Effective surgical infection prevention requires redesigning systems to reduce risk factors and to optimize evidence-based processes of care. Essential process for prevention of surgical site infections are core measures in the Surgical Care Improvement Project and have been essential components in IHI surgical safety efforts: selection, timing, and duration of antimicrobial prophylaxis; glucose control in cardiac surgery; hair removal technique and other basic prevention strategies.
Changes for Improvement
Use Prophylactic Antibiotics Appropriately
An estimated 40–60 percent of Surgical Site Infections (SSIs) are preventable with appropriate use of prophylactic antibiotics. Overuse, under use, improper timing, and misuse of antibiotics occurs in 25–50 percent of operations. A large number of hospitalized patients develop infections caused by Clostridium difficile, and 16 percent of this type of infection in surgical patients can be attributed to inappropriate prophylaxis use alone. Inappropriate use of broad spectrum antibiotics or prolonged courses of prophylactic antibiotics puts all patients at even greater health risks due to the development of antibiotic-resistant pathogens.
- Designate responsibility and accountability for preoperative prophylactic antibiotic administration (e.g., preoperative nurse, circulating nurse, anesthesiologist) connected to key point in process
- Standardize administration process to occur with commonly performed activity within one hour prior to incision
- Through the use of antibiotic standing orders specific to surgical site, administer prophylactic antibiotics according to guidelines based on local consensus
- Make agreed upon antibiotics available in the operating room (OR)
- Standardize delivery process to ensure timely delivery of preoperative antibiotics to the holding area
- Provide visible reminder or checklist to give antibiotics on each case (e.g., brightly colored sticker)
- Ensure systematic documentation of antibiotic administration on every patient chart (paper or electronic)
- Develop system where antibiotic is hanging at head of patient’s bed ready for administration
- Design protocols to deliver antibiotic to OR with patient
- Educate OR staff regarding the importance and reasoning of antibiotic timing, selection, and duration
- Provide feedback on prophylaxis compliance and infection data monthly
- Involve pharmacy staff to ensure timing, selection, and duration are maintained
- Institute a computerized physician order entry system with procedure-specific fields for antibiotic selection, timing, and duration
- Improve screening for allergies to beta lactam antibiotics to eliminate false positives
- Consider weight-based antibiotic dosing (higher dose for larger patients). As this may be cumbersome, may want to increase cephalosporins from 1 to 2 grams for all patients since minor issues around toxicity.
- Re-dose for longer surgeries (e.g., after 3 hours for short half-life cephalosporin)
Avoid Shaving Operative Site
In addition to the proper use of prophylactic antibiotics and good surgical technique, other factors under the control of the operative team have been demonstrated to affect significantly the risk of SSI. These other factors include avoiding hair removal at the operative site or when necessary, not using razors to remove hair. This preventive measure provides opportunities for improvement in most hospitals.
- Avoid hair removal unless necessary for the procedure.
- When necessary, remove hair with clippers right before surgery - but not in the operating room itself.
- Remove all razors from operating room and supply area.
- Establish protocol for when and how to remove hair in affected areas.
- Provide patient education and materials on appropriate hair removal techniques to prevent shaving at home.
- Avoid shaving heart surgery patients for EKG conducted shortly before surgery.
Maintain Postoperative Glucose Control for Major Cardiac Surgery Patients
Review of medical literature shows that the degree of hyperglycemia in the postoperative period was correlated with the rate of surgical site infection in patients undergoing major cardiac surgery (Lthan. Infection Control and Hospital Epidemiology. 2001;22:607; Dellinger. Infection Control and Hospital Epidemiology. 2001;22:604). Other articles have demonstrated that stringent glucose control in surgical intensive care unit patients reduces mortality (Van den Berghe. New England Journal of Medicine. 2001;345:1359).
1."Glucose control" is defined as serum glucose levels below 200 mg/dl, collected once on each of the first two postoperative days.
2.Tight glycemic control (e.g., using an insulin drip) is often performed in an intensive care setting or equivalent for safety.
- Develop one protocol to be used for all surgical patients.
- Regularly check preoperative blood glucose levels on all patients to identify hyperglycemia; this is best done early enough that the assessment of risk can be completed and treatment initiated if appropriate.
- Assign responsibility and accountability for blood glucose monitoring and control
Use Basic Prevention Strategies from Category IA Center for Disease Control Recommendations
- Exclude patients with prior infections.
- Stop patient tobacco use prior to surgery.
- Apply sterile dressing for 24–48 hr.
- Shower with antiseptic soap.
- Provide positive pressure ventilation in OR with at least 15 air changes/hr.
- Keep OR doors closed.
- Use sterile instruments.
- Wear a mask.
- Cover hair.
- Prepare skin with appropriate agent.
- Wear sterile gloves; double-glove.
- Maintain short nails; remove artificial nails.
- Handle tissue gently.
- Ensure that surgeons/staff clean hands with appropriate agents and methods.
- Delay primary closure for heavily contaminated wounds.
- Exclude infected surgeons.
- Use closed suction drains (when used)