection 10 specifies that active warming should be used intraoperatively–OR–the
patient should have at least one temperature of ≥36.0°C within 30 minutes immediately before or 15 minutes
immediately after anesthesia end time. The measure applies to all patients undergoing surgical procedures
under general or neuraxial anesthesia of 60 minutes or longer.
„„
Unplanned perioperative hypothermia is one of the most common complications of surgery; even mild
hypothermia increases the incidence of several serious adverse consequences, including SSIs, adverse
cardiac events, increased blood loss, alteration in medication metabolism, and prolonged lengths of stay
in the post anesthesia care unit (PACU) as well as the hospital.
11
„„
There are many factors inherent in the OR environment that can cause patients to become clinically
hypothermic during surgery; these include anesthesia, anxiety, wet skin preparations, and skin exposure
in cold ORs. There is evidence to show that preventing hypothermia is beneficial in reducing the
associated complications noted above, and it is clearly more comfortable for patients. Changes for
improvement in temperature management include:
●●
●●
●●
●●
●●
●●
●●
Use warmed forced-air blankets preoperatively, during surgery, and in the PACU;
Use warmed intravenous (IV) fluids;
Use warming blankets under patients on the OR bed;
Use hats and booties on patients perioperatively;
Adjust engineering controls so that ORs and other patient care areas are not permitted to become
excessively cold overnight, when many rooms are closed; and
Designate responsibility and accountability for thermoregulation.
Sugar
o Glucose control – cardiac surgery patients should have controlled 6 a.m. serum glucose (≤ 200mg/dL) on
postoperative Day 1 and Day 2.
„„
A review of the medical literature demonstrates that the degree of hyperglycemia in the postoperative
period correlated with the rate of surgical site infection in patients undergoing major cardiac surgery.
Changes for improvement in glucose control include:
●●
●●
●●
●●
Implement a glucose control protocol (e.g., a sliding scale or insulin drip);
Develop one protocol to be used for all surgical patients;
Regularly check preoperative blood glucose levels on all patients to identify hyperglycemia; this
is should be done early enough so that the risk assessment can be completed and treatment
initiated if indicated; and
Assign responsibility and accountability for blood glucose monitoring and control.
Hand Hygiene and Surgical Hand Antisepsis
Hand hygiene is another process variable in reducing the risk for SSIs. Skin is a major source of microbial contamination
in the surgical environment.25 Furthermore, microorganism transfer from the hands of health-care workers to patients is an
important factor in health care-associated infection (HAI); hand hygiene is recognized as a primary method of decreasing
HAIs.26 Hand hygiene, hand washing, and surgical hand scrubs are the most effective methods for preventing and
controlling infections; they represent the least expensive means of achieving both.
The normal skin flora on the hands include both transient and resident microorganisms; transient flora are microorganisms
that colonize the superficial layers of the skin and are the microorganisms acquired by healthcare workers when caring
for patients and coming into contact with contaminated surfaces.27 Transient microorganisms are easier to remove during
hand washing. Resident flora are bacteria that are seated in the deeper skin layers and are more difficult to remove. Both
transient and resident bacteria usually maintain a constant level on individuals’ hands. Therefore, the purposes of surgical
hand hygiene and antisepsis are:28
12
●●
To remove dirt, skin oil, and transient microorganisms from the nails, hands, and forearms;
●●
To reduce the resident microbial count to as near zero as possible; and
●●
To leave an antimicrobial residue on the skin to prevent regrowth of microbes for several hours.
AORN Recommended Practices state: A surgical hand scrub should be performed by health care personnel before donning
sterile gloves for surgical or other invasive procedures. Use of either an antimicrobial surgical scrub agent intended for
surgical hand antisepsis or an alcohol-based antiseptic surgical hand rub with documented persistent and cumulative
activity that has met US Food and Drug Administration (FDA) regulatory requirements for surgical hand antisepsis is
acceptable.
In addition, the use of a brush for surgical hand scrubs is not necessary for adequate reduction of bacterial counts.
