Running head: SURGICAL SITE INFECTION 1

Surgical Site Infection

Mary Davidson
Old Dominion University




SURGICAL SITE INFECTION 2

Surgical Site Infection
An estimated 16 million operative procedures were performed in acute care hospitals in
the United States in 2010 (CDC, 2014). The community hospital where I work has a busy O.R.
department with nine surgical suites, and we perform roughly 7,000 surgeries per year. Safety
and asepsis is the foundation of all surgical procedures. If asepsis is compromised, surgical site
infections (SSI) can occur. This is an unintended and often times preventable consequence of
surgery. SSIs are the second most common hospital acquired infections (HAI) reported in
hospitalized patients, resulting in increases in costs, readmissions, lengths of stay and patient
mortality; it is estimated that 40% to 60% of these infections could be prevented (Spruce, 2014).
The annual cost of HAIs to the U.S. health care system ranges from $28.4 billion to $45 billion
(Spruce, 2014). Preventing SSIs is not only in the best interest of the patient and their families,
but also alleviates an enormous financial burden on the health care system.
Clinical Problem
In the past 8 months our O.R. has had a 9% increase in our SSI rates for neurosurgical
patients, which is an alarming increase for a short period of time. The other surgical specialties
have not seen a difference in their infection rates; in fact, our orthopedic service continues to
have the lowest SSI rate in the state. An internal investigation is underway to determine the
cause of the increase. The patients have been tracked and there are no clear answers as to why
this is occurring. This problem places a significant burden on our patients, families, staff and
hospital resources. Preventing SSIs has become a national priority, as bacteria become
increasingly resistant to antibiotics. Perioperative nurses are on the front lines of helping to
prevent SSIs, and must be accountable for their own actions as well as that of the surgical team.
There is a substantial amount of literature related to preventing SSIs, and although advances
SURGICAL SITE INFECTION 3

have been made in infection prevention practices, SSIs continue to be a significant cause of
morbidity and mortality. Surgical site infections are preventable, and carrying out nursing
interventions to prevent them are a fundamental basic of perioperative nursing. I chose this
topic because it has a tremendous negative impact on patients, providers, and the health care
system. The recent increase in surgical site infections is directly affecting my work environment.
The entire O.R. department is working diligently to take corrective measures to ensure patient
safety related to asepsis. As a perioperative nurse, I have a responsibility to my patients to carry
out every preventative measure to avoid a surgical site infection.
Current Clinical Practice
Current clinical practice to prevent SSIs is guided by recommendations by the Surgical
Care Improvement Project (SCIP), which began in 2006 and is a national partnership of
organizations committed to improving the safety of surgical care (The Joint Commission, 2014).
These national initiatives aim to improve outcomes for patients having surgery, and are the gold
standard for acute care hospitals. Several core strategies have been recommended by SCIP
including appropriate choice, dosage and timing of antimicrobial prophylaxis, preventing
perioperative patient hypothermia, and appropriate application of skin antiseptic agent. These
among other interventions have been recommended as standard of practice to decrease the
incidence of SSIs. Additionally, Association of periOperative Registered Nurses (AORN)
guidelines and recommendations are followed in the perioperative setting. These guidelines
address all phases of the surgical process that impact asepsis, and contribute to prevention of
SSIs
The formal mechanism for addressing SSI prevention in my workplace is to follow SCIP
protocol for every patient, beginning in the preoperative phase of surgery. The surgeon selects
SURGICAL SITE INFECTION 4

