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The purpose of this
course is to update healthcare
professionals in the most recent CDC recommendation. This course also
discusses risks, consequences and prevention of surgical site
infections.
After completing the
course, the learner will be able to:
1. identify patient specific factors that increase the risk
of Surgical Site Infections (SSIs),
2.
identify preoperative,
intraoperative and postoperative
characteristics that increase the
risk of SSIs,
3.
identify the rational for use of
antimicrobial prophylaxis,
4.
identify the Surgical Wound
Classification of common procedures,
and
5.
identify recommendations to prevent
SSIs.
Based on National Nosocomial
Infections Surveillance (NNIS)
system reports, Surgical Site
Infections (SSIs), formerly called
surgical wound infections, are the
third most frequently reported
nosocomial infection. They account
for 14% to 16% of all nosocomial
infections among hospitalized
patients (Mangram, Horan, Pearson,
Silver, & Jarvis, 1999).
A SSI prevention technique is an
action or set of actions
intentionally taken to reduce the
risk of an SSI. Some techniques are
directed at reducing opportunities
for microbial contamination of the
patient’s tissues or sterile
surgical instruments; others are
adjunctive, such as using
antimicrobial prophylaxis or
avoiding unnecessary traumatic
tissue dissection. Optimization of
SSI prevention measures requires
that a variety of patient and
operation characteristics be
carefully considered (Mangram, et
al., 1999).
Patient characteristics possibly
associated with an increased risk of
an SSI include coincidental, remote
site infections or colonization,
diabetes, cigarette smoking,
systemic steroid use, obesity,
extremes of age, poor nutritional
status, and preoperative transfusion
of certain blood products (Mangram,
et al., 1999).
The contribution of diabetes to SSI
risk is controversial. More research
is needed to assess the efficacy of
perioperative blood glucose control
as a prevention measure (Mangram, et
al., 1999). Nicotine use delays
primary wound healing and may in
turn increase the risk of SSI.
Patients who are receiving steroids
or other immunosuppressive drugs
preoperatively may be predisposed to
developing SSI, but the data
supporting this relationship are
contradictory (Mangram, et al.,
1999).
In some studies, severe
protein-calorie malnutrition has
been crudely associated with
postoperative nosocomial infections,
impaired wound healing dynamics, or
death. Severe preoperative
malnutrition should increase the
risk of SSI; however, is difficult
to demonstrate, the benefits of
total parenteral nutrition (TPN) and
total enteral alimentation (TEA) in
reducing SSI risk are unproven. When
a major elective operation is
necessary in a severely malnourished
patient, surgeons often use both pre
and postoperative nutritional
support. In addition, postoperative
nutritional support is important for
some major oncologic operations; for
some major trauma victims; or in
patients suffering catastrophic
surgical complications that prevent
eating or that trigger a
hypermetabolic state (Mangram, et
al., 1999).
Prolonged preoperative hospital stay
is frequently thought to be a
patient characteristic associated
with increased SSI risk. However,
the length of preoperative stay may
be an indicator of severity of
illness and co-morbid conditions
requiring inpatient work-up and/or
therapy before the operation
(Mangram, et al., 1999).
Staph Aureus (S. Aureus) is a
frequent SSI isolate. This pathogen
is carried in the nares of 20% to
30% of healthy humans. S. Aureus is
definitely associated with
preoperative nares carriage of the
organism in surgical patients (Mangram,
et al., 1999). Mupirocin ointment is
effective as a topical agent for
eradicating S. aureus from the nares
of colonized patients; however, the
effect of mupirocin on reducing SSI
risk has not yet been determined (Mangram,
et al., 1999).
Perioperative transfusion of
leukocyte-containing allogeneic
blood components is an apparent risk
factor for the development of
postoperative bacterial infections,
including SSI. However, more
research is needed. There is
currently no scientific basis for
withholding necessary blood products
from surgical patients as a means of
SSI risk reduction (Mangram, et al.,
1999).
The following are operative
characteristics that may be
associated with an increased risk of
SSI (Mangram, et al., 1999.