Scrubbing with a brush is associated with an increase in skin cell shedding. The skin on hands can become damaged with
the use of brushes resulting in an increase in bacterial load.29
Reducing Bacteria on the Body – Patient Preparation
To minimize both the clinical and fiscal costs of SSIs, a focus on effective prevention strategies is critical. Prevention
takes on even greater significance when the emergence and spread of antibiotic-resistant causative microorganisms is
taken into consideration. As noted, inappropriate prophylactic antibiotics increases the development of antibiotic-resistant
pathogens. Resistant infections are more likely to require treatment with a second- or third-choice antibiotic; these drugs
tend to be less effective, more toxic, and more expensive than the first-line drug. 30 Therefore, a key process variable is
reducing the bacteria on the patient’s body. The role of the patient’s endogenous flora in the development of a surgical site
infection as discussed above means that a major aspect of SSI prevention is proper preparation of the patient’s skin before
surgery and in the operating or procedure room in order to minimize microbial colonization near the incision site. To prevent
bacteria on the skin from entering the surgical wound, the skin at and around the proposed incision site must be cleaned
and disinfected.31 Two patient skin preparation measures are preoperative showering or bathing and preoperative skin
antisepsis.
PREOPERATIVE BATHING
The CDC recommends that patients be required to shower or bathe with an antiseptic agent at least the night before the
day of the operation.32 The AORN Recommended Practices for Preoperative Patient Skin Antisepsis outline that patients
undergoing open Class I surgical procedures below the chin should have two preoperative showers with chlorhexidine
gluconate (CHG) before surgery, when appropriate.33 The act of washing and rinsing removes microorganisms from
the skin; some organisms may be difficult or impossible to kill with the application of CHG alone. However, unless
contraindicated, patients should be instructed or assisted to perform two preoperative baths or showers with CHG before
surgery in order to reduce the number of microorganisms on the skin and reduce the risk of subsequent contamination
of the surgical wound. Four percent CHG is more effective than povidone-iodine or soap, and more than one shower is
needed to achieve the greatest antiseptic effectiveness. A sequential process of two applications of CHG with a minimum of
two minutes contact time for intraoperative skin preps is suggested by the manufacturer’s recommendations.
PREOPERATIVE PATIENT SKIN ANTISEPSIS
The recommendations for antimicrobial agent selection for preoperative patient skin antisepsis outlined by the CDC and
AORN state that an “appropriate antiseptic” be used for skin preparation; neither states that one antiseptic agent is
preferred over another. The CDC recommendations state that an appropriate antiseptic agent for skin preparation should be
used.34 Preoperatively, the antiseptic skin preparation should be applied in concentric circles moving toward the periphery.
The prepared area must be large enough to extend the incision or create new incisions or drain sites, if necessary. An
antiseptic agent that has immediate and persistent activity that meets the U.S. Food and Drug Administration (FDA)
regulatory requirements for a patient preoperative skin prep and is approved by the health care organization’s infection
control personnel should be used for all preoperative skin preparation. The AORN recommended practices state that
preoperative skin antiseptic should:36
●●
significantly reduce microorganisms on intact skin;
●●
contain a nonirritating antimicrobial preparation;
13
●●
be broad spectrum;
●●
be fast acting; and
●●
have a persistent effect.
Based on these recommendations, it is important to note that currently, no one prepping agent has been found to be
superior; when possible, an alcohol-based skin prep with a second active ingredient – either CHG or povidone iodine –
should be used. In its 2010 Safe Practices for Healthcare, the National Quality Forum (NQF) includes prevention of SSI
in Safe Practice #22.35 The practice of prepping the skin prior to surgery is included in these recommendations and states:
“Preoperatively use solutions that contain isopropyl alcohol as skin antiseptic preparation until other alternatives have been
proven as safe and effective, and allow appropriate drying time per product guidelines.” This statement is in line with CDC,
SHEA, IDSA and AORN guidelines and recommended practices to use an appropriate skin prep agent.
