By Don Sadler
Despite the many amazing advancements in modern medicine, surgical site infections (SSIs) remain a problem for hospitals and ambulatory surgery centers (ASCs) nationwide. According to the Agency for Healthcare Research and Quality (AHRQ), SSIs occur in approximately 2% to 4% of all patients undergoing inpatient surgical procedures and account for up to 20% of preventable healthcare associated infections (HAIs), costing $3.3 billion annually.
The CDC’s National Healthcare Safety Network (NHSN) estimates that approximately 110,800 SSIs occur in inpatient surgeries each year. However, the actual number of SSIs could be significantly higher.
“I believe that the SSI rate is under-reported due to limitation with our current 30- and 90-day follow-up with surgical patients,” says independent perioperative consultant Peter Graves BSN, RN, CNOR. “If we were to conduct more robust SSI follow-up over a much longer time, SSI statistics would likely result in a significantly higher SSI rate.”
According to Doe Kley, RN, MPH, CIC, surgical site infections remain one of the most preventable complications associated with surgical care. “Yet they continue to burden patients and surgical organizations alike,” she says.
Types of SSIs
Independent infection prevention consultant Maureen Spencer, M.Ed, BSN, RN, CIC, FAPIC, identifies three classifications of SSIs: superficial incisional, deep incisional and organ/space.
“Superficial incisional infections are the most frequent while deep and organ/space infections are usually the most clinically significant since they affect deeper tissues or cavity/organs within the body,” says Spencer. “In practice, perioperative teams are most concerned about the deeper and organ/space infections that most often drive significant morbidity, readmissions and reoperations.”
“In both hospitals and ASCs, which now perform an increasing share of surgical volume, SSIs remain the primary infection concern,” says Kley. “While ASCs often care for healthier patients undergoing lower-acuity procedures, the consequences of an SSI can still be significant, especially given the expectation of same-day discharge and rapid recovery.”
SSIs can lead to myriad problems for both patients and healthcare facilities. “Infections increase readmissions, repeat surgery and recovery time for patients while hospitals and ASCs face financial, operational and reputational impacts,” says Kley.
Adds Spencer: “For patients, SSIs link to delayed healing, pain, anxiety, prolonged antibiotic therapy, emergency department visits and, in worst-case scenarios, sepsis or death. For facilities, SSIs drive length of stay, utilization, cost and quality-reporting pressure.”
According to AHRQ estimates, the additional inpatient cost per SSI is approximately $28,219 on average.
In addition, SSIs increase mortality risk from two- to 11-fold, according to the NHSN, and patients with SSIs have a three- to five-times higher risk of readmission. SSIs also extend the length of hospital stay by about 10 days.
Spencer says ASCs face the additional challenge that SSIs may manifest after discharge, resulting in urgent center calls, ED visits, surgeon office visits and transfer of care or readmission elsewhere. “Educating patients about infection risks before they go home is important, as is careful wound monitoring by the patient for signs of infection,” she says.
SSI Prevention: Key Takeaways
• Surgical site infections (SSIs) remain the most common and costly healthcare associated infection (HAI).
• SSIs increase readmissions, repeat surgeries and patient recovery time.
• Hospitals and ASCs face financial, operational and reputational impacts from SSIs.
• Routine hand hygiene is critical to SSI prevention — even outside the sterile field. Glove use does not replace hand hygiene.
• Easy access to hand hygiene products improves adherence.
• Consistent execution of basic practices remains the strongest defense against infections.
Bundled Approach
The biggest key to preventing SSIs is taking a bundled approach to infection prevention. “Maureen and I commonly discuss the use of the 7S bundle as a structured approach to SSI reduction,” says Graves. “These key bundle elements draw primarily from the CDC’s Core Infection Prevention and Control Practices and the current AORN Guidelines.”
According to Amber Wood, MSN, RN, CNOR, CIC, FAPIC, senior perioperative practice specialist with the Association of periOperative Registered Nurses (AORN), the AORN Guidelines for Perioperative Practice contain a new addition related to SSI prevention.
