Help the Surgical Team Sidestep Infection in the OR
By Sue Sebazco, Rn, BS, CIC
The Centers for Disease Control and Prevention (CDC) estimates
that 27 million surgical procedures are currently performed in the United States
each year.1 The CDC's National Nosocomial Infections Surveillance (NNIS)
system reports that surgical site infections (SSIs) are the third most
frequently reported nosocomial infection. This accounts for 14 percent to 16
percent of all nosocomial infections among hospitalized patients. It is a fact
supported by published studies that increased length of stay and cost are
associated with SSIs.2-4
Although there have been advances in infection control practices, SSIs remain
a substantial cause of morbidity and mortality in hospitalized patients. Some of
the reasons given for this are the emergence of antimicrobial-resistant
pathogens, increased numbers of immunocompromised patients who are having
surgery, and increased numbers of prosthetic implants and organ transplant
operations being performed. If the risk of SSIs is to be reduced, it must be
recognized that risks are influenced by characteristics of the patient,
operation, personnel and the hospital. This article will review practices that
should contribute to the reduction of SSIs in patients.
Achieving best practices in the operating room (OR) is a complex endeavor.
There are multiple disciplines on the surgical team. There are guidelines and
recommendations available on infection control practices from the CDC and the
surgical team's professional associations, such as the Association of
periOperative Registered Nurses (AORN), the American College of Surgeons and the
American Society of Anesthsiologists. The infection control practitioner (ICP)
should be familiar with the content of these references to identify best
practices that should be incorporated into the organization's policies,
procedures and practices.
When an increase in SSIs is noted in a facility, it can trigger increased
apprehension among surgical personnel, administration and risk management. When
this occurs, other staff members often look to the ICP to find the reason for
the increased rate. It is up to the ICP to validate the problem and, if
warranted, begin an investigation. The ICP should keep in mind that risk of
infection is influenced by characteristics of the patient, the procedure
performed, the personnel and the hospital. The investigation can be multifaceted
Through routine surveillance activities or reports received from the staff,
an opportunity for improvement may emerge. Once identified, it should be
determined if there is evidence that this is a departure from the facility's
normal experience; this can be done by reviewing data collected during a
previous reporting period and comparing it to the current incidence.
Benchmarking the facility's incidence with the NNIS System data can also help
determine the need for further investigation. CDC classifies SSIs into
incisional, organ or other organs and spaces manipulated during an operative
procedure. Incisional infections are either superficial (skin and subcutaneous
tissue) or deep (deep soft tissue and fascia). When defining SSIs, these
criteria should be consistently applied to insure credible data that can be
If the increase of SSIs is noted overall or on a specific service, a review
of current practices needs to be initiated. At this point, having a checklist of
recommended practices from the various resources can aid in making sure the
review is thorough.
The ICP should meet with a core group representing the affected area, either
independently or as a group, to review recommendations and compare with current
practice. The OR staff may begin to contribute theories on why the increase has
occurred. These suggested theories must be considered but not accepted on face
value. All identified SSIs, past and present, must be reviewed for common
factors. All too often, there is a demand for environmental cultures voiced from
one or many staff. Cultures are necessary only if there is an epidemiological
association with a person or an environmental source.1
The CDC "Guideline for Prevention of Surgical Site Infection, 1999"
lists the patient and operation characteristics that influence the risk of
surgical site infection development. Consideration should be given to patient
characteristics when trying to determine the source of an SSI rate increase. The
patient's age and nutritional status may be associated with increased risk in
certain kinds of operations. Although the contribution of diabetes to SSI risk
is controversial, there are some preliminary findings that showed an association
with increased glucose levels (greater than 200mg/dl) in the immediate
postoperative period.5-6 Other characteristics that may contribute to
a greater risk for developing an SSI are nicotine use, obesity, coexisting
infections at a remote body site, colonization with microorganisms, altered
immune response and length of the preoperative stay. The operation
characteristics include the duration of the surgical scrub, skin antisepsis and
preoperative shaving and skin preparation. Also, the length of the operation and
antimicrobial prophylaxis can influence the development of an SSI. Foreign
material in the surgical site can increase risk. The OR ventilation and
inadequate sterilization of instruments can add to the risk. Surgical technique
by the scrub team is another characteristic to consider. Gentle handling and
manipulation of the tissue during the operative procedure can prevent tissue
trauma that can lead to infection at the site.
The primary reservoir for organisms that are isolated from SSIs are the
patient's endogenous flora. The pathogens that are isolated from SSIs are
usually predictable depending upon the procedure performed. In clean surgical
procedures Staphylococcus aureus from the patient's skin flora or from the
exogenous environment is the usual cause of infection. When the site of the
procedure is the respiratory tract, gastrointestinal and genitourinary, the
aerobic and anaerobic pathogens isolated most frequently from an infection
resemble the microflora that is endogenous to the specific site.
The CDC's SSI guideline makes the following Category 1A recommendations for
prevention of SSIs. A Category 1A ranking is one that is strongly recommended
for implementation and supported by well-designed experimental, clinical, or
- Identify and treat all infections remote to the surgical site until
resolved prior to surgery.
- Do not remove hair preoperatively unless the hair at or around the
incision site will interfere with the operation.
- If hair is removed, remove immediately before the operation, preferably
with electric clippers.
