Surgical Best Practices for Infection Prevention

The goal of surgical best practices is to prevent surgical site infections (SSIs), which can be triggered by contamination from the surgical instrument or by skin flora at the incision site, as well as by bacterial cross-contamination or by surgical hypothermia.

Brennan, et al. (1991) note that SSIs are the second most common type of adverse events occurring in hospitalized patients, while Kirkland, et al. (1999) observe that SSIs have been shown to increase mortality, readmission rate, length of stay and costs. According to the Institute for Healthcare Improvement (IHI), an estimated 40 percent to 60 percent of these infections are preventable, and that implementing several components of care — such as appropriate use of prophylactic antibiotics, appropriate hair removal and maintaining normothermia — can help reduce SSIs.

Bratzler, et al. (2005) conducted a review of 34,133 charts for the Centers for Medicare & Medicaid Services (CMS) that indicated significant opportunity for improvement in SSI prevention. Bratzler, et al. found that appropriate antibiotic selection occurred in 92.6 percent of cases; antibiotics were given within one hour of incision time to 55.7 percent of patients; and prophylactic antibiotics were discontinued within 24 hours of surgery end time for only 40.7 percent of patients.

The Oklahoma Foundation for Medical Quality says Surgical Care Improvement Project (SCIP) data show that while performance has improved considerably, gaps remain between national averages and benchmarks as recently as the second quarter of 2007:

• Antibiotics within one hour: 87.6 percent average (benchmark 98.6 percent)

• Correct antibiotics: 93.7 percent (99.5 percent)

• Antibiotic discontinued within 24 hours: 82.9 percent (97.4 percent)

• No razors: 93.7 percent (100 percent)

• Maintaining normothermia: 81.2 percent (99.3 percent)

The most recently published guidelines for prevention of SSI were released by Mangram et al. (1999), but adding to the current body of knowledge on SSI prevention is the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals (2008) published by SHEA-IDSA (in partnership with The Joint Commission, Association for Professionals in Infection Control and Epidemiology (APIC) and the American Hospital Association). The Compendium, which includes practice recommendations to address SSIs, states that the pathogenesis of and likelihood of developing an SSI involve a complex relationship among the following factors:

• Microbial characteristics (degree of contamination and virulence of pathogen)

• Patient characteristics (immune status and co-morbid conditions)

• Surgical characteristics (type of procedure, introduction of foreign material, and amount of damage to tissues)

The Compendium further suggests that policies and practices for SSI prevention should include but are not limited to to:

• Reducing modifiable patient risk factors

• Optimal cleaning and disinfection of equipment and the environment

• Optimal preparation and disinfection of the operative site and the hands of the surgical team members

• Adherence to hand hygiene

• Traffic control in operating rooms

The IHI’s Getting Started Kit: Prevent Surgical Site Infections How-to Guide offers the following SSI prevention best practices:

1. Appropriate use of prophylactic antibiotics

Antibiotic process measures include:

• Prophylactic antibiotic received within one hour prior to surgical incision

• Prophylactic antibiotic selection for surgical patients consistent with national guidelines

• Prophylactic antibiotics discontinued within 24 hours after surgery end time

The IHI suggests involving representatives from pharmacy, infection control and infectious disease staff to ensure appropriate timing, selection and duration of prophylactic antibiotics. It also suggests developing pharmacist- and nurse-driven protocols that include preoperative antibiotic selection and dosing based on surgical type and patient-specific criteria such as age, weight, allergies, renal clearance, etc.

2. Appropriate hair removal

• Seropian, et al. (1971) were among the earliest to suggest that the use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all.

• The use of clippers has been found to be the best method in many hospitals but clinicians must be trained in the proper use of clippers to avoid damaging the patient’s skin.

• If hair must be removed preoperatively, it is generally recommended that this not occur in the operating room itself, as loose hairs are difficult to control.

• Educate patients not to self-shave preoperatively.

• Remove all razors from the entire hospital.

• Work with the purchasing department so that razors are no longer purchased by the hospital.

Proper surgical hand antisepsis is a key component of SSI prevention, as skin is a major potential source of microbial contamination in the surgical environment. The Association of periOperative Registered Nurses (AORN) Recommended Practice for Surgical Hand Hygiene* notes, “Hand hygiene is a critical step in preventing infections and the spread of infections, is of critical importance for the entire healthcare team, and remains the most effective and least expensive measure to prevent the transmission of microorganisms and healthcare-associated infections.”

