Reducing Surgical Site Infections
By Don Sadler
The technological advances that have been made in medicine and surgery in recent years are nothing short of astounding. But even the most high-tech, whiz-bang OR equipment and procedures don’t seem to be making a dent in the prevalence of health care-associated infections (HAIs), including surgical site infection (SSIs).
According to the Centers for Disease Control and Prevention (CDC), between 5 and 10 percent of all hospital patients become infected with an HAI each year, or a total of about two million patients, and nearly 100,000 of them die as a result of the HAI.
Meanwhile, about 400,000 surgical patients become infected with an SSI each year, so SSIs account for about 20 percent of all HAIs. SSIs are the second most common type of adverse event occurring in hospitalized patients, with between 2-5 percent of all surgical patients becoming infected with an SSI. It costs an extra $22,995 on average to care for a patient who contracts an SSI.
Important But Not Urgent
An SSI occurs when micro-organisms from the skin or the environment enter the surgical incision. They can develop any time from between two to three days after surgery
until the wound has completely healed, which is typically two to three weeks after the surgery.
“SSIs are considered a ‘never event’ but they are obviously still a very big problem,” says Kaye Reiter, RN, MSN, the vice president of surgical services for Summa Health System in Akron, Ohio.
“One patient infection is too many,” adds Amber Wood, MSN, RN, CNOR, CIC, Perioperative Nursing Specialist with the Association of periOperative Registered Nurses (AORN). “That’s why we are always striving to achieve zero HAIs and SSIs.”
SSIs can lead to a wide range of patient problems.
“Patients with SSIs face longer hospital stays, higher readmission rates and increased medical costs,” says Wood. “They also experience a higher degree of pain and suffering, and they are at higher risk for developing other medical complications, including higher mortality risk.”
In addition, an infected wound can eviscerate and it takes longer to heal, Wood adds, and there may be complications if the wound doesn’t heal correctly.
“The scar that is left from the infected wound may have to be revised at a later date, which means an additional surgical procedure,” Wood explains.
“The bottom line is that recovering from an SSI can be a long and exhausting process for the patient,” Wood says.
A Top Priority
“SSIs can be devastating, which is why reducing SSIs is a top priority for most ORs today,” adds Sherry S. Hardee, MSN, RN, CNOR, NEA-BC, vice president, Catawba Valley Medical Center in Hickory, North Carolina. “When they do occur, we do a deep dive to look at every factor related to the patient’s care that could have been a contributing factor to the SSI. We want to look at all the pieces of the puzzle and address any contributing factors so they don’t happen again.”
The most important key to preventing SSIs is strict adherence to sterile and aseptic technique.
“There is a move now to go back to the basics of sterile technique,” says Hardee. “This includes following the Surgical Care Improvement Project (SCIP) guidelines.”
Melissa Lingle, BSN, RN, CNOR, the unit director for the operating room at Summa Health System in Akron, Ohio, emphasizes the importance of choosing the right prep solutions and allowing them to dry appropriately.
“Patient skin prep is key — using the right prep solutions the right way,” she says.
During pre-admission prep, Lingle says that patients are given chlorhexidine wipes three days prior to surgery and told how to wipe and clean the surgical site before coming in to the hospital.
“We also tell them to wear clean pajamas and sleep on clean bed sheets the night before surgery and to shower the morning before surgery,” Lingle says.
“The goal should be to educate and prep patients to prevent infection every step of the way, including before they come in to the hospital for surgery,” she says.
Wood says that perioperative nurses can incorporate actions from evidence-based guidelines into their nursing practice to prevent SSIs.
“For skin antisepsis, OR nurses should review the manufacturer’s instructions for use to ensure that they are using the product safely and effectively,” she says. “Allowing skin antiseptics to be in contact with the skin and dry for the recommended time will enable the antiseptic to work to its full potential.”
The Importance of Hand Hygiene
One of the simplest and most effective things that OR nurses and other perioperative team members can do to prevent SSIs, Wood stresses, is to frequently and thoroughly wash their hands, especially before beginning the preoperative skin antisepsis.
“Also make sure all perioperative surfaces are clean before beginning the perioperative skin antisepsis,” she says.
“It’s terrible to think we don’t have time to wash our hands, but that’s how it feels sometimes when we have so much to do,” Wood adds. “Unfortunately, the pressure to save time and increase efficiency will always be there. But we have to remember that the first and most important priority is keeping our patients safe.”
“Every OR leader’s mantra should be: Yes, efficiency is important, but not at the cost of safety,” says Reiter. “We have a safety program in place that includes mandatory education for both nurses and physicians that’s designed to eliminate potential breakdowns in safety processes that could lead to HAIs and SSIs.”
“No nurse would ever do anything to intentionally harm a patient,” adds Lingle. “But it’s kind of an unspoken rule in many ORs today that speed is important — you’ve got to get the patient on the operating table and get going. We need to make sure we slow down enough to make sure patients’ skin is properly prepped and the prep has time to dry so it can do its job fighting bacteria.”
These cost and efficiency pressures can be especially overwhelming for new nurses who are still trying to find their voice in the OR, says Hardee.
“All OR nurses, regardless of their tenure, need to feel empowered to speak up for patient safety when they feel they need to,” she says.
OR nurses can overcome pressures to increase efficiency possibly at the expense of safety by explaining their rationale to perioperative team members and providing supporting documentation, such as evidence-based guidelines and manufacturers instructions for use.
“Leadership support is also vital to the bedside perioperative nurses’ success in making an impact on team members,” says Wood.
AORN SSI Guidelines Updated
According to Wood, AORN guidelines addressing SSIs were approved by the Guidelines Advisory Board as final and published in the 2015 AORN Guidelines for Perioperative Practice.
She says the top changes for this year include recommendations that the patient should bathe or shower before surgery with either a soap or an antiseptic, guidance for selecting safe and effective skin antiseptics at the facility level and for individual patients, and an emphasis on applying skin antiseptics in accordance with the manufacturer’s instructions for use.
“The AORN Guidelines also incorporate new guidance from the FDA that skin antiseptics must be stored in their original, single-use containers,” she says.
When it comes to SSIs, “one patient infection is too many,” says Wood. “That’s why we are always striving to achieve zero SSIs.”
