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 and comprehensive.
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 benchmarked accurately.
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 epidemiological studies.
- 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 the OR.
- 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 operation.
- 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 intravenous drugs.
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 rationale.
- 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 nails.
- 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 surgical site.
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 final formulation.
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.