Surgical hand antisepsis refers to the antiseptic surgical scrub or antiseptic hand rub performed before donning sterile attire preoperatively, and according to the AORN recommended practice, its purpose is to remove debris and transient microorganisms from the nails, hands, and forearms; reduce the resident microbial count to a minimum; and inhibit rapid rebound growth of microorganisms. The surgical hand antiseptic agent should significantly reduce microorganisms on intact skin; contain a nonirritating, antimicrobial preparation; be broad spectrum; be fast acting; and have a persistent effect.

AORN’s Recommended Practice for Surgical Hand Hygiene advises these key principles:

All personnel should practice general hand hygiene.

An FDA-compliant, surgical hand antiseptic agent approved by the facility’s infection control personnel should be used for all surgical hand antisepsis/hand scrubs.

Surgical hand antisepsis/hand scrub should be performed before donning sterile gloves for surgical or other invasive procedures. Use of either an FDA-compliant, antimicrobial surgical scrub agent intended for surgical hand antisepsis or an FDA-compliant, alcohol-based antiseptic hand rub with documented persistent and cumulative activity that has been approved for surgical hand antisepsis is acceptable.

Surgical hand antisepsis/hand scrub using an FDA-compliant, traditional antimicrobial scrub agent should include a standardized hand scrub procedure that follows the manufacturer’s written directions for use and is approved by the healthcare facility.

Surgical hand antisepsis/hand rub with an FDA-compliant, alcohol-based surgical hand rub product should follow a standardized application according to the manufacturer’s written directions for use.

Policies and procedures for surgical hand antisepsis should be developed, reviewed periodically and readily available in the practice setting. These policies and procedures should include identifying facility-approved, FDA-compliant, surgical hand antisepsis agents; defining the duration of surgical hand antisepsis procedures; and establishing standardized protocols for each hand antisepsis method used.

Sacred Cows in the OR

In today’s modern operating room, is there room for those so-called sacred cows that just won’t head out to pasture?

Diana Beck, RN, MSN, CNOR, perioperative education specialist at St. Mary’s Good Samaritan, Inc. in Centralia, Ill. has seen her share of these practices that die hard. “It is my experience that over-draping is the main sacred cow related to disease transmission and prevention. I wouldn’t really call it a problem in causing disease transmission. It is more of a practice that wastes financial resources, since single-layer draping is adequate with many current disposable drapes. It is best to follow the manufacturer’s directions for the specific use of each drape to get the best outcomes. Although all surgical specialties have surgeons who over-drape, I have observed that orthopedic surgeons over-drape the most. In general, utilization of other personal protective equipment (PPE) shows no overuse in my observations. Since I am a perioperative staff development educator I have personally educated OR staff and surgeons on PPE and draping and have seen appropriate use of PPE if education is ongoing. The best compliance is immediately after education and for several weeks or months after the education.”

Roberta Clark, RN, BS, MSHA, CNOR, perioperative educator at Shands Jacksonville CC-OR in Jacksonville, Fla., says that while she has not encountered the troublesome sacred cows at her facility, she acknowledges, “As far as PPE goes, I sometimes have trouble getting some staff to protect themselves, especially about wearing gloves, but they are getting better.” Such situations, she says, can be addressed and resolved through continuous education efforts, including the use of posters and other visual reminders. “Hopefully they will work if the evidence is provided.”

At some facilities, the practice of double-gloving — donning two layers of surgical gloves to reduce the number of breaks to the innermost glove that might allow cross-infection — is either vilified or glorified. Tanner and Parkinson (2006) conducted a literature review to determine if additional glove protection reduces the number of SSIs or bloodborne infections in patients or the surgical team, as well as to determine if additional glove protection reduces the number of perforations to the innermost pair of surgical gloves, considered to be the last barrier between the patient and the surgical team.

The researchers included randomized controlled trials involving single-gloving, double-gloving, triple-gloving, glove liners, knitted outer gloves, steel-weave outer gloves and perforation indicator systems. Two trials were found which addressed SSIs in patients and both reported no infections. Thirty-one randomized control trials (RCTs) measuring glove perforations were identified and included in the review. Fourteen trials of double-gloving showed there were significantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95 percent CI 3.30 to 5.09). Eight trials of indicator gloves showed that significantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95 percent CI 0.06 to 0.16) or with standard double gloves compared with indicator gloves (OR 0.08, 95 percent CI 0.04 to 0.17). Two trials of glove liners (OR 26.36, 95 percent CI 7.91 to 87.82), three trials of knitted gloves (OR 5.76, 95 percent CI 3.25 to 10.20) and one trial of triple-gloving (OR 69.41, 95 percent CI 3.89 to 1239.18) all compared with standard double gloves, showing there were significantly more perforations to the innermost glove of a standard double glove in all comparisons.