an appropriate antibiotic, dose and timing for it to be administered. The O.R. nurse or anesthesia
provider would administer the intravenous antimicrobial agent at the appropriate time. The
majority of antibiotics used are dosed within one hour of incision. It has been shown that
hospitals that have a high SCIP compliance rate, particularly with choice of antibiotic as well as
timing of antibiotic, have significantly lower SSI rates (Cataife, Weinberg, Wong, Kahn, 2014).
Other SCIP measures to prevent SSI are conducted in the O.R. suite, including maintaining a
core body temperature of 98.6F, and appropriate use of surgical skin prep agents. These are
well-supported interventions that contribute to the goal of SSI prevention. Following SCIP
protocol as well as AORN recommendations is the standard of practice O.R. nurses are expected
to adhere to.
The informal mechanism for addressing SSI prevention where I work is quite often
compromised by lack of communication and rushing. An antibiotic order by the surgeon may
be written or given verbally. The O.R. nurse may be unaware of a verbal order if the pre-op
nurse doesnt give a proper hand off. In fact, unintentional mistakes are accidental and occur
when verbal orders are missed altogether because personnel are overloaded with competing tasks
(Cvetic, 2011). The pre-op area is often busy and chaotic with nurses trying to get patients ready
for surgery. Occasionally the surgeon forgets to order the antibiotic, and the O.R. nurse may
assume no antibiotics are indicated for the surgical case. The O.R. nurse is extremely busy at
the beginning of the surgery, and may forget to ask the surgeon about antibiotics before incision
is made. The nurse may also be too busy to put the warming blanket on the patient before the
surgeon starts draping, preventing the ability to maintain a core body temperature intraop.
Furthermore, new skin aseptic products are frequently introduced in the O.R., often times with
limited staff training. The O.R. staff may not be as familiar with how to use these new agents
SURGICAL SITE INFECTION 5

that are critical in preventing SSIs. In addition to breaks in communication, general chaos and
rushing occurs as the team is attempting to stay on time and quickly turnover the O.R. suite. Our
department is currently understaffed, so there are typically no extra nurses to help expedite
turnovers. We have found that rushing directly affects the incidence of mistakes, and although
the O.R. nurse attempts to follow SCIP protocol and AORN standards, occasionally this effort
falls short.
The discrepancy of what should be done and what is being done to prevent SSIs is partly
due to a lack of communication, and general chaos in the pre-op areas as well as in the O.R.
suite. The perioperative environment is fast paced and production driven, which creates
potential for communication errors. Rushing to prepare patients for surgery also contributes to
suboptimal observance of SCIP protocol and AORN standards. The result of poor
communication and rushing can result in health care mistakes, and can negatively impact the
procedures to prevent SSIs.
Nursing Interventions
Improving communication among the perioperative team members would be a crucial
nursing intervention for the O.R. nurse in preventing SSI infections. Simplifying and
standardization of communication processes are ways to improve O.R. interactions and minimize
errors. Preoperative checklists would be a helpful tool to improve hand off communication
between the admitting nurse and the O.R. nurse. Including pre-op antibiotics on the checklist
would help eliminate confusion when verbal orders are given. Several studies have
recommended the use of structured checklists as a way to improve communication in the
perioperative setting (Cvetic, 2011). AORN as well as the World Health Organization has
developed surgical safety checklists to enhance communication among O.R. staff. Effective
SURGICAL SITE INFECTION 6

communication between members of the perioperative team would be beneficial in not only
refining SSI prevention, but also enhancing a culture of professionalism and patient safety. I
believe that this nursing intervention would have the greatest impact on reducing our increase in
SSIs at my workplace. It has widespread implications among O.R. staff in that it would focus
our attention on protocols and get back to the fundamentals of SSI prevention.
Maintaining core body temperature in the O.R. is another intervention that nurses can do
to help prevent SSIs. The operating room is typically a cold environment. The reason for this is
two-fold; colder temperatures inhibit microbial growth, and it also keeps surgeons comfortable
as they can overheat due to wearing masks, gowns and gloves. All anesthetized surgical patients
are at risk for developing hypothermia (less than 98.6 F), which increases the risk of a
postoperative surgical site infection (Steelman and Graling, 2013). A literature review published
in 2012 estimates that as many as 70% of surgical patients experience hypothermia
intraoperatively (Knaepel, 2012). Forced-air warming (FAW) is one measure a nurse can take
to maintain normothermia in the O.R. Baer Hugger is one type of FAW machine that attaches to
a specialized warming blanket that is placed over the patient. AORN guidelines recommend
FAW in the pre-op area as well as continuous warming throughout surgery (AORN Perioperative
Standards and Recommended Practices, 2014). Warmed IV fluids should be used in addition to
FAW to minimize heat loss. Surgical patients who receive warmed IV fluids have been found to
have higher core temperatures when combined with pre-warming and intraoperative warming
(Andrzejowski, Turnbull, Nandakumar, Gowthaman, and Eapen, 2010).
A common source of SSIs is the patients own flora, and surgical incisions provide an
opportunity to introduce microorganisms that may cause infection (Zinn, Jenkins, Harrelson,
Wrenn, Haynes, and Small, 2013). Appropriate selection and application of the surgical skin
SURGICAL SITE INFECTION 7