NASAL DECONTAMINATION
Nasal decontamination is another measure in reducing bacteria on the patient. Humans carry a significant amount of
bacteria in our noses. Of particular interest is S. aureus. Approximately 30 percent of the population carries S. aureus in
their nose, and of those who carry S. aureus, 1 percent carries MRSA.36 In addition, nasal carriage of S. aureus has been
identified as a major risk factor for wound infections after both orthopedic total joint and cardiac surgery.37, 38
Mupirocin ointment is effective as a topical agent for eradicating S. aureus from the nares of colonized patients or
healthcare workers and is indicated for use during institutional outbreaks. An early study suggested that the risk of SSI
was reduced in patients undergoing cardiothoracic operations when mupirocin was applied preoperatively to their nares,
regardless of their carrier status.39 In this study, the SSI rates for 752 mupirocin-treated patients were compared with those
previously observed for an untreated group of 928 historical control patients; the significant SSI rate reduction was attributed
to the mupirocin treatment. A more recent report concluded for patients who are nasal carriers of S. aureus, the use of
mupirocin ointment results in a statistically significant reduction in S. aureus infections.40
One of the growing concerns with the use of mupirocin ointment, because it is an antibiotic, is development of resistance.
Surveillance studies have reported mupirocin resistant MRSA strains in up to 13 percent of patients in institutions that do not
practice routine use of mupirocin and in up to 65 percent of patients in areas with widespread mupirocin use.41
ASEPTIC TECHNIQUE
The creation and maintenance of a sterile field can directly influence patient outcomes.42 Further, rigorous adherence to
aseptic practices by all members of the surgical team assists in fulfilling the professional responsibility to protect the patient
from injury; it is also the foundation of surgical site infection prevention. For example, others who work in close proximity to
the sterile surgical field, such as anesthesia providers who are separated from the sterile field only by a drape barrier, also
must abide by these principles.43
TRAFFIC PATTERNS
Establishing and maintaining traffic patterns also assist in reducing the patient’s risk for developing a surgical site infection. The air in the operating room may contain microbial-laden dust, lint, skin squames, or respiratory droplets; the microbial
level in the air is directly proportional to the number of people moving about in the room.44 Clearly define and enforced
traffic control practices protect the patient, as well as personnel, supplies, and equipment from cross contamination.45
Therefore, efforts should be made to minimize personnel traffic in an OR during surgical procedures.
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SURGICAL ATTIRE AND DRAPES
The human body and inanimate surfaces inherent to the perioperative practice setting are major sources of microbial
contamination and transmission of microbes.46 An individual sheds millions of skin squames daily; 5% to 10% of skin
squames carry bacteria.47 As previously noted, patients are at risk of contamination from both endogenous and exogenous
sources during an operative or invasive procedure; therefore, the use of surgical attire and drapes assists in promoting a
high level of cleanliness and hygiene within the perioperative environment.
STERILITY ASSURANCE
A key measure in minimizing the risk of SSIs is to provide surgical items that are free from contamination at the time of use,
as inadequate sterilization of surgical instruments has resulted in SSI outbreaks.48
The sterilization process starts with proper cleaning and decontamination of surgical items followed by a sterilization
process. Sterilization processes should always be monitored to detect potential failure modes with the goal of improving
patient outcomes. A variety of monitoring tools are used to help ensure sterility, such as physical monitors, chemical
indicators and biological indicators. These monitoring tools are used to help ensure that instruments and supplies being
used on patients are free from viable microorganisms. Biological indicators are used to assess cycle lethality as they have
the ability to detect conditions that are not sufficient to kill spores.49
SURGICAL TECHNIQUE
Excellent surgical technique is also believed to reduce the risk of SSI. Surgical techniques include achieving and
maintaining effective hemostasis while preserving adequate blood supply; gentle handling of tissues; avoiding inadvertent
entries into a hollow viscus; removing devitalized (e.g., necrotic or charred) tissues; using drains and suture material
appropriately; eradicating dead space; and appropriate management of the incision postoperatively. Any foreign body,
including suture material, a prosthesis, or drain, may lead to inflammation at the surgical site; this in turn, may increase the
probability of SSI after otherwise benign levels of tissue contamination.50
CONCLUSION
Infection prevention is one of the surgical team’s greatest responsibilities; one of the expected outcomes for every surgical
patient is that he/she is free from the signs and symptoms of infection. The development of an SSI results in unnecessary
discomfort, increased lengths of stay, and additional health care costs. Today, there are increased economic pressures on
health care facilities and personnel to develop and implement effective infection prevention strategies. There are several
patient and process variables that increase a patient’s risk for the development of a surgical site infection. As patient
advocates, all members of the perioperative team must understand these risk factors and implement appropriate measures
to prevent SSIs, as outlined by the SCIP, CDC, and AORN. Through this knowledge and intervention, all members of the
surgical team will play an integral role in proactively minimizing the risk for surgical site infections, and ultimately improve
patient outcomes.