- Administer a prophylactic antimicrobial agent only when indicated, and
select it based on its efficacy against the most common pathogens causing
SSI for a specific operation and published recommendations.
- Administer by intravenous route the initial dose of prophylactic
antimicrobial agent, timed such that a bactericidal concentration of the
drug is established in serum and tissues when the incision is made. Maintain
therapeutic levels of the agent in serum and tissues throughout the
operation and until, at most, a few hours after the incision is closed in
- Before elective colorectal operations in addition to above, mechanically
prepare the colon by use of enemas and cathartic agents. Administer
non-absorbable antimicrobial agents in divided doses on the day before the
- For high-risk cesarean section administer the prophylactic antimicrobial
agent immediately after the umbilical cord is clamped.
- Adhere to principles of asepsis when placing intravascular devices, spinal
or epidural anesthesia catheters, or when dispensing and administering
Following are some of the recommendations that are ranked Category 1B, those
that are strongly recommended for implementation and supported by some
experimental, clinical or epidemiological studies and strong theoretical
- Adequately control serum blood glucose levels in all diabetic patients and
particularly avoid hyperglycemia perioperatively.
- Encourage tobacco cessation.
- Do not withhold necessary blood products.
- Require patients to shower or bathe with an antiseptic agent on at least
the night before the operative day.
- Thoroughly wash and clean at and around the incision site to remove gross
contamination before performing antiseptic skin preparation.
- Use an appropriate antiseptic agent for skin preparation.
- Surgical team members should keep nails short and not wear artificial
- Perform a preoperative surgical scrub for at least 2 to 5 minutes using an
appropriate antiseptic, scrubbing the hands and forearms up to the elbows.
- After performing the surgical scrub, keep the hands up and away from the
body so that the water runs from the tips of the fingers toward the elbows.
Dry hands with a sterile towel and don a sterile gown and gloves.
- Surgical personnel who have signs and symptoms of a transmissable
infectious illness should report conditions promptly to their supervisory
and occupational health service personnel.
- Develop well-defined policies concerning patient care responsibilities
when personnel have potentially transmissable infectious conditions.
- Obtain appropriate cultures from and exclude from duty those surgical
personnel who have draining skin lesions until infection has been ruled out
or personnel have received adequate therapy and infection has resolved.
- Do not routinely exclude surgical personnel who are colonized with
organisms such as Staphylococcus aureus or group A Streptococcus unless such
personnel have been linked epidemiologically to dissemination of the
organism in the healthcare setting.
- Maintain adequate positive-pressure ventilation in the OR with respect to
the corridors and adjacent areas.
- Maintain a minimum of 15 air changes per hour, of which at least three
should be fresh air.
- Filter all air, recirculated and fresh, through the appropriate filters
per the Amercian Institute of Architects' recommendations.
- Introduce all air at the ceiling and exhaust near the floor.
- Keep all OR doors closed except as needed for passage of equipment,
personnel and patient.
- Use EPA-approved hospital disinfectants to clean areas visibly soiled with
blood or body fluids between cases.
- Sterilize all surgical instruments according to published guidelines.
- Perform flash sterilization only for patient care items that need to be
used immediately, not for convenience or as an alternative to purchase
additional instrument sets or to save time.
- Wear a surgical mask that fully covers the mouth and nose when entering
the operating room if the operation is about to begin or underway or if
sterile instruments are exposed and throughout the operation.
- Wear sterile gloves if you are a scrubbed surgical team member.
- Use surgical gowns and drapes that are effective barriers when wet .
- Use a sterile dressing for 24 to 48 hours postoperatively to protect an
incision that has been closed primarily.
- Wash hands before and after dressing changes and any contact with the
The guideline includes additional recommendations that have been previously
discussed or they are ranked Category II (suggested for implementation and
supported by suggestive clinical or epidemiological studies or theoretical
rationale. or no recommendation, unresolved issue (practices for which
insufficient evidence or no consensus regarding efficacy exists.)
Since these CDC guidelines were published in 1999, more recent
recommendations or published articles present some updated information for
consideration when addressing how to prevent SSIs.
A recently published article reported on the use of mupirocin ointment to
prevent postoperative Staphylococcus aureus infections.7 The authors
concluded that prophylactic intranasal application of mupiricin did not
significantly reduce the rate of Staphylococcus aureus SSIs overall, but did
significantly decrease the rate of all nosocomial Staphylococcus aureus
infections among the patients who were Staphylococcus aureus carriers.
The draft version of the anticipated CDC "Guideline for Hand Hygiene in
Healthcare Settings" addresses using an alcohol-based handrub or an
antimicrobial soap before donning sterile gloves when performing surgical
procedures. Also, to reduce the number of bacteria on the hands of surgical
personnel, while minimizing skin damage related to surgical hand antisepsis,
hands should be decontaminated without a brush. A word of caution should be
noted when evaluating the newer brushless surgical scrub agents. Make sure the
product has been approved by the FDA for use as a surgical scrub agent in its
The sound judgment and proper technique of the surgeon and surgical team and
the general health and disease state of the patient are the most critical
factors in the prevention of SSIs.8 When problems arise and best
practices are revisited, it is common for the rate of SSIs to decrease. The
surgical team should be vigilant at all times and compliant with recommended
practices to prevent postoperative infections in the surgical patient.
Sue Sebazco RN, BS, CIC, is the infection control/employee health director
at Arlington Memorial Hospital in Arlington, Texas.