Tanner and Parkinson (2006) concluded that there is no direct evidence that additional glove protection worn by the surgical team reduces SSIs in patients; however, the addition of a second pair of surgical gloves significantly reduced perforations to innermost gloves, and perforation indicator systems result in significantly more innermost glove perforations being detected during surgery.

Clipping vs. Shaving

As we have seen, a practice that can have significant consequences for surgical patients is the removal of hair from the surgical site, with some clinicians disregarding best practice and clinging to preoperative shaving when recommended practices indicate that clipping is preferable because it can reduce the incidence of SSI. There is some clinical thought that any kind of pre-operative hair removal is deleterious to patients because this action – by depilatory cream, shaving or clipping — can cause SSIs.

Tanner, et al. (2006) attempted to determine if routine pre-operative hair removal resulted in fewer SSIs than not removing hair. They identified in the literature 11 RCTs comparing hair removal with no hair removal, different methods of hair removal, hair removal conducted at different times prior to surgery and hair removal carried out in different settings. Three trials involving 625 people compared hair removal using either depilatory cream or razors with no hair removal and found no statistically significant difference between the groups in terms of SSIs. No trials were identified which compared clipping with no hair removal. Three trials involving 3,193 people compared shaving with clipping and found that there were statistically significantly more SSIs when people were shaved rather than clipped. Seven trials involving 1,213 people compared shaving with removing hair using a depilatory cream and found that there were statistically significantly more SSIs when people were shaved than when a cream was used. No trials were found that compared clipping with a depilatory cream. One trial compared shaving on the day of surgery with shaving the day before surgery and one trial compared clipping on the day of surgery with clipping the day before surgery; neither trial found a statistically significant difference in the number of SSIs. No trials were found that compared depilatory cream at different times or that compared hair removal in different settings.

Tanner, et al. (2006) concluded the evidence finds no difference in SSIs among patients who have had hair removed prior to surgery and those who have not and note that if it is necessary to remove hair, then both clipping and depilatory creams results in fewer SSIs than shaving using a razor. They found no difference in SSIs when patients are shaved or clipped one day before surgery or on the day of surgery.

“Preoperative clipping is one of many ongoing competencies that should be performed by observation of practice,” Beck says. “I have found that if a facility allows manual razors to be purchased and stocked anywhere in the building, occasionally staff may revert back to shaving rather than clipping for preoperative hair removal. It’s a good practice for the educator or the manager to do spot checks of clipping to assure that the manual razors have not re-appeared in the perioperative setting. I know the driver to purchase razors is sometimes a request by nurse assistants to use razors to shave a male patient’s facial hair during daily bathing and hygiene. In this case, the razors are not meant for pre-operative hair removal, but if they are accessible and a clipper is not at the time of a pre-operative hair removal, a razor could be used instead of a clipper. In speaking with colleagues about pre-operative hair removal by clipping, most are well aware that the reason to use a clipper is for infection prevention. I feel this awareness and use of clippers has increased over the past several years. The best way to change the mindset on this issue (as with many issues) is ongoing education, including not only presentations but interactive discussion and feedback.”

Clark says all razors have been removed from the department, in order to follow AORN recommendations in the institution’s policies and practices. “There are clippers with disposable heads in every operating room,” she says. “We had strong input from the chief of surgery in getting the surgeons on-board and expediting the change citing research. He said this should have occurred several years ago. A couple of specialty services (orthopedics and neurology) balked at first. We still have a few razors available (hidden) in the department, but, to my knowledge have not been used. And, I have not found any stashed in the operating rooms.”

Preoperative Bathing and Surgical Hand Antisepsis

When it comes to removing flora from the entire body pre-surgery, some researchers feel it may not be necessary to require preoperative bathing or showering with skin antiseptics such as chlorhexidine gluconate (CHG) to prevent SSIs, while others confirm that skin asepsis is a sentinel strategy for reducing risk of SSIs. Edmiston, et al. (2008) sought to determine effective CHG levels on most skin sites. In this study, CHG skin concentrations were determined after preoperative showering/skin cleansing using 4 percent CHG soap or a 2 percent CHG-impregnated polyester cloth. After showering or skin cleansing with either CHG product, subjects’ CHG surface concentrations were determined at five separate skin sites. CHG concentrations were compared with CHG minimal inhibitory concentration that inhibits 90 percent of staphylococcal skin isolates. The researchers found that effective CHG levels were achieved on most skin sites after using 4 percent CHG; gaps in antiseptic coverage were noted at selective sites even after repeated application. Use of the 2 percent CHG polyester cloth resulted in considerably higher skin concentrations with no gaps in antiseptic coverage. The researchers noted that effective decolonization of the skin before hospital admission can play an important role in reducing SSI risk.