“The Guideline for Implementing Enhanced Recovery After Surgery (ERAS) reinforces a holistic, evidence‑based approach to care throughout the perioperative continuum,” says Wood. “It highlights that SSI risk is influenced by multiple interconnected factors, including patient optimization, perioperative practices and postoperative care.”
Adds Wood: “When patients recover more efficiently and complications such as poor wound healing, hyperglycemia and hypothermia are reduced, the overall risk for SSIs decreases. This mindset shifts the focus from reacting to infections to proactively creating conditions that promote healing and lower SSI risk.”
Dr. Lisa Maragakis, the president of the Society of Healthcare Epidemiology of America (SHEA), believes that SSI prevention requires multi-disciplinary collaboration and a multi-layered set of interventions. “Hand hygiene is the foundation of infection prevention and one of the most effective measures to prevent transmission of pathogens,” she says.
Spencer calls hand hygiene “fundamental because all other sterile processes fall apart if organisms are transmitted on hands. The CDC core practices focus on performing hand hygiene before contact with the patient, after blood/body fluid or surface contamination and immediately after removing gloves.”
“Hand hygiene is one of the pillars of infection control that can be most effective in preventing an infection,” says Haley Hoffman, BSN, RN, CIC, an infection preventionist/emergency management specialist at Crystal Clinic Orthopaedic Center in Akron, Ohio. This applies not only to the perioperative team but to patients after they are discharged.
“TTop of Formhink of all the things patients may have touched throughout the day and now think of a brand-new wound,” says Hoffman. “For example, did they go to the bathroom and forgo washing their hands and then scratch an itch on the fresh surgical site? Now they have taken any of the organisms that naturally live in fecal matter and put them in an environment they don’t belong and let them flourish. All of this could have been prevented if the patient took the time to wash their hands.”
Hoffman believes nurse education is critical to improving hand hygiene in the perioperative environment. “If an OR nurse doesn’t understand how to properly scrub their hands or maintain a sterile field, then they may have inadvertently contaminated the case, which could spread to more cases,” she says. “So, make sure your staff are trained properly and test their skills at hire and annually to catch problems before they turn into an outbreak.”
A High-impact, Evidence-based Practice
According to Graves, hand hygiene has been a high-impact, evidence-based practice since Semmelweis’s hand hygiene (HH) recommendation in 1847.
“Unfortunately, we are still discussing hand hygiene after 179 years,” he says. “It’s time we more aggressively utilize automation to increase tracking and compliance in every unit, including the operating room.”
Kley differentiates between routine hand hygiene and surgical scrubbing. “While clinicians may associate the OR primarily with sterile technique, many opportunities for contamination occur outside the sterile field,” she says.
Examples include entering and exiting the OR; handling equipment, supplies, charts or computers; touching anesthesia workstations, monitors or medication carts; and moving between clean and contaminated tasks.
“Hand hygiene should be treated as expected, not optional, behavior,” says Kley. “Alcohol-based hand sanitizer should be readily accessible and perioperative staff should be trained on appropriate indications.”
More SSI Prevention Practices
In addition to practicing hand hygiene, Graves lists a number of evidence-based SSI prevention practices:
- Proper use of personal protective equipment (PPE): This includes performing hand hygiene before donning and immediately after doffing, with proper disposal of PPE in facility-approved waste receptacles.
- Safe injection practices and aseptic technique during procedures: This includes but is not limited to the use of ultrasound probes that have not been high-level disinfected prior to use in invasive procedures.
- Antimicrobial prophylaxis: “In a study published in Surgical Infections, we reported that antibiotic prophylaxis was better than other colorectal bundle elements, but still not 100 percent so we still have work to do here,” says Graves.
- Preoperative patient preparation: This includes a full-body shower/bath with soap or antiseptic the night before surgery, avoiding unnecessary hair removal (using clippers if needed), optimizing glycemic control and smoking cessation.
