1. Surgical Site Infections (SSIs): What the Direct Caregiver Should Know
Preventing
Surgical Site Infections (SSIs):
What the Direct Caregiver Should Know
Prepared by
Ann Bailey, RNC, BSN, CIC
Joanne Dixon, RN, MN, CIC
December 16, 2009

2. Define Surgical Site Infection
Objectives Upon completion of this module, the learner will be able to:
Define Surgical Site Infection
Name 4 factors that may influence the development of surgical site infections
List 3 bundle components SFoH practices which decrease the risk of surgical site infections
From CDC’s NNIS

3. What Is a Surgical Site Infection?
Infection at the site of surgery that occurs within 30 days of surgery if there is no implant (hardware, artificial graft, mesh, etc) OR occurs within 1 year of the surgery with an implant in place
Types of SSIs:
Superficial incisional
Deep incisional
Organ or body space
From CDC’s NNIS

4. Why Prevent SSIs?
Approximately 500,000 surgical site infections (SSI) occur annually in the United States
Patients that develop SSI have twice the mortality and are:
60% more likely to spend time in ICU
5 times more likely to be readmitted
From CDC’s NNIS

5. Why Prevent SSIs?
SSI increases length of stay in hospital by an average of 7.5 days
$2,734 to $26,019 extra cost per SSI (1985, US dollars)
$130 million to $845 million per year estimated national costs in the USA
From CDC’s NNIS

6. Factors That may Influence SSI Development
Patient
Age
Nutritional status
Diabetes
Smoking
Obesity
Coexistent infections at a remote body site
Colonization with microorganisms
Altered immune response
Length of preoperative stay
CDC Guideline for Prevention of Surgical Site Infections, 1999

7. Factors That may Influence SSI Development
Operation
Duration of surgical scrub
Skin antisepsis
Preoperative shaving
Duration of operation
Antimicrobial prophylaxis
Operating room ventilation
Inadequate sterilization of instruments
Foreign material in the surgical site
Surgical drains
Surgical technique
CDC Guideline for Prevention of Surgical Site Infections, 1999

8. What Are We Doing at SFOH to Prevent SSIs?
Utilizing good surgical hand antisepsis & hand hygiene

9. What Are We Doing at SFOH to Prevent SSIs?
Using a best practice “bundle” on all surgical patients
Adapted from the Surgical Care Improvement Project (SCIP) Infection prevention components

10. Remember a Bundle is:
A grouping of best practices that individually improve care, but when applied together result in substantially greater improvement.
Science behind the bundle elements is well established – the standard of care.
Bundle element compliance can be measured as
“ yes/no.”
“All or none” approach.

11. Surgical Site Infection Prevention Bundle Components
1. Prophylactic antibiotic given within one hour prior to surgical incision
2. Prophylactic antibiotic selection for surgical patients
3. Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac surgery)
4. Cardiac surgery patients with controlled 6 A.M. postoperative serum blood glucose

12. Surgical Site Infection Prevention Bundle Components
5. Surgery patients with appropriate hair removal
6. Surgery Patients with Perioperative Temperature Management - maintaining normothermia 
7. Urinary Catheter Removal on Postoperative Day 1 or 2 with day of surgery being day zero.

13. Surgical Site Infection Prevention Bundle Components
1. Prophylactic antibiotic given within one hour prior to surgical incision
-The goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of incision.
Rationale: “…reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses.*”
*CDC Guideline for Prevention of Surgical Site Infections, 1999

14. Surgical Site Infection Prevention Bundle Components
2. Prophylactic antibiotic selection for surgical patients
Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure) have fewer surgical site infections
Rationale: “Use an AMP (surgical antimicrobial prophylaxis) for all operations or classes of operations in which its use has been shown to reduce SSI rates based on evidence from clinical trials…*”
*CDC Guideline for Prevention of Surgical Site Infections, 1999

15. Surgical Site Infection Prevention Bundle Components
3.Prophylactic antibiotics discontinued within 24 hours after surgery end time
Rationale: Short duration antibiotics are as effective in preventing infection as long duration antibiotics
Long duration antibiotics are more likely to cause development of drug resistant bacteria

16. Surgical Site Infection Prevention Bundle Components
4. Cardiac surgery patients with controlled postoperative blood glucose
Rationale: Hyperglycemia has been associated with increased in-hospital morbidity and mortality for multiple medical and surgical conditions.
-Risk of infection is significantly higher for patients undergoing CABG if blood glucoses are elevated.
-Deep wound infections in diabetic patients undergoing cardiac surgery is reduced by controlling blood glucose levels < 200 mg/dL in the immediate postoperative period.

17. Surgical Site Infection Prevention Bundle Components
5. Surgery patients with appropriate hair removal
Hair removal, if indicated should be accomplished with clippers rather than razors or depilatories.
Rationale: Razor shaving has been associated with increased SSIs attributed to microscopic cuts in the skin that serve as foci for bacterial multiplication*
*CDC Guideline for Prevention of Surgical Site Infections, 1999

18. Surgical Site Infection Prevention Bundle Components
6. Surgery Patients with Perioperative Temperature Management - Maintaining normothermia 
Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature ≥ 96.8oF/36oC recorded within the 30 minutes prior to or the 15 minutes immediately after anesthesia end time. 
Rationale: Hypothermia (<36oC) increases the risk for surgical site infection
*CDC Guideline for Prevention of Surgical Site Infections, 1999

19. Surgical Site Infection Prevention Bundle Components
7. Urinary Catheter Removal on Postoperative Day 1 or 2 with day of surgery being day zero.
Rationale: Removing the indwelling urinary catheter decreases risk of urinary tract infection and associated complication of bacteremia that could lead to increased length of stay, more frequent readmissions and increased morbidity and mortality
*CDC Guideline for Prevention of Surgical Site Infections, 1999

20. Other SSI Prevention Measures*
Encourage patient tobacco
cessation prior to surgery
Ask patients to shower or bathe with antiseptic agent on at least the night before the operative day
*CDC Guideline for Prevention of Surgical Site Infections, 1999

21. Other SSI Prevention Measures*
Ill surgical staff refrain from working
Surgical team keeps nails short and does not wear artificial nails
Surgical team performs
appropriate hand/forearm
antisepsis prior to surgery
*CDC Guideline for Prevention of Surgical Site Infections, 1999

22. Other SSI Prevention Measures*
Surgical team wears appropriate
surgical attire
Uses proper aseptic and surgical
technique during procedures
Use appropriate antiseptic agent for skin prep
*CDC Guideline for Prevention of Surgical Site Infections, 1999

23. Other SSI Prevention Measures*
Protect closed incision with sterile
dressing for hours
postoperatively
Maintain adequate/recommended
ventilation processes in the
operating rooms
*CDC Guideline for Prevention of Surgical Site Infections, 1999

24. Other SSI Prevention Measures*
Perform adequate cleaning and
disinfection of environmental
surfaces in the surgery areas
Sterilize all surgical instruments
according to published guidelines
*CDC Guideline for Prevention of Surgical Site Infections, 1999

25. Your Role
Follow the bundle components specific to your role in the patient’s care
Provide appropriate/indicated patient teaching regarding these bundle component and other recommended practices
Document patient education related to the goal of SSI prevention
Patient education materials related to SSI prevention can be found on the Intranet:
Remind peers of the importance of following the recommended practices if they are observed to be non-compliant

26. Questions?
Contact the Infection Preventionist at your site

27. References