15
GLOSSARY
Antiseptic Technique
Method by which contamination with microorganisms is prevented.
Clean Wounds (Class I)
Uninfected operative wounds in which no inflammation is encountered
and the respiratory, alimentary, genital, or uninfected urinary tract is
not entered.
Clean/Contaminated Wounds (Class II)
Operative wounds in which the respiratory, alimentary, genital, or
urinary tracts are entered under controlled conditions and without
unusual contamination.
Contaminated Wound
(Class III)
Open, fresh, accidental wounds; operations with major breaks in
sterile technique (e.g., open cardiac massage) or gross spillage from
the gastrointestinal tract, and incisions in which acute, nonpurulent
inflammation is encountered. Deep Incisional SSI
An infection involving deep soft tissue, fascia, and muscle.
Dirty/Infected Wounds
(Class IV)
Old traumatic wounds with retained devitalized tissue and those that
involve existing clinical infection or perforated viscera; this definition
suggests that the organisms causing postoperative infection were
present in the operative field before the operation.
Endogenous
Growing from or on the inside; caused by factors within the body or
arising from internal structural or functional causes.
Exogenous
Growing from or on the outside; caused by factors (as food or a
traumatic factor) or an agent (as a disease-producing organism) from
outside the organism or system; introduced from or produced outside
the body.
Healthcare-Associated Infection (HAI)
An infection acquired by patients during hospitalization, with confirmation of diagnosis by clinical or laboratory evidence. The infective
agents may originate from endogenous or exogenous sources. HAIs,
which are also known as nosocomial infections, may not become apparent until the patient has been discharged from the hospital.
The invasion and multiplication of microorganisms in body tissues that
cause cellular injury and clinical symptoms.
Infection
Microorganism
An organism that is too small to be seen with the naked eye and
requires a microscope. Bacteria, viruses, fungi, and protozoa are
generally called microorganisms.
Normothermia
Core body temperature between 36 – 38°C (96.8° – 100.4°F).
Organ or Space SSI
An infection that involves any part of the anatomy (e.g., organs or
spaces), other than the incision, which was opened or manipulated
during an operation.
Pathogen
A microorganism that causes disease.
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Resident Flora
Microorganisms persistently isolated from most people’s skin. These
microorganisms are considered to be permanent residents of the skin
and are not readily removed by mechanical friction.
Squame
Superficial SSI
A scale or flake, as of skin.
Surgical Attire
An infection involving the skin and subcutaneous tissue as opposed to
deep tissue.
Nonsterile apparel designated for the OR practice setting that includes
two-piece pantsuits, cover jackets, head coverings, shoes, masks,
protective eyewear, and other protective barriers.
Surgical Site Infection (SSI)
An infection at the site of a surgical incision; the infection may be
superficial, deep, or it may extend to organs.
Surgical Site Infection Risk
Measure of the likelihood that a patient will suffer an SSI.
Transient Flora
Microorganisms isolated from the skin, but not demonstrated to be
consistently present in the majority of people. They are considered
transient because they can be readily transmitted on hands unless
removed by mechanical friction and soap and water washing.
17
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