- Intraoperative measures: These include alcohol-based skin preparation, maintaining normothermia, sterile technique and environmental controls (e.g., proper ventilation, instrument sterilization) and keeping the OR doors closed.
Maragakis recommends the following SSI prevention steps:
- Optimizing nutrition and the treatment of chronic conditions
- Clipping hair outside the OR before the surgery
- Sterile technique and proper instrument processing
- Maintaining normal body temperature and blood glucose levels during and after surgery
- Environmental cleaning and air handling systems designed for the OR
- Minimizing traffic in and out of the OR during cases
Barriers to Implementation
While evidence-based SSI prevention practices such as these are well-documented, not all hospitals and ASCs follow them consistently. There are several well-documented obstacles that prevent perioperative teams from doing so.
According to Graves, these barriers fall into a few specific categories: individual, organizational/institutional, leadership/management and environmental/resource. “Many are interconnected and overcoming them requires multi-modal, context-specific strategies,” says Graves.
Spencer lists the following obstacles to following SSI prevention practices:
- Surgical throughput workflow pressure
- Inconsistent team adherence
- Poor placement or availability of hand hygiene supplies
- Normalization of shortcuts
- Lack of OR traffic control
- Variation in the implementation from case to case of infection prevention bundles
“The best way to break through these barriers is to make sure you design the system, so the appropriate action is also the easy action,” says Graves. “For example, place alcohol-based hand sanitizer where it’s needed, standardize SSI bundle elements, regularly audit compliance with standards, minimize unnecessary OR traffic, and create a culture of safety in which anyone can speak up if technique slowly drifts.”
ASCs face unique challenges when implementing SSI prevention practices, says Spencer.
“Limited space, lean staffing and rapid room turnover can further complicate compliance for ASCs,” Spencer says. “Also, clinical staff, not environmental services staff, perform the room turnover cleaning in ASCs. They often have not been properly trained on cleaning and disinfection practices and adhering to the disinfectant label’s directions for use, including the all-important contact time.”
Spencer lists the following tips for overcoming these challenges:
- Place hand hygiene products at clear points of use, including anesthesia areas.
- Design workflows that support compliance without slowing care.
- Reinforce that glove use does not replace hand hygiene.
- Provide role-specific education tailored to OR and ASC workflows.
- Use observation with just-in-time feedback to normalize best practices.
Maragakis acknowledges the time pressure, workflow constraints and staffing shortages that can make it difficult to consistently follow infection prevention practices. “The complexity of the OR environment and the number of different healthcare personnel and disciplines involved make it difficult to ensure that evidence-based SSI prevention measures happen consistently,” she says.
Ideally, infection prevention practices are built into the normal OR workflow so it’s easy to follow the right steps. “Real‑time reminders and leadership support are also important to foster a culture of safety,” says Maragakis.
Applying Infection Prevention Practices
Graves stresses that while infection preventionists and dedicated IPC teams often lead facility-wide efforts, OR staff represent one of the most intensely focused and specialized groups in applying infection prevention practices daily.
“This stems from the high-stakes nature of the operating room environment, where even minor lapses can directly contribute to SSIs,” says Graves. “OR teams are frequently at the forefront of implementing evidence-based bundles and they often serve as champions for these practices within their units and beyond.”
Graves points to resources like AORN’s Guidelines for Perioperative Practice and the APIC Infection Preventionist’s Guide to the OR as especially helpful in the battle to eliminate SSIs. “AORN’s Guidelines integrate infection prevention across numerous recommendations, many of which form the core strategies we use in the OR to prevent SSIs,” he says.
“Preventing infections requires team coordination – surgeons, anesthesiologists, nurses, environmental services and administrators all play vital roles,” says Maragakis. “It’s also essential to keep up with the latest evidence and guidelines to ensure practices evolve with the science.”
Spencer says preventing SSIs is almost never a single dramatic fix or “magic bullet. It’s about executing the prevention measures at an exceptional level, for every patient and every procedure, every time.”
