Chapter 13 Preventing Surgical Site Infections

Prevention of surgical site infections (SSIs) is a key risk management and quality improvement issue. A surgical site infection is one of the most common hospital-acquired infections (HAIs) and is a significant cause of morbidity and mortality (Centers for Disease Control and Prevention [CDC], 2009b). SSIs have a significant impact on the patient and place an additional cost burden upon individuals, families, payers, and society. In addition to the financial impact, the physical and psychologic impact on the patient cannot be underestimated. The goal for every facility should be a zero surgical site infection rate; unfortunately, to achieve this goal changes in conventional practices must be supported and implemented. Several factors may be tied to contracting an SSI (Box 13-1).

BOX 13-1 Patient and Surgical Factors That May Be Tied to Surgical Site Infection

PATIENT CHARACTERISTICS

Microbial colonization

Remote infection

Altered immune response

Perioperative length of stay

SURGICAL ELEMENTS

Preoperative skin preparation

Hair removal (shaving)

Surgical hand antisepsis of surgical team members

Environmental controls

Surgical attire and drapes

Instrument sterilization

Length of operation

Surgical technique

Antimicrobial prophylaxis

Modified from World Health Organization: WHO guidelines for safe surgery (first edition), Geneva, Switzerland, 2008b, available at http://www.gawande.com/documents/WHOGuidelinesforSafeSurgery_001.pdf. Accessed August 17, 2009.

Today’s health care environment is quickly evolving with a commitment and clear focus of payer groups, governmental agencies, health care organizations, and other stakeholders to do something about the spiraling cost burden upon society as a result of these infections. Preventing SSIs requires a team commitment and approach that enlists not just the surgical department, but every practitioner, administrator, organization, and recommending body responsible for delivering or affecting patient care. Initiatives focusing upon pay for performance, never events, and cost containment, driven by both the Centers for Medicare & Medicaid Services (CMS) and Congress, are forcing change upon the health care system.

CHALLENGES

Surveillance

Current epidemiology has met a true challenge with early discharge and outpatient surgical procedures. This challenge is in part a result of a shortened duration of postoperative hospitalization, which is now measured in hours or days, not weeks. This complicates the ability to monitor and observe for the development of a surgical infection. In some cases or situations, infections may go virtually untracked. Although the true number of SSIs may never be known, there are many variables to identify and correct to prevent surgical site infections.

Many organizations use a variety of methods (e.g., risk index) to stratify surgical procedures into groups so that data can be effectively reviewed for infection risk based upon similar patient populations. In addition, active surveillance and self-reported surveys are sent to surgical practitioners as an assessment of surgical site infections identified postoperatively. This is one of the common surveillance strategies used. Unfortunately, this method may not always capture every surgical site infection in every situation. It is important to remember that 96% of superficial surgical site infections occur within the first 28 days of surgery (World Health Organization [WHO], 2008b).

An SSI is commonly defined as occurring at the site of surgery. Surveillance of the surgical sites lasts for 30 days if the operation does not include an implantable device (e.g., pacemaker, heart valve, orthopedic implant). If an implant is involved, then tracking takes place for a year and is conducted by both the surgeon and the infection preventionist.

Across the United States, health care organizations use follow-up interviews for their same-day surgery patients. The phone interview may explore postoperative pain issues, surgical site appearance (if visualized), patient teaching, satisfaction with care received, and reminders for follow-up appointments. This call normally takes place within a prescribed time frame after discharge. In many situations, little actionable information can be gathered from this interview with respect to surgical site infections. Postdischarge surveillance requires a robust effort to track patients and involves the entire surgical team and the organization. To put this in perspective, consider a methicillin-susceptible Staphylococcus aureus (MSSA) infection. A common gram-positive opportunistic pathogen responsible for many wound infections, coagulase-positive S. aureus commonly has an incubation period of about 5 days before signs and symptoms become evident. This example highlights the difficulty in tracking some, but not all, hospital-acquired infections when the SSI does not manifest itself until after the patient is discharged or telephonic follow-up is conducted.

Prevalence

More than 50 million procedures are performed per year, and the incidence of SSIs has been reported to be about 300,000 per year, which account for approximately 22% of all the health care–acquired infections each year (CDC, 2009b). The majority of the 300,000 SSIs are not life threatening; however, the CDC estimates that SSI results in approximately 8000 deaths annually (CDC, 2009b). When looking at the prevalence of SSIs, about 70% involve the superficial skin, whereas the other 30% are considered more serious. These numbers place a significant burden on society when considering the estimated average cost of an SSI infection is $35,000 per event (Scott, 2009).