antiseptic agent is a critical nursing intervention in preventing SSIs. Some agents are better than
others in preventing microbial growth. Each agent also has instructions for application that must
be followed in order to ensure its full antiseptic mechanism. The O.R. nurse applies the prep
solution to the incision site using sterile technique, and must be aware of not contaminating the
surgical site. A recent study found that Chlorhexidine Gluconate (CHG) antiseptic agent
demonstrated the lowest incidence of SSIs in open abdominal procedures (Zinn et. al, 2013).
Regardless of what skin prep agent is used, the O.R. nurse should be proficient in its application.
Training and in-services should be conducted periodically to ensure staff is proficient in applying
new skin prep solutions correctly and effectively. Being knowledgeable in old and new
products, as well as understanding the advantages and disadvantages of surgical skin antiseptics
will augment the RNs ability to make informed recommendations and assessments toward
preventing SSIs.
Summary
Surgical Site infections can be a devastating and costly result of surgical procedures. The
focus to prevent SSIs has never been more important, as patient morbidity and mortality rise,
microorganisms increasingly resistant to antibiotics, non-reimbursement for HAIs, among other
trends in health care. Perioperative nurses are in a unique position to reduce the incidence of
SSIs by consistently following standard infection measures. SCIP protocol as well as AORN
guidelines direct nursing practice, and are outstanding reference points is planning patient care.
Several nursing interventions have been studied and well documented in preventing SSIs,
including simplifying communication by utilizing surgical checklists, maintaining intraoperative
normothermia, and selection and application of appropriate surgical skin antiseptics. Surgical
site infections are preventable, and asepsis along with SSI prevention is at the core of
SURGICAL SITE INFECTION 8

perioperative nursing. Well continue to seek solutions for the increased infection rate at my
workplace, but in the meantime, my nursing practice will improve and Ill remain diligent in my
commitment to preventing surgical site infections.




















SURGICAL SITE INFECTION 9

References
Andrzejowski, J.C., Turnbull, D. Nandakumar, A., Gowthaman, S., Eapen, G. (2010). A
randomized single blinded study of the administration on pre-warmed fluid vs active fluid
warming on the incidence on peri-operative hypothermia in short surgical procedures.
Anaesthesia, 65, 942-945.
Caraife, G., Weinberg, D., Wong, H., Kahn, K. (2014). The Effect of Surgical Care
Improvement Project (SCIP) Compliance on Surgical Site Infections (SSI). Medical
Care, 52 (2), 66-73.
Centers for Disease Control and Prevention. (2014). Surgical site infection (SSI) event.
Retrieved from http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf.
Cvetic, E. (2011). Communication in the perioperative setting. AORN Journal, 94, 261-270.
Knaepel, A. (2012). Inadvertent perioperative hypothermia: a literature review. Journal of
Perioperative Practice, 22 (3), 86-90.
Recommended practices for preoperative patient skin asepsis. (2013). Perioperative Standards
and Recommended Practices (2013 Edition, pp. 75-89). AORN, Inc. Denver, CO.
Spruce, L. (2014). Back to Basics: Preventing Surgical Site Infections. AORN Journal, 99 (5),
600-611.
Steelman, V. & Graling, P. (2013). Top 10 Patient Safety Issues: What More Can We Do?
AORN Journal, 97 (6), 679-701.
The Joint Commission. (2014). Surgical Care Improvement Project. Retrieved from
http://www.jointcommission.org/surgical_care_improvement_project/
Zinn, J., Jenkins, J., Harrelson, B., Wrenn, C., Haynes, E., Small, N. (2013). Differences in
Intraoperative Prep Solutions: A Retrospective Chart Review.
SURGICAL SITE INFECTION 10

AORN Journal, 97 (5), 552-558.






















SURGICAL SITE INFECTION 11

Honor Pledge:
I have neither given nor received unauthorized aid on this examination (or other material turned
in for credit) nor do I have reason to believe anyone else has. Mary P. Davidson