Operation
Skin antisepsis
Preoperative shaving
Preoperative skin prep
Duration of operation
Antimicrobial prophylaxis
Operating room ventilation
Inadequate sterilization of
instruments
Foreign material in the surgical
site
Surgical drains
Surgical technique
Poor hemostasis
Failure to obliterate dead space
Tissue trauma
Duration of surgical scrub
A preoperative antiseptic shower or
bath decreases skin microbial colony
counts. Repeated antiseptic showers
are indicated, because chlorhexidine
gluconate-containing products
require several applications to
attain maximum antimicrobial
benefit. Even though preoperative
showers reduce the skin’s microbial
colony counts, they have not
definitively been shown to reduce
SSI rates (Mangram, et al., 1999).
Preoperative shaving of the surgical
site the night before an operation
is associated with a significantly
higher SSI risk than either the use
of depilatory agents or no hair
removal. The increased SSI risk has
been attributed to microscopic cuts
in the skin that serve as areas for
bacterial multiplication. Shaving
immediately before the operation
compared to shaving within 24 hours
preoperatively is associated with
decreased SSI rates. Clipping hair
immediately before an operation has
also been associated with a lower
risk of SSI than shaving or clipping
the night before an operation. Some
studies have shown that the use of
depilatories is associated with a
lower SSI risk than shaving or
clipping. However, depilatories
sometimes produce hypersensitivity
reactions. Some studies have shown
that preoperative hair removal by
any means was associated with
increased SSI rates and suggested
that no hair be removed (Mangram, et
al., 1999). AORN, the Centers for
Disease Control and Prevention
(CDC), and other regulatory agencies
and organizations recommend that
hair is best left at the surgical
site. Hair should be removed only if
it will interfere with the
procedure. If hair is to be removed,
hair removal should occur
immediately before the procedure.
Removal should be performed away
from the area where the procedure
will be performed. Hair should not
be removed in the vicinity of the
sterile field because the dispersal
of loose hair has the potential to
contaminate the surgical site and
sterile field (Connor, 2003).
Commonly used antiseptic agents for
preoperative preparation of skin are
theiodophors (e.g., povidone-iodine),
alcohol-containing products, and
chlorhexidine gluconate. There are
no studies that have adequately
assessed the comparative effects of
these preoperative skin antiseptics
on SSI risk. Aqueous 70% to 92%
alcohol solutions have germicidal
activity against bacteria, fungi,
and viruses, but spores can be
resistant. Alcohol is readily
available, inexpensive, and remains
the most effective and rapid-acting
skin antiseptic. However, alcohol is
flammable, which is a disadvantage
for use in the operating room.
Chlorhexidine gluconate and
iodophors have broad spectra of
antimicrobial activity. In some
comparisons of these two antiseptics
as preoperative hand scrubs,
chlorhexidine gluconate had greater
reductions in skin microflora than
did povidone-iodine and also had
greater residual activity after a
single application. Blood or serum
proteins do not inactivate
Chlorhexidine gluconate. Iodophors
may be inactivated by blood or serum
proteins, but exert a bacteriostatic
effect as long as they are present
on the skin (Mangram, et al., 1999).
Before the skin preparation of a
patient is initiated, the skin
should be free of gross
contamination. Apply the antiseptic
in concentric circles, beginning in
the area of the proposed incision.
The prepared area should be large
enough to extend the incision or
create new incisions or drain sites,
if needed (Mangram, et al., 1999).
Modified skin preparation procedures
have not been shown to have any
advantage over the above described
procedure. Those modifications are
removing or wiping off the skin
preparation antiseptic agent after
application; using an
antiseptic-impregnated adhesive
drape; merely painting the skin with
an antiseptic in lieu of the skin
preparation procedure described
above; or using a “clean” versus a
“sterile” surgical skin preparation
kit (Mangram, et al., 1999).
Members of the surgical team who
have direct contact with the sterile
operating field or sterile
instruments or supplies perform a
traditional procedure known as
scrubbing immediately before donning
sterile gowns and gloves. However,
in October 2002, the CDC updated its
hand hygiene recommendations and
essentially abolished the
traditional long presurgical scrub.