Wendt, et al. (2007) endeavored to study the efficacy of whole-body washing with chlorhexidine for the control of MRSA through a randomized, placebo-controlled, double-blinded clinical trial at a university hospital. Of 114 patients, 11 were MRSA-free 30 days after treatment, and only groin-area colonization was significantly better eradicated by the use of chlorhexidine. The researchers concluded that whole-body washing can reduce skin colonization, but it appears necessary to extend eradication measures to the gastrointestinal tract, wounds, and/or other colonized body sites if complete eradication is the goal.

Other researchers have endeavored to measure the amount of bacteria on the hands before and after surgical procedures and found that when using aqueous scrubs, chlorhexidine was more effective in reducing the amount of bacteria than povidone iodine. The evidence from comparisons of aqueous scrubs with alcohol rubs which contain additional active ingredients is mixed, as there is evidence from studies in favor of both forms of antisepsis.

Tanner et al. (2008) sought to determine the effects of surgical hand antisepsis on the number of SSIs in patients, as well as to determine the effects of surgical hand antisepsis on the numbers of colony-forming units (CFUs) of bacteria on the hands of the surgical team. The researchers conducted a review of the literature and looked for randomized controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions; 10 trials were included in their review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4,387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45 percent propanol-2, 30 percent propanol-1 with 0.2 percent ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1 percent chlorhexidine gluconate in 61 percent ethyl alcohol or zinc pyrithione in 70 percent ethyl alcohol against aqueous povidone iodine. A fourth trial found 4 percent chlorhexidine gluconate scrubs more effective than chlorhexidine in 70 percent alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found CHG scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between CHG scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one-minute hand wash, a three-minute rub appears to be more effective than the five-minute rub using alcohol disinfectant. The other comparisons demonstrated no difference.

Tanner, et al. (2008) concluded that alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs; however, this evidence comes from only one cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from four studies suggests that CHG-based aqueous scrubs are more effective than povidone iodine-based aqueous scrubs in terms of the numbers of CFUs on the hands. The researchers noted there is limited evidence regarding the effects on CFUs and numbers of different scrub durations, and there is no evidence regarding the effect of equipment such as brushes and sponges.

“From my most recent research readings, I feel that CHG has been shown to be the better skin antisepsis product not only for perioperative skin antisepsis but other applications such as IV and central line dressings,” Beck says. “As for application of the product, I’m a firm believer in using any product, device, or equipment according to that manufacturer’s recommendation. Each antiseptic has its own properties and the product can be useless if applied incorrectly. It would be impossible for AORN or any other organization to recommend the proper method for each product. Thus, the recommendation should be to follow the manufacturer’s instructions.”

Clark advises that hospitals should have both CHG and non-CHG products on hand, as well as a product such as Techni-Care surgical scrub. “Surgeons here have been approached by the vendors of DuraPrep and ChloraPrep, plus they cite evidence that CHG is better that the iodine products. I personally have not researched either product for efficacy pre-incision, during the procedure, or post- procedure; with or without the use of plastic sticky drapes (clear or with impregnated Betadine) prior to paper drapes being applied.” Clark adds that while she adheres to AORN recommended practices for application of surgical prep products, she also says it is important to know and follow the manufacturers’ recommendations for use.

Some researchers say there is no clear-cut evidence to suggest that preoperative skin antisepsis prevents post-operative surgical wound infection. Lipp and Holmes conducted a review of RCTs evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. They found insufficient evidence from the various trials to support or refute the use of one antiseptic over another, although they identified one study indicating there were fewer SSIs when the skin was prepared using chlorhexidine in comparison with preparation using iodine. They also did not find evidence to show that iodophor-impregnated incise drapes reduced infections when compared to using no incise drapes. Lipp and Holmes note, “The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however it is unclear whether preoperative skin antisepsis actually reduces post-operative wound infection and if so which antiseptic is most effective.” They add, “Further research is needed.”

