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Surgical Site Infection PreventionELIZABETH BUDGE-NEAL RN,CIC

Learning Objectives

Identify PrehospitalInterventions to improve

patient outcomes.

Identify Hospital Interventions that will decrease surgical site

infection risk.

Identify Intraoperative Interventions that will reduce

the risk of surgical site infection.

Identify Post-hospital Interventions for the

prevention of surgical site Infections.

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Introduction: Surgical Site Infections

Surgical Site Infections are infections of the incision or organ or space that occur after surgery.

SSI accounts for 20% of all hospital acquired infections. They are quite common and can be associated with poor outcomes.

SSI increases patients length of stay, risk for re-admission-return to OR, decreased function and increased risk for mortality.

Evidence suggests that SSI can be prevented by using evidence-based strategies. (SSI Prevention Bundle)

American College of Surgeons and Surgical Infection Society, CDC, expert panel review created guidelines.

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Classification for Surgical Site Infection:4

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Chain of Infection:Infection Agent:

BacteriaFungiVirus

ProtozoaParasite

Reservoir:People

EquipmentWater

Portal of Exit:ExcretionsSecretionsDroplets

Mode of Transmission: Contact

DropletAirborne

Vectorborne

Portal of Entry: Respiratory Tract

Gastrointestinal TractGenitourinary TractMucus Membrane

Skin

Susceptible Host: Immune compromised

ElderlySurgical Patients

BurnsDiabetic

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Break the Chain:

Treatment of Primary Disease: Optimize the patient, Recognize High Risk Patients.

Aseptic technique, Wound Care, Hand Hygiene, Surgical Prep.

Environmental Controls: Airflow, Temperature, humidity, Decontamination, Disinfection/Sterilization, OR traffic.

Proper Attire, proper environmental sanitation and disposal.

Rapid identification of organism and prompt treatment.

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Modifiable: Smoking status, Glycemic control-diabetic status, alcohol use status, obesity, immunosuppression, nutritional status.

Non-Modifiable: Age, recent radiotherapy, Skin or soft tissue infection, other co-morbidities.

Procedure related risks: Emergent case, complex surgery and wound classification, duration of case, asepsis, poor surgical scrub, implants.

Facility risks: Ventilation, traffic in OR, disinfection/sterilization of equipment and OR environment.

Pre-op Risks: Skin infection, inadequate skin prep, hair removal, antibiotic selection and administration.

Risk Factors: Intrinsic patient factors (Modifiable/Non-Modifiable)

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Pre-Hospital Interventions

• Glycemic Control-Levels < 140.

• CHG Bathing

• Smoking Cessation 4-6 weeks prior to

surgery.

• MRSA screening/nasal Decolonization.

• Bowel preparations.

• Medical Optimization

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Hospital Interventions:

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• Hair removal should be avoided unless interference with

surgery.

• Skin Preparation-Chlorhexdine/iodine when combined with

alcohol. If alcohol cannot be included in prep, CHG should be used instead of iodine

unless contraindications

exist.

• Surgical hand scrub/hygiene.

• Surgical attire-no jewelry, clean surgical scrubs,

disposable bouffant hats, clean covered shoes.

• Prophylactic Antibiotics when indicated within 1 hr

of incision. Weight adjusted.

• Re-dose to maintain adequate tissue level

based on half-life or blood loss.

Hospital Interventions cont:

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• Supplemental Oxygen in

immediate postop period.

• Wound care/Standardized

wound management.

• Normothermia. Pre-op/Intraop

recommended.

• Reduced OR traffic

• Glucose control: Maintain target110-

150.

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Post-Hospital Interventions:

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FOLLOW UP: Advise and educate patients

of signs and symptoms of surgical

site infections.

Contact primary surgeons office

immediately with any concerns surrounding

infection.

• Scheduled outpatient follow up

with primary surgeon.

Discussion:

The most widely used definition of SSI has been provided by the CDC/NHSN. The definitions are used for research, quality improvement, public reporting, and pay for performance comparisons.

SSI classifications are by depth and tissue spaces involved. Superficial, deep, or organ space.

SSI complication leads to increased cost, morbidity and mortality.

Achieving low SSI rates serves as a good measure/indicator for evaluating the surgical practice and quality of care delivered.

SSI risk is related with several factors including patient, intervention and postoperative dependent factors that could lead to observed differences in SSI rates.

SSI factors are not all under the surgical team’s control. Using all the strategies as a bundle to decrease the risk is crucial to the success of SSI reduction efforts.

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Discussion:

Surgical Site infections occur as a complex interaction during the chain of infection.

Different surgical procedures are at different risks for infection.

Co-Morbidities/ acute and chronic medical conditions of your patient become important variables in the likelihood of the patient developing an SSI.

The multiple preventative measures discussed have been demonstrated to reduce the frequency of SSI. Even with all the measures in place, Infections still occur and require effective management.

Bundling pre-hospital, hospital, and post-hospital interventions have been shown to decrease SSI. Successful implementation requires the key stakeholders support and compliance.

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References:

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons,2017 Volume 224,Issue 1, Pages 59-74.

The Journal of Arthroplasty. Volume 36, Issue2, February 2021, Pages 752-766. IS preoperative Staphylococcus aureus Screening and Decolonization at reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis.

Surgical Sit infection in hip arthroplasty in a 10 year follow-up prospective study: Risk and factors associated. American Journal of Infection Control December 2020 Volume 48 Number 12.

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784-791.doi:10.1001/jamasurg.2017.0904

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References:

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Association of Perioperative Registered Nurses 2006. Recommended standards for practices and guidelines. AORN practice resources.

SHEA/IDSA Strategies to prevent Surgical Site Infections in Acute Care Hospitals: 2014

American Journal of Infection Control. Guide to the elimination of orthopedic surgical site infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide. August 26,2011 Vol 40, Issue 4 P384-386

APIC Text: Surgical Site Infection. Chapter 38 Donald E fry, MD. Northwestern University Feinberg School of Medicine Chicago Il. May 21,2018

Questions/Comments:

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