For surgical hand antisepsis, the
new guideline recommends using
either an antimicrobial soap or an
alcohol-based hand rub with
persistent activity. Washing with
regular soap is still necessary
before using alcohol rub products,
because alcohol rub products are not
cleaning agents and don't remove
surface dirt. No recommendation on
the use of brushes was made (Maithias,
2003).
The benefits of selecting a
brushless, alcohol-based surgical
hand product may include fast and
easy application, limited or
decreased damage to the user's skin,
improved compliance with hand
antisepsis protocols, simplified
application technique, and reduced
material waste (i.e., water,
brushes, packaging). Disadvantages
may include user training needed;
failure of the user to properly wash
his or her hands before applying the
product; and potential fire hazard
(e.g., failure of the user to allow
the alcohol to evaporate before he
or she dons sterile gloves and gown,
improper storage) (Conner, 2003).
The best antiseptic for use in the
scrub should have a broad spectrum,
fast-action, and have a persistent
effect. Antiseptic agents
commercially available in the United
States for this purpose contain
alcohol, chlorhexidine, iodine/iodophors,
para-chloro- meta-xylenol, or
triclosan. Povidone-iodine and
chlorhexidine gluconate are the most
common agents of choice for most
U.S. surgical teams. However, a 7.5%
povidone-iodine or 4% chlorhexidine
gluconate compared to an alcoholic
chlorhexidine (60% isopropanol and
0.5% chlorhexidine gluconate in 70%
isopropanol), revealed that
alcoholic chlorhexidine was found to
have greater residual antimicrobial
activity. No agent is ideal for
every situation, and a major factor
is its acceptability by operating
room personnel after repeated use.
No clinical trials have evaluated
the impact of scrub agent choice on
SSI risk (Mangram, et al., 1999).
Other factors that influence the
effectiveness of the surgical scrub
are scrubbing technique, the
duration of the scrub, the condition
of the hands, and the techniques
used for drying and gloving. Recent
studies suggest that scrubbing for
at least 2 minutes is as effective
as the traditional 10-minute scrub
in reducing hand bacterial colony
counts; however, the optimum
duration of scrubbing is not known (Mangram,
et al., 1999). The first scrub of
the day should include a thorough
cleaning underneath fingernails. It
is not clear that such cleaning is a
necessary part of subsequent scrubs
during the day. After performing the
surgical scrub, hands should be kept
up and away from the body (elbows in
flexed position) so that water runs
from the tips of the fingers toward
the elbows. Sterile towels should be
used for drying the hands and
forearms before the donning of a
sterile gown and gloves (Mangram, et
al., 1999).
AORN recommends that cuticles,
hands, and forearms should be free
of open lesions and breaks in skin
integrity. Personnel should not
scrub or provide patient care with
open lesions and should be assigned
other duties (Peterson, 2003).
A surgical team member who wears
artificial nails may have increased
bacterial and fungal colonization of
the hands despite performing an
adequate hand scrub. The
relationship between nail length and
SSI risk is unknown; but long nails
may be associated with tears in
surgical gloves. The relationship
between the wearing of nail polish
or jewelry by surgical team members
and SSI risk has not been adequately
studied (Mangram, et al., 1999).
Surgical personnel who have active
infections or are colonized with
certain microorganisms have been
linked to outbreaks or clusters of
SSIs. Therefore, policies should
address management of job-related
illnesses, provision of post
exposure prophylaxis after
job-related exposures and, when
necessary, exclusion of ill
personnel from work or patient
contact. While work exclusion
policies should be enforceable and
include a statement of authority to
exclude ill personnel, they should
also be designed to encourage
personnel to report their illnesses
and exposures and not penalize
personnel with loss of wages,
benefits, or job status (Mangram, et
al., 1999).
Surgical antimicrobial prophylaxis
(AMP) refers to a very brief
infusion of an antimicrobial agent
initiated just before an operation
begins. AMP is not an attempt to
sterilize tissues, but a critically
timed adjunct used to reduce the
microbial burden of intraoperative
contamination to a level that cannot
overwhelm host defenses. AMP does
not pertain to prevention of SSI
caused by postoperative
contamination. AMP indications
pertain to elective operations where
skin incisions are closed in the
operating room (Mangram, et al.,
1999).
