Help the Surgical Team Sidestep Infection in the OR

October 1, 2002

Help the Surgical Team Sidestep Infection in the OR

Help the Surgical Team Sidestep Infection in the OR

By Sue Sebazco, Rn, BS, CIC

The Centers for Disease Control and Prevention (CDC) estimatesthat 27 million surgical procedures are currently performed in the United Stateseach year.1 The CDC's National Nosocomial Infections Surveillance (NNIS)system reports that surgical site infections (SSIs) are the third mostfrequently reported nosocomial infection. This accounts for 14 percent to 16percent of all nosocomial infections among hospitalized patients. It is a factsupported by published studies that increased length of stay and cost areassociated with SSIs.2-4

Although there have been advances in infection control practices, SSIs remaina substantial cause of morbidity and mortality in hospitalized patients. Some ofthe reasons given for this are the emergence of antimicrobial-resistantpathogens, increased numbers of immunocompromised patients who are havingsurgery, and increased numbers of prosthetic implants and organ transplantoperations being performed. If the risk of SSIs is to be reduced, it must berecognized that risks are influenced by characteristics of the patient,operation, personnel and the hospital. This article will review practices thatshould 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 andrecommendations available on infection control practices from the CDC and thesurgical team's professional associations, such as the Association ofperiOperative Registered Nurses (AORN), the American College of Surgeons and theAmerican Society of Anesthsiologists. The infection control practitioner (ICP)should be familiar with the content of these references to identify bestpractices 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 increasedapprehension among surgical personnel, administration and risk management. Whenthis occurs, other staff members often look to the ICP to find the reason forthe increased rate. It is up to the ICP to validate the problem and, ifwarranted, begin an investigation. The ICP should keep in mind that risk ofinfection is influenced by characteristics of the patient, the procedureperformed, the personnel and the hospital. The investigation can be multifacetedand comprehensive.

Surveillance

Through routine surveillance activities or reports received from the staff,an opportunity for improvement may emerge. Once identified, it should bedetermined if there is evidence that this is a departure from the facility'snormal experience; this can be done by reviewing data collected during aprevious reporting period and comparing it to the current incidence.Benchmarking the facility's incidence with the NNIS System data can also helpdetermine the need for further investigation. CDC classifies SSIs intoincisional, organ or other organs and spaces manipulated during an operativeprocedure. Incisional infections are either superficial (skin and subcutaneoustissue) or deep (deep soft tissue and fascia). When defining SSIs, thesecriteria should be consistently applied to insure credible data that can bebenchmarked accurately.

Investigation

If the increase of SSIs is noted overall or on a specific service, a reviewof current practices needs to be initiated. At this point, having a checklist ofrecommended practices from the various resources can aid in making sure thereview is thorough.

The ICP should meet with a core group representing the affected area, eitherindependently or as a group, to review recommendations and compare with currentpractice. The OR staff may begin to contribute theories on why the increase hasoccurred. These suggested theories must be considered but not accepted on facevalue. All identified SSIs, past and present, must be reviewed for commonfactors. All too often, there is a demand for environmental cultures voiced fromone or many staff. Cultures are necessary only if there is an epidemiologicalassociation with a person or an environmental source.1

Risk Factors

The CDC "Guideline for Prevention of Surgical Site Infection, 1999"lists the patient and operation characteristics that influence the risk ofsurgical site infection development. Consideration should be given to patientcharacteristics when trying to determine the source of an SSI rate increase. Thepatient's age and nutritional status may be associated with increased risk incertain kinds of operations. Although the contribution of diabetes to SSI riskis controversial, there are some preliminary findings that showed an associationwith increased glucose levels (greater than 200mg/dl) in the immediatepostoperative period.5-6 Other characteristics that may contribute toa greater risk for developing an SSI are nicotine use, obesity, coexistinginfections at a remote body site, colonization with microorganisms, alteredimmune response and length of the preoperative stay. The operationcharacteristics include the duration of the surgical scrub, skin antisepsis andpreoperative shaving and skin preparation. Also, the length of the operation andantimicrobial prophylaxis can influence the development of an SSI. Foreignmaterial in the surgical site can increase risk. The OR ventilation andinadequate sterilization of instruments can add to the risk. Surgical techniqueby the scrub team is another characteristic to consider. Gentle handling andmanipulation of the tissue during the operative procedure can prevent tissuetrauma that can lead to infection at the site.

Microbiology

The primary reservoir for organisms that are isolated from SSIs are thepatient's endogenous flora. The pathogens that are isolated from SSIs areusually predictable depending upon the procedure performed. In clean surgicalprocedures Staphylococcus aureus from the patient's skin flora or from theexogenous environment is the usual cause of infection. When the site of theprocedure is the respiratory tract, gastrointestinal and genitourinary, theaerobic and anaerobic pathogens isolated most frequently from an infectionresemble the microflora that is endogenous to the specific site.

Prevention

The CDC's SSI guideline makes the following Category 1A recommendations forprevention of SSIs. A Category 1A ranking is one that is strongly recommendedfor implementation and supported by well-designed experimental, clinical, orepidemiological 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, thosethat are strongly recommended for implementation and supported by someexperimental, clinical or epidemiological studies and strong theoreticalrationale.

  • 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 previouslydiscussed or they are ranked Category II (suggested for implementation andsupported by suggestive clinical or epidemiological studies or theoreticalrationale. or no recommendation, unresolved issue (practices for whichinsufficient evidence or no consensus regarding efficacy exists.)

Recent Developments

Since these CDC guidelines were published in 1999, more recentrecommendations or published articles present some updated information forconsideration when addressing how to prevent SSIs.

A recently published article reported on the use of mupirocin ointment toprevent postoperative Staphylococcus aureus infections.7 The authorsconcluded that prophylactic intranasal application of mupiricin did notsignificantly reduce the rate of Staphylococcus aureus SSIs overall, but didsignificantly decrease the rate of all nosocomial Staphylococcus aureusinfections among the patients who were Staphylococcus aureus carriers.

The draft version of the anticipated CDC "Guideline for Hand Hygiene inHealthcare Settings" addresses using an alcohol-based handrub or anantimicrobial soap before donning sterile gloves when performing surgicalprocedures. Also, to reduce the number of bacteria on the hands of surgicalpersonnel, while minimizing skin damage related to surgical hand antisepsis,hands should be decontaminated without a brush. A word of caution should benoted when evaluating the newer brushless surgical scrub agents. Make sure theproduct has been approved by the FDA for use as a surgical scrub agent in itsfinal formulation.

Conclusion

The sound judgment and proper technique of the surgeon and surgical team andthe general health and disease state of the patient are the most criticalfactors in the prevention of SSIs.8 When problems arise and bestpractices are revisited, it is common for the rate of SSIs to decrease. Thesurgical team should be vigilant at all times and compliant with recommendedpractices to prevent postoperative infections in the surgical patient.

Sue Sebazco RN, BS, CIC, is the infection control/employee health directorat Arlington Memorial Hospital in Arlington, Texas.