SURGICAL SITE INFECTION GUIDELINES

Although every SSI cannot be blamed on the health care system, one of the important tools being used to identify and prevent the causes of these infections is the Surgical Care Improvement Project (SCIP) initiative (MEDQIC, 2007). SCIP is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications. SCIP is a unique partnership that is proving to be a transformational undertaking in health care. The four goals of SCIP in preventing SSIs to reduce the incidence of surgical complications nationally 25% by the year 2010 are as follows:

Although SCIP is not the only quality partnership under way in perioperative settings, some of these recommendations found in SCIP can be traced back to the “Guideline for Prevention of Surgical Site Infection” (Mangram et al, 1999). The CDC guideline offered 72 recommendations (Mangram et al, 1999). Using an evidence-based rating system, eight of these recommendations were assigned a 1A rating, which designates the highest level of evidence. Many health care organizations often look to the weight of the evidence to help drive implementation and compliance in the clinical setting. However, with the various practice settings in place today (e.g., hospital, surgical center, office based), not all facilities have universally implemented these recommendations. One such example is the slow implementation of the 1A recommendation to use a clipper, not a razor, if hair removal is required (Edminston, 2007).

There are numerous differences between the SCIP and the CDC “Guideline for Prevention of Surgical Site Infection”; one of the most noticeable differences appears in the data collection tools and the definitions. The data collection tools used by SCIP are much larger and more complex, requiring a significant investment in labor. However, the data collected by SCIP is providing greater insight into the world of infections. This is resulting in evidence-based recommendations that are driving the decision-making process and affecting patient outcomes in a significant way.

In addition to SCIP initiatives and the CDC’s guidelines to prevent SSIs, numerous other stakeholders are aggressively promoting the prevention of SSIs. One example is the Society for Healthcare Epidemiology of America, which recently published “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” (Yokoe et al, 2008). The strategies emphasize the importance of surveillance, the need for feedback and education for the entire health care team, attention to practice issues highlighted in other guidelines, and the development of special approaches for facilities to address specific locations or populations (Yokoe et al, 2008).

SURGICAL ENVIRONMENT

Environmental Hygiene

There is increasing pressure upon organizations to maintain and minimize the risk of transmission of transmissible infections within the health care facility. One of the key factors for prevention of infections is a clean environment (Dancer, 2008). Environmental cleaning is both time consuming and a labor-intensive process. Thorough environmental cleaning requires training and monitoring to validate that cleaning is adequate.

It is well acknowledged that implementation of appropriate hand hygiene practices reduces infections. By targeting environmental cleaning efforts within the health care facility on patient and health care touch points (e.g., door handles, surfaces, phones), the environmental cleaning regimen has been easier to maintain than hand hygiene improvements. As a method to stop the spread of multidrug-resistant organisms (MDROs), this strategy could have significant benefits to the surgical environment, as well as the entire health care facility (Dancer, 2008).

The Association of periOperative Registered Nurses (AORN) in the “Recommended Practices for Environmental Cleaning in the Perioperative Setting” clearly describes the methodology and the rigor needed for environmental cleaning in the surgical setting (AORN, 2009a). The unfortunate aspect is that some facilities may fall short in meeting these recommendations as a result of emphasis upon production (e.g., turnover time). When the surgical environment (surfaces, equipment, or supplies) is not thoroughly cleaned, the transfer of pathogenic organisms becomes a possibility. When individuals do not follow the prescribed application time (wet time) of the surface cleanser—failure to use a product per the manufacturer’s written instructions—they achieve less than the desired effects and reduce efficacy of the product. Visual inspection of surfaces does little to guarantee an environment free of pathogenic organisms (Dancer, 2008). This can be seen in the reports of infection outbreaks when incomplete or inadequate environmental surface cleaning takes place within facilities, such as reports of methicillin-resistant S. aureus (MRSA) or Clostridium difficile transmission from improper or inadequate cleaning. This is a crucial aspect of the prevention of infections within the perioperative environment. An example of an SSI outbreak took place at some ambulatory surgery centers (ASCs) and is described in the following (CDC, 2009a):

ASCs in the United States have been the fastest growing provider type participating in Medicare, increasing in number by more than 38% between 2002 and 2007. A 2008 hepatitis C outbreak in Nevada was traced to poor infection control practices at various ASCs (potentially affecting more than 50,000 people). Follow-up surveys throughout Nevada found infection control deficiencies at more than 40% of the ASCs.

HEALTH CARE PROVIDER ISSUES

Hand Hygiene

Much has been written about hand hygiene being the most important action a health care worker can take to prevent the spread of infections. In surgery the term sterile conscience, which describes doing the right thing even when no one is watching, is always applied. It is inconceivable to break sterile technique and not do anything to minimize or remedy the break.

Health care organizations are now being required by The Joint Commission to have stricter policies and performance monitoring in place as a way to improve and maintain hand hygiene practices. Clean hands do save lives by breaking the chain of infection. Hand hygiene should involve hand washing with soap (plain or antimicrobial) and water if hands are visibly soiled. If hands are not visibly soiled, the use of an alcoholic agent is preferred (Boyce and Pittet, 2002; WHO, 2008a). In the surgical environment all health care workers should perform a soap-and-water hand wash initially to ensure that hands are physically clean when arriving to work, before and after using the restroom, before meals, and before going home at the end of one’s shift. Scrubbed staff should wash their hands with soap (plain or antimicrobial) and water before their first scrub of the day (AORN, 2009b).