An AMP agent should be used only for
operations or classes of operations
in which its use has been shown to
reduce SSI rates; or for those
operations where incisional or
organ/space SSI would be a
catastrophe. The AMP agent should be
safe, inexpensive, and have a
bactericidal spectrum that covers
the most probable intraoperative
contaminants for the operation. The
infusion should be timed so that the
initial dose of antimicrobial agent
gives a bactericidal concentration
of the drug in serum and tissues by
the time the skin is incised.
Therapeutic levels should be
maintained throughout the operation
and until, at most, a few hours
after the incision is closed in the
operating room. When the duration of
an operation is expected to exceed
the time in which therapeutic levels
of the AMP agent can be maintained,
additional AMP agent should be
infused (Mangram, et al., 1999).
The concept of “on-call” infusion of
AMP is flawed because of delays in
transport or schedule changes can
mean that suboptimal tissue and
serum levels may be present when the
operation starts. Simple protocols
of AMP timing and oversight
responsibility should be designed to
be practical and effective (Mangram,
et al., 1999).
The CDC's wound classification
system is widely accepted for
classifying the degree of inherent
microbial contamination of a
surgical site. Descriptive
characteristics are used to predict
the degree of microbial
contamination at the time of
surgery. Wound classification is
used as an indicator for determining
prophylactic antimicrobial treatment
and for reporting surgical site
infections (Peterson, 2003). The
following are standard wound
classifications (Mangram, et al.,
1999).
Class I, Clean, is an uninfected
operative wound in which no
inflammation is encountered and the
respiratory, alimentary, genital, or
uninfected urinary tract is not
entered. In addition, clean wounds
are primarily closed and, if
necessary, drained with closed
drainage (i.e., breast
augmentation). Operative incisional
wounds that follow nonpenetrating
(blunt) trauma should be included in
this category if they meet the
criteria.
Class II, Clean-Contaminated, is an
operative wound in which the
respiratory, alimentary, genital, or
urinary tracts are entered under
controlled conditions and without
unusual contamination. Specifically,
operations involving the biliary
tract, appendix, vagina, and
oropharynx are included in this
category, provided no evidence of
infection or major break in
technique is encountered.
Class III, Contaminated, is an open,
fresh, accidental wounds. In
addition, operations with major
breaks in sterile technique (e.g.,
open cardiac massage) or gross
spillage from the gastrointestinal
tract, and incisions in which acute,
nonpurulent inflammation is
encountered are included in this
category.
Class IV, Dirty-Infected, is an old
traumatic wound with retained
devitalized tissue and those that
involve existing clinical infection
or perforated viscera (example,
colon resection). This definition
suggests that the organisms causing
postoperative infection were present
in the operative field before the
operation.
Operating room air may contain
microbial-laden dust, lint, skin
squames, or respiratory droplets.
The microbial level in operating
room air is directly proportional to
the number of people moving about in
the room. Therefore, personnel
traffic during operations should be
minimal. Outbreaks of A
beta-hemolytic streptococci SSIs
have been traced to airborne
transmission of the organism from
colonized operating room personnel.
In these outbreaks, the strain
causing the outbreak was recovered
from the air in the operating room (Mangram,
et al., 1999).
Operating rooms should be maintained
at positive pressure with respect to
corridors and adjacent areas.
Positive pressure prevents airflow
from less clean areas into the
operating rooms. All ventilation or
air conditioning systems in
hospitals, including those in
operating rooms, should have two
filter beds in series, with the
efficiency of the first filter bed
being >30% and that of the second
filter bed being >90% (Mangram, et
al., 1999). Conventional operating
room ventilation systems produce a
minimum of about 15 air changes of
filtered air per hour, 20% of which
must be fresh air. In rooms not
engineered for horizontal laminar
airflow, air should be introduced at
the ceiling and exhausted near the
floor (Anonymous, 2003). Laminar
airflow has been suggested as an
additional measure to reduce SSI
risk for certain operations. Laminar
airflow is designed to move
“ultraclean air” over the aseptic
