By Raynetta Stansil (surgical-solutions.com)
Of all the surgical procedures performed annually, most heal without complications. Surgical site infections (SSI) are common complications that may occur 30 days after surgery. These infections can be incisional or organ-related infections. These infections may delay healing and can increase the cost of care. Understanding the clinical and financial impact of SSIs is of critical importance to patients and health care facilities. Many of these complications can be avoided by implementing these five SSI prevention strategies.
- All members of the surgical team including the surgeon, the operating room technician, the surgical technician, and others who will work on the operating field should scrub arms and hands with antiseptic solution.
- Sterile gloves must be worn and changed immediately after any inadvertent punctures.
- The operating site should be scrubbed with a detergent and an antiseptic soap should be applied.
- Sterile drapes must be placed on the patient and on any equipment included in the sterile field.
- Good surgical technique must be used to decrease procedure duration which lowers the risk of SSI.
All members of the surgical team must practice these strategies for each and every procedure. Deviations from these strategies can lead to increased SSIs which endangers patient safety and increases costs for both the patient and health care facility.
Following proper hand hygiene protocol is often seen as the most effective way to prevent surgical site infections. Between each patient contact, hands need to be washed. Surgical hand antisepsis cleans health care workers’ skin and removes debris and microorganisms present on the nails, hands and forearms. Personnel should perform their scrub process according to the established facility policies and procedures. Surgical hand antiseptic solution should be readily available and approved by the facility’s infection control center. Institutions use different scrub products, each with distinct manufacturer directions for scrubbing technique and times. Some organizations use medicated hand scrub products, and others have implemented brushless, waterless scrubbing techniques using waterless alcohol-based products. This solution should be used prior to sterile gloves being put on. All facilities should establish protocols based on the Center for Disease Control or World Health Organization guidelines for hand hygiene. These should be reviewed periodically to maintain compliance. Establishing this protocol is only one piece to this solution. Ensuring that every member of the facility’s staff is regularly following this protocol requires routine monitoring and disciplinary action if not followed.
The below outlines the general procedure for the Surgical Hand Scrub as detailed by the AORN Standards for Surgical Attire:
- Remove jewelry, including watches, bracelets, and rings, as they may harbor microorganisms.
- Wear appropriate surgical attire, including head covering that covers hair (including sideburns and neckline), a mask that covers the nose and mouth, protective eyewear or face shield, shoes that provide protection.
- Fingernails should be short, clean, and healthy. Artificial nails are not permitted for any health care personnel having direct contact with patients.
- Cuticles, hands and forearm are free of open lesions and breaks in the skin.
- An effective antimicrobial surgical hand scrub agent approved by the Infection Control Committee is used for the surgical hand scrub.
- The surgical hand scrub procedure is standardized – anatomical timed scrub, counted stroke scrub or the brushless hand rub/scrub.
- Roll sleeves of scrub top to at least 3 inches above the elbow, and tuck scrub shirt into scrub pants.
- Open the sterile scrub brush package and position it for easy access.
- Adjust the water to a comfortable temperature and flow to prevent spraying scrub attire. Water is controlled with knee panel on sink.
- Wet hands and forearms.
- Lather hands and forearms 2 inches above the elbows, using an antimicrobial soap. This loosens the surface debris and removes cross-contamination.
- Rinse hands and arms while keeping fingers pointed upward so water drips at the elbows away from the scrub attire.
- Dry hands and arms thoroughly with paper towels.
- Remove nail cleaner from package; clean under nails of both hands using nail cleaner while holding hands under running water. Discard nail cleaner.
- Rinse hands.
- Remove scrub brush and squeeze it under water to dispense soap (if brush contains soap) or apply soap from dispenser.
- Avoid contact with faucet or sides of sink. If contact occurs, the scrub procedure must be started again using a new brush.
- Using either the anatomic timed scrub or the counted stroke method, hold the brush perpendicular to the fingertips and scrub the nails, scrub the fingers using a back and forth motion on all four sides of each finger, pay attention to the webbed spaces of each hand, bend the fingers to flatten the creases or knuckles while scrubbing. A clock should be visible when the timed scrub method is used.
- Scrub the palm and the back of the same hand to the wrist using a circular motion.
- Maintain the lather and ensure that friction is used on all skin surfaces and that the skin is sufficiently exposed to the antimicrobial agent.
- Move to the arm: Scrub by mentally dividing the arms into thirds, each third having four planes. The first third is the wrist, the second third is the middle area, and the last third is the proximal third, which is about 2 inches above the elbow. Scrub for 15 strokes for each plane or 2 minutes.
- Transfer the scrub brush to the other hand and repeat steps for scrubbing from fingertips to 2 inches above elbow.
- Discard the brush into the waste container, dropping it in, keeping hands up and away from body.
- Rinse hands and arms under running water, starting at fingertips and working toward elbow, keeping the hand upright and elbow in a downward position
In addition to proper hand hygiene, surgical attire and personal protective equipment (PPE) are essential to preventing infection. The operating room should have clearly written policies and procedures for personnel attire and should monitor to ensure that staff follow hospital-approved policies. All operating room staff should be appropriately attired for the semi-restricted and restricted areas. Each facility determines its own policy for personnel attire for the physicians, nurses, assistants, technologists who work in the operating room and other support staff who enter for specific purposes such as bringing or removing supplies, laundry, instruments and wastes. AORN provides three main recommendations regarding surgical staff attire:
- Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting.
- All individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a health care-accredited laundry facility or disposable scrub attire provided by the facility and intended for use within the perioperative setting.
- Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears and facial hair.
Staff should wear clean, freshly laundered scrubs. Scrubs should be laundered by the hospital to ensure correct water and drying temperatures and management of clean linen. Also, staff should wear head coverings over all hair. Fabric head coverings should be laundered at least daily and after contaminated cases. Frequently, bouffant coverings made of disposable material are used to ensure that all hair is enclosed. If surgeons or assistants have beards or other facial hair, this hair must be covered. A mask is required when staff members are in the operating room to setup for the surgical procedure and during the procedure. Other PPE, such as a mask with face shield or a mask with goggles, should be used when splashing to the face is anticipated. Shoe coverings in the preoperative care areas are not indicated unless the personnel will enter the semi-restricted or restricted areas of the operating room.
Another important key to prevention is tracking. Typically, a surgical site infection will occur after a patient has left the facility. It’s essential that data from the patient in which the infection occurred is gathered and tied back to the surgical team and procedure that was completed. Without this step, further infections in other patients become difficult to prevent. If the reason for the infection can be identified, further steps can be taken, and re-education may be needed.
It is the responsibility of every member of the surgical team to work together to prevent the number of surgical site infections that occur in patient’s post-surgery.
– Raynetta Stansil is an independent health care consultant and clinical educator at Surgical Solutions.