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Take the initiative to reduce surgical site infections

Woodruff, Julie, MBA, BSN, RN; Hohler, Sharon E., BSN, RN, CNOR

doi: 10.1097/01.NURSE.0000546454.56122.93
Department: Patient Safety

At Saint Francis Healthcare System in Cape Girardeau, Mo., Julie Woodruff is the CNO and Sharon E. Hohler was the team coordinator for orthopedics before recently retiring.

The authors have disclosed no financial relationships related to this article.

THE OR MANAGER sat and listened to the surgical services director's challenge: Reduce the surgical site infection (SSI) rate by 50%. “Our infection rate is only 1%, below the national average of 2% to 5%,” she thought. “What more can we do?” But being a quality leader, she recognized that although the current SSI rate was admirable, reducing it even further would greatly benefit Saint Francis Medical Center in Cape Girardeau, Mo., and its patients.

This article describes an initiative focused on preventing deep SSIs and their potentially devastating complications, as well as how resulting procedural changes dramatically reduced the facility's SSI rate. (For a general overview and guidelines, see How can SSIs be prevented?)

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Preliminary approach

First, the previous 3 years of SSI data were analyzed. Statistically significant results showed that 62% of those infections involved skin and respiratory tract pathogens. This indicated possible contamination from environmental and human factors such as cleaning the facility, hand hygiene practices, and surgical staff and healthcare provider attire. After researching evidence-based practices, the hospital enhanced cleaning measures and introduced testing for methicillin-resistant Staphylococcus aureus (MRSA) carriers.

Another finding revealed a relationship between an increase in SSI and patient comorbidities such as hypertension, obesity, peripheral vascular disease, tobacco usage, diabetes mellitus, obstructive sleep apnea, heart failure, and chronic obstructive pulmonary disease. We then considered how to support each patient's health status to reduce SSI risk.

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Looking for problems and solutions

A team of medical staff caring for each patient assembled to look at each deep SSI in an apparent cause analysis (ACA) meeting. In one case, the caregivers found a problem with the patient's preexisting positive MRSA nasal culture. This patient had been treated with intranasal mupirocin but had received only cefazolin, not vancomycin as recommended.1 After staff members realized this, a procedural change was made. Patients presenting with a MRSA-positive culture are pretreated with intranasal mupirocin and I.V. vancomycin in addition to another appropriate antibiotic. For example, an orthopedic patient without beta-lactam allergy should receive cefazolin as a preoperative antibiotic. If this same orthopedic patient were MRSA-positive, he or she would receive both cefazolin and vancomycin preoperatively after pretreatment with mupirocin.2

Routine MRSA nasal swab testing was expanded to include preoperative patients undergoing orthopedic, neurosurgery, cardiovascular, and vascular surgery. Wound care specialists and surgeons were recommended to obtain swab wound culture specimens from the patient for any suspected infections.

At that first ACA meeting, a pharmacist pointed out that we were giving patients half of the recommended dose for some antibiotics.2 To correct this problem, an update was added to the computerized provider order entry (CPOE) system with the pharmacy providing weight-based dosages of prescribed antibiotics. CPOE sets were updated to include pretreatment with mupirocin and vancomycin for patients who were MRSA-positive and to verify that surgeons' admission orders include both MRSA testing and treatment as well as the appropriate antibiotics, per American Society of Health-System Pharmacists guidelines.2 An antibiotic redosing schedule was hardwired into the electronic health record to remind anesthesia care providers to redose during long surgical procedures.

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Improving environmental care

The healthcare professionals attending ACA meetings after each SSI successfully identified problems and implemented needed changes. For example, improved cleaning practices were implemented in the ORs. The new one-step 0.55% sodium hypochlorite cleaning wipe approved for the OR and patient-care areas kills fungi, spores, viruses, and bacteria, including Mycobacterium tuberculosis and Clostridium difficile.3 An educational review reminded staff members of proper cleaning techniques. The OR staff-development program included the enhanced cleaning protocol recommended by the Association of periOperative Registered Nurses (AORN).3 The environmental cleaning staff attended a staff-development program on this enhanced cleaning protocol.