Clark confirms that some studies in the literature are less clear whether reducing skin microflora leads to a lower incidence of SSI. “I did read about this recently, but I think a person’s immune system is already tuned in to the chemistry and any ‘bugs’ they may have on their skin,” Clark says. “I think the percentage of alcohol in the aforementioned products is what chemically kills, or renders skin flora inactive, not the percentage of iodine or CHG. I think these extend the efficacy of the alcohol. Alcohol alone is too flammable and too caustic to solely use on the skin for an invasive procedure. More research will need to be done to prove lowering skin flora will reduce SSI. Maybe a simple and inexpensive skin test could be developed to testing a person’s skin flora before surgery.”

Maintaining Normothermia

The IHI points out that anesthesia, anxiety, wet-skin preparations and skin exposure in cold operating rooms can cause patients to become clinically hypothermic during surgery. Numerous studies in the medical literature indicate that patients undergoing surgery have a decreased risk of SSI if they are not allowed to become hypothermic during the perioperative period. The IHI’s 5 Million Lives Campaign and SCIP also point to evidence showing that preventing hypothermia is beneficial in reducing other complications, while also being comforting to surgical patients.

“Our poor patients are subjected to varying room temperatures,” Clark says. “Warm for children and neonates and when a trauma patient comes in; cool to cold for most other patients.”

The IHI suggests the following ways to help maintain normothermia:

Prevent hypothermia at all phases of the surgical process

Use warmed forced-air blankets preoperatively, during surgery and in PACU

Use warmed fluids for IVs and flushes in surgical sites and openings

Use warming blankets under patients on the operating table

Use hats and booties on patients perioperatively.

Adjust engineering controls so that operating rooms and patient areas are not permitted to become excessively cold overnight, when many ORs are closed

Measure and monitor temperature with a standard type of thermometer

Fighting MRSA and Other MDROs

Clinicians are on high alert against skin and soft tissue infections, particularly those caused by MRSA and other multidrug-resistant organisms (MDROs). Among the best practices OR nurse educators recommend to surgical team members include going back to basics.

“While there is not one clear solution, identification of the patient with MRSA must be the basis for good infection prevention and control,” Beck says. “These measures include good hand hygiene, Standard Precautions and Transmission-Based Precautions. Since overuse of antibiotics has caused organisms to become resistant, healthcare facilities should determine how antibiotics should be used to combat further resistant organisms.”

“All perioperative staff must know the history of the patient regarding any past diagnosis of MRSA (or other processes resistant to antibiotics),” Clark recommends. “It goes beyond universal precautions. In today’s world, we all need to get the mindset that all patients are contaminated with something, and need to make sure we prevent cross-contamination from us to the patient, or instruments to patient (correct sterilization after appropriate enzymatic cleaning, ultrasonic and disinfection, and packaging), or patient to patient, or staff to staff.” Clark continues, “Patients come to us from the community already MRSA compromised and we do not know it until it is discovered in our facility whether before surgery or after. We are then held liable for giving it to them since it was not diagnosed before admission and will not be reimbursed for any treatment provided. The public needs to be educated to get tested through their healthcare provider or community health department.”

* The Association of periOperative Registered Nurses (AORN0 Recommended Practice for Surgical Hand Hygiene was open for public review and comment until Feb. 9, 2009.

References:

Brennan, et al. Incidence of adverse events in hospitalized patients. N Engl J Med. 1991;324:370-376.

Kirkland, et al. The impact of surgical site infections in the 1990s. Infect Control Hosp Epidemiol. 1999;20:725.

Bratzler, et al. Use of antimicrobial prophylaxis for major surgery. Arch Surg. 2005;140:174-182.

Seropian, et al. Wound infections after preoperative depilatory versus razor preparation. Am J Surg. 1971;121:251.

5 Million Lives Campaign. Getting Started Kit: Prevent Surgical Site Infections How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008.

Mangram, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78.

Anderson, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008;29:S51-S61.

Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database of Systematic Reviews 2006, Issue 3.

Edmiston CE Jr, Krepel CJ, Seabrook GR, Lewis BD, Brown KR, Towne JB.

Preoperative shower revisited: can high topical antiseptic levels be achieved on the skin surface before surgical admission? J Am Coll Surg. 2008 Aug;207(2):233-9.

Edwards P, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews 2004, Issue 3.

Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews 2008, Issue 1.

Tanner J and Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database of Systematic Reviews 2006, Issue 3.

Wendt C, Schinke S, Württemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol. 2007 Sep;28(9):1036-43.

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