Prevention of surgical site infections (SSIs) is even more important than ever now that the Centers for Medicare & Medicaid Services (CMS) is no longer reimbursing healthcare facilities for SSIs regarding several operations. These include SSIs following coronary artery bypass graft, certain orthopedic procedures, and bariatric surgery.¹ Saving lives is the No. 1 goal, but saving money is important too, and any healthcare worker who wants to improve the financial landscape of their facility will do as much as possible to reduce SSIs.
Proper skin antisepsis is one of the cheapest and most simple ways to reduce risk of SSI. Surgeons and their staffs take skin preparation “very seriously,” says Kelly Manning, RN, BSN, CIC, of the infection control department at Community Health Network in Indianapolis.
However, she adds: “I think sometimes it is hard to change what you have always done (Betadine scrub, shaving). Surgeons are creatures of habit and many are very ritualistic regarding their technique, thus the resistance to change. From my experience, having a surgeon champion that is well respected by other surgeons is the key to moving beyond what you have always done. Physicians respond well to data and literature that supports change and are generally willing to change their practice if it is clear that it is in the best interest of the patient.”
Surgeons and their staffs take skin antisepsis of their patients seriously, according to Robert Sawyer, MD, associate professor and co-director of the Surgical Trauma Intensive Care Unit in Charlottesville, Va. However, preparation of staff skin is sometimes a different story, he believes.
“Preparation of the surgeon’s or staff’s skin is taken less seriously, probably because the evidence is less compelling on how to do it well — scrub for two minutes versus five minutes versus alcohol rubs,” Sawyer says.
Surgeons and their staff members are all used to “meticulous sterile protocol,” says, William Ducey, MD, chief of surgery at Reid Hospital and Health Care Services in Richmond, Ind. “We do not allow barricades to good skin care,” he says. Ducey adds that one way to ensure good skin antisepsis is through meticulous technique and availability of appropriate antimicrobials and scrub supplies.
The consequences of poor surgical scrubbing can be fatal, but there are consequences to proper surgical scrubbing too — as any healthcare worker knows, thorough scrubbing can disrupt skin health.
“Every healthcare provider understands the importance of surgical scrubs and no one deliberately ignores it,” says Deborah Gardner LPN, OPA-C, CIC, technical manager of infection prevention for 3M. “The problem is what it does to your hands and the time it takes to appropriately scrub. The main barricade to good surgical scrubbing is what happens to the condition of your hands.
“For someone who scrubs four to five times or more a day, five days a week, hands can become irritated, raw and painful,” she adds. “The other barricade is time. With the shortage of both nursing staff and surgeons, time spent on scrubbing becomes crucial. It is extremely important for manufacturers to provide solutions that are easy on hands and efficient.”
Shaving Versus Clipping
At one time, preoperative shaving versus clipping was a debate, but since then clipping has taken a clear lead.
“Clipping is superior based on older data, probably because of less trauma to the skin itself,” Sawyer says. “We clip about 99 percent of the time in our hospital, and my impression is it is becoming the method of choice at most other hospitals.”
Ducey says clipping is the “de facto standard.” He says his facility has been clipping exclusively for many years, and suggests that clipping immediately before an operation is best.
For Manning, there is also no question about shaving versus clipping. He adds that using a razor for skin prep should never happen.
“The literature clearly shows that shaving puts patients at a higher risk of infection due to the trauma to the skin that can drastically increase the amount of organisms growing on the skin,” Manning says. “Due to the adoption of the SCIP (Surgical Care Improvement Project) measure by CMS, I think most hospitals are becoming increasingly compliant with clipper use.”
The shaving/clipping debate may be collecting dust, but the issue of antibiotic cycling is still up in the air. The literature on antibiotic cycling is in flux, Ducey says.
“Some proponents are in favor of antibiotic cycling in ICUs for prevention of hospital-acquired MRSA (methicillin-resistant Staphylococcus aureus) and other authors believe that cycling decreases development of antibiotic resistant strains of gram-negative organisms,” Ducey says. “These studies are interesting and intriguing but are not yet widely corroborated, and antibiotic cycling is therefore not yet the standard of care. So far it has not been proposed or thought to be of benefit in an operating room, or with respect to surgical infections.”
According to Sawyer, the benefits of cycling appear to reduce the “monotonous exposure” to one agent over time and reduce the selection pressures for any single agent.