Surgical Hand Antisepsis

In 2002 Parienti et al demonstrated that there was no statistical difference in surgical site infections between the use of surgical hand scrubbing (i.e., scrub brush, antiseptic soap, and water) and the use of surgical hand rubbing (i.e., 1-minute timed wash followed by application of an alcoholic agent) (Table 13-1). There was a noticeable lack of compliance with performance in both groups. This study was a randomized equivalency study over a 17-month period evaluating approximately 4400 patients (Parienti et al, 2002). To increase compliance, operating room leadership should consistently monitor, enforce, and reward proper surgical hand antisepsis behaviors through education, observation, and counseling.

TABLE 13-1 Surgical Hand Antisepsis Comparison

Protocol	SSI Rate (95% Confidence Interval)	Performance Compliance (retrospective, P = 0.008)
Surgical hand rub	55/2252 (2.44%)	44%
Surgical hand scrub	53/2135 (2.48%)	28%

From Graves PB, Twomey CT: Surgical hand antisepsis: an evidence based review, Perioper Nurs Clin 1(3):235-249, 2006.

AORN’s “Recommended Practices for Hand Hygiene in the Perioperative Setting” (2009b), CDC’s “Guideline for Hand Hygiene in Health-Care Settings” (2002), and WHO’s Guidelines on Hand Hygiene in Health Care (2008a) each recommend that practitioners follow the manufacturer’s written instructions for product use and use the recommended amount. If practitioners choose to use a product for less than its prescribed time or amount, the desired efficacy may not be realized (Graves and Twomey, 2006). The intent of the surgical scrub or rub is to eliminate transient flora and to reduce colonizing flora to minimize the potential SSI risk to the patient.

Surgical Attire

In 1883 Gustav Neuber encouraged the use of gown and cap, and in 1897 Mirculiz advocated the use of a mask to reduce organisms from the mouth and nose. Dr. William Halsted, credited by many as the father of modern-day surgery, encouraged the use of surgical gloves along with dedicated surgical attire in 1899. Although gloves were initially worn to protect Dr. Halsted’s scrub nurse, it soon became apparent that the surgical glove reduced the patient’s exposure to a surgeon’s flora and the potential for SSIs. Surgical attire has not made a dramatic design change since that time.

The surgical uniform, or “scrubs,” is intended to be worn within the semirestricted and restricted areas that are designed to promote hygiene and cleanliness. Today surgical attire takes on many different looks and styles, but the basic intent remains unchanged—maintaining a professional hygienic appearance to our patients and the public.

Today there are three types of surgical attire: (1) facility-provided surgical attire (hospital owned and laundered, hospital owned and third-party laundered, or leased [fee per use]); (2) home-laundered surgical attire; and (3) single-use disposable surgical attire, which is gaining in popularity and acceptance as a result of improved nonwoven fabrics.

Many health care organizations and recommending bodies (e.g., AORN, Association for the Advancement of Medical Instrumentation [AAMI], Association for Professionals in Infection Control and Epidemiology [APIC]) have taken different positions on how surgical attire should be laundered, worn, and managed within the surgical environment. This inconsistency has created confusion for health care workers and organizations alike. There is an acknowledged lack of well-characterized studies that demonstrate that laundering of worn surgical attire in the home is a safe and effective practice. Rather, there is emerging evidence that home laundering may not render surgical attire as clean as hospital and commercial third-party laundering processes. Guidelines such as the AORN’s “Recommended Practices for Surgical Attire” (2009f) do not recommended home laundering of surgical attire.

Whatever process is chosen by the health care organization to clean the surgical uniform, it should be validated by the organization, as in the case of hospital and third-party commercial laundry facilities. Health care organizations should have a process in place to confirm that the surgical uniform is clean and has met the same criteria used by the facility to validate other linen (process validation). Although there has been no study that links surgical scrubs to infections in patients, it has been demonstrated that MDROs can survive on fabrics for an extended period of time (Neely and Maley, 2000).

Surgical scrubs intended to be worn within the restricted areas should not be worn into the area from outside the health care facility. If scrubs are worn outside, they should be classified as street clothes and changed before entering the semirestricted or restricted environment. Only freshly laundered or single-use disposable surgical attire should be worn in the semirestricted or restricted environment of the surgical department.

Personal Protective Equipment

Surgical Caps and Hoods

The Occupational Safety and Health Administration (OSHA) (2009) requires head covering as a part of universal precautions. In addition to OSHA’s mandate, AORN recommends covering all hair in an effort to reduce contamination of the surgical field from exposed hair and scalp. There have been reports of SSI outbreaks traced back to the hair and scalp of surgical personnel (Mastro et al, 1990).

Only gold members can continue reading. Log In or Register to continue