Another change was exchanging cotton string mops for microfiber mops. Although either type of mop is acceptable per AORN guidelines, one study found microfiber mops removed microorganisms more effectively (95%) than cotton string mops (68%).3

The environmental cleaning staff was assigned to clean rooms used during the weekend, which was previously done by the perioperative staff, to provide a terminally cleaned room as we improved overall cleaning practices. Improved lidded trash bins were provided for OR trash. More frequent trash pickups also helped prevent insects, such as flies, in the OR.

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Changing OR practices

Staff and management recognize that although doors must be opened for patient and equipment traffic, the OR doors need to be closed to allow air exchanges to function properly. Air exchanges make the OR safer for patients and decrease the risk of SSIs.4 After education and reinforcement, the OR staff became more mindful to keep the doors closed.

Another change involved covering male healthcare workers' facial hair with fine mesh beard covers.

In addition, circulating nurses in the OR were asked to wear long-sleeved jackets while performing surgical skin prep, which helps prevent surgical site contamination from arm hair or skin cells that are shed during the procedure.5

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Brushing up on hygiene issues

Performing hand hygiene is a basic but critically important behavior for healthcare workers throughout any facility. Not only does performing hand hygiene protect the patient from healthcare workers' organisms, but it also protects healthcare workers from the patients' organisms.6

Proper hand hygiene includes wetting hands under warm running water, applying soap to all surfaces and rubbing for 15 seconds, then rinsing and drying with a paper towel, which is used to turn off the faucet. When hands are not visibly soiled, an alcohol-based antiseptic is an acceptable alternative. Proper technique for alcohol-based hand hygiene involves applying the gel and rubbing hands together until they are dry (approximately 20 seconds).7

The CDC recommends healthcare workers perform hand hygiene at these times:

  • before and after touching the patient's intact skin
  • after contact with any body fluids including blood, wounds, mucous membranes, and contaminated dressings
  • after contact with furniture or medi-cal equipment in the patient's vicinity
  • after removing gloves
  • after touching a contaminated area of the patient's body and before touching anywhere else
  • before eating and after using the restroom.7

Healthcare facilities may find the free Joint Commission Hand Hygiene Targeted Solutions Tool (TST) helpful.8 The recommended steps involve setting up a team that observes healthcare workers' hand hygiene practices and documents the observations in the TST. The tool generates charts and gives feedback on staff members' hand hygiene practices. For example, do nurses and other staff members wash their hands or use alcohol-based gel as they enter and leave each patient room? The TST can be found at

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Surgical hand rubs and scrubs

A review of surgical hand scrubs was conducted during staff re-education. These AORN standards for hand rub include the following:

  • removing jewelry
  • putting on a surgical mask
  • washing soiled hands with soap and water
  • cleaning under fingernails before drying hands and arms
  • applying the hand rub product to hands and arms and allowing it to dry before putting on a sterile gown and gloves.

Always follow recommendations provided by the manufacturer of the surgical hand rub product.

For those who prefer a surgical scrub, follow the first four steps of AORN standards for hand rub, then follow these steps:

  • Scrub according to product instructions.
  • Rinse hands and arms while holding your hands higher than your elbow.
  • Enter the OR to dry your hands while keeping surgical clothes from getting wet before putting on a gown and gloves.7
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Optimizing patient status

During this project, staff members recognized that some patients arrive malnourished and some surgeries put patients at risk for protein depletion, especially gastrointestinal or cancer surgeries. This increases the risk of poor healing, infection, and pressure injuries.9

Changes intended to optimize nutrition began with patients scheduled for elective colon and cystectomy-ileal conduit surgeries. These patients are screened at the general surgeons' office preoperatively using the Malnutrition Screening Tool, which identifies malnourished patients and patients at risk for malnourishment based on recent weight loss and appetite.10

Patients are sent home with an immunonutrition drink to help reduce the risk of infection after major elective surgery and instructed to drink it twice a day for 5 days before surgery and the first 5 days postoperatively as soon as diet permits.

In this population, nutritional optimization decreased the SSI rate from 5% to 1.5% and readmissions from 20% to 3%. The patients receiving this nutritional supplement have had no readmissions or infections. Because of the success of this program, it has been expanded to include all malnourished patients and patients at risk for malnutrition.

Certain general surgeries put patients at increased risk for infection.10 During these surgeries, the general surgeons have begun irrigating the abdominal cavity with a chlorhexidine solution and applying new technology called negative-pressure incision therapy (NPIT). This NPIT protocol shows promise, lowering infection rates to 2% versus 11% when used after colorectal surgery.11

Educating patients and their caregivers about the best ways to prevent infections at home includes having them watch an educational video, “Keep it Clean: Preventing Surgical Site Infections,” before leaving the medical center. This video provides instructions appropriate for both inpatient and outpatient surgical patients.

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Improving for the future

Current analysis shows for the first 6 months of 2017, the facility's deep SSI rate is 0.1% and overall SSI rate is 0.3%, a new low. Analyzing data on that 0.1% population, we learned that 40% of those patients have diabetes mellitus. Evidence-based practice shows that maintaining normal blood glucose levels before and during surgery and immediately postoperatively helps the patient heal.12 Would optimal blood glucose control for a longer time frame postoperatively decrease the risk of deep SSI? This future challenge involves teaching patients to ensure they control their blood glucose levels after being discharged from the medical center.

This project achieved a dramatic reduction in the deep SSI rate at our facility. The medical center staff is proud of our 0.1% deep SSI rate but continues working toward zero.

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How can SSIs be prevented?1,2

Efforts to decrease SSIs have been ongoing for years. Current best OR practices for preventing infections include the following:

  1. Timely delivery of prophylactic I.V. antibiotics within 1 hour before incision. I.V. vancomycin and fluoroquinolones should be infused over 2 hours. These antibiotics should be infused before tourniquets on the operative limb are inflated.
  2. Appropriate antibiotics (per guidelines) will be given.
  3. Antibiotics should be discontinued within 24 hours after surgery.
  4. Dosing of antibiotics should be weight-based.
  5. Redosing antibiotics for long surgical procedures is recommended at intervals of two half-lives.
  6. Razors to shave the surgical site have not been recommended for years because of the risk of nicks and of introducing bacteria into the area. Instead, clippers or a depilatory agent is appropriate preoperatively for hair removal if necessary.
  7. Maintaining the patient's blood glucose level at less than 180 mg/dL helps prevent infections and complications.
  8. Keeping the patient normothermic helps prevent blood loss and decreases the risk of SSIs.
  9. Using supplemental oxygen during and immediately following surgical procedures involving general anesthesia and mechanical ventilation helps improve tissue perfusion and healing and decreases the risk of SSIs.
  10. Alcohol-based surgical skin prep solutions (2% chlorhexidine gluconate in 70% isopropyl alcohol or povidone-iodine-alcohol), unless contraindicated, are associated with lower rates of infection than alcohol-free surgical skin prep solutions.
  11. Using an impervious plastic wound protector for abdominal surgery helps prevent SSIs.
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1. Anderson DJ, Podgorny K, Berríos-Torres SI, et al Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605–627.
2. American Society of Health-System Pharmacists. Clinical practice guidelines for antimicrobial prophylaxis in surgery.
3. Guidelines for environmental cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2017:7–28.
4. Environment of care, part 2. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2017:2276–2277.
5. Guidelines for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2017:105–127.
6. Guidelines for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2017:29–50.
7. Centers for Disease Control and Prevention. Clean hands count for healthcare providers. 2017.
8. Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool.
9. Fairfield KM, Askari R. Overview of perioperative nutritional support. UpToDate. 2018.
11. Mihaljevic AL, Schirren R, Müller TC, Kehl V, Friess H, Kleeff J. Postoperative negative-pressure incision therapy following open colorectal surgery (PONIY): study protocol for a randomized controlled trial. Trials. 2015;16:471.
12. Khan NA, Ghali WA, Cagliero E. Perioperative management of blood glucose in adults with diabetes. UptoDate. 2018.
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