“The potential drawbacks are that if you expose bacteria in an ICU to a series of antibiotics, you may actually increase your likelihood that resistance will show up to a multitude of agents,” he says.
Patient warming is another issue on which the jury is out. Healthcare professionals generally agree that patient warming is a factor in SSI occurrence, but sometimes disagree on the extent and the solutions.
For Nancy Coyne, RN, BS, however, the issue is quite clear. Coyne is a retired nurse and is a healthcare consultant for Cincinnati Sub Zero and says that unplanned hypothermia (even mild hypothermia) has been attributed to postoperative patient complications such as shivering, wound infections, and cardiovascular problems. Plus, metabolism of drugs is prolonged, Coyne says.
“All of these complications can contribute to prolonged postoperative recovery,” she adds. “Maintaining the patient’s temperature during the intraoperative period is important to prevent complications resulting from hypothermia. It would be a good research study to determine just how many hospitals are using preoperative measures to prevent hypothermia. There may be a direct correlation between the use of preoperative warming devices and surgical site wound infections.”
Coyne believes that there is not enough attention paid to the preoperative use of warming devices, and that this leads to intraoperative “catch-up” to achieve normothermia.
Temperature control has been studied best in colorectal surgery patients, according to Sawyer. “I know in our hospital we track those patients carefully and have been successful in bringing most patients to the recovery room with a temp (greater than 36 degrees), including the non-colorectal patients,” he says.
Some people have thought that temperature control has little influence on SSIs, but that theory is getting another look, Manning believes.
“The literature available suggests consequences of hypothermia such as adverse myocardial events, coagulopathy, reduced drug metabolism, thermal discomfort for the patient and increased risk of surgical site infection,” she says. “...I think initially the evidence was controversial but as we have learned more over time, active warming in the operating room is the right thing to do.”
Temperature of the patient is important to the immune system and is therefore a key factor in the prevention of wound infection, Ducey says. In fact, he believes that if every patient is kept normothermic, the amount of patients who develop SSIs will decrease. He adds that guidelines and national exposure brought patient warming toward the forefront of healthcare discussion.
“I think that every hospital in the country has or is developing protocols to make sure that every patient completes their operation and goes to the surgical recovery area in a normothermic state,” he says.
Troy Bergstrom, communications manager for Arizant Healthcare Inc., thinks that more education should be conducted to highlight the connection between SSIs and unintended hypothermia.
Hospital-acquired infections — including SSIs — claim many American lives, yet each year 14 million surgical patients still suffer from inadvertent hypothermia, and nationwide, between 30 percent to 40 percent of all surgical patients are hypothermic upon admission to recovery, according to Bergstrom.
Patient warming seems to be used selectively for surgical procedures, but should become commonplace for all surgical procedures, starting in the preoperative setting, he says.
“It’s something so inexpensive to implement — especially when compared to the cost of treating an infection — that not warming a surgical patient really just doesn’t make sense,” Bergstrom says. “Every surgical patient, no matter their age, sex or procedure length, deserves the benefit of forced-air warming.”
The relationship between hypothermia and SSIs is well documented, Bergstrom says. “The easiest way to prevent hypothermia in the OR is through prewarming,” he adds. “By beginning patient warming before surgery, you can significantly reduce the effects of temperature redistribution — the initial drop in temperature that results from anesthesia induction. You have to warm patients coming into the OR where warming can continue during surgery.”
The best way to prevent SSIs is to follow all known infection control protocols and to monitor compliance of those protocols, Ducey says.
“It then requires being meticulous in following all surgical patients for possible post operative infections, and tracking results so that surgeons and staff are kept fully informed about rates and types of infections, so that any potential negative trend can be acted upon quickly,” Ducey adds.
Manning agrees that practices must be monitored to ensure compliance. Manning also suggests strict adherence to measures from SCIP and the Association of Perioperative Registered Nurses (AORN). By following these guidelines, “surgical teams can significantly reduce the risk of surgical site infection in their patients,” she says.
Sawyer claims there must be a culture of safety for the whole operative procedure and staff, including timeouts, appropriate identification, intraoperative decision-making, etc. He is also a self-described big fan of standardization.
“If we can streamline the process so we don’t need to reinvent the wheel every time, there are fewer errors and unanticipated events,” he says.
1. Centers for Medicare & Medicaid Services. Medicare Takes New Steps To Help Make Your Hospital Stay Safer. 2008. www.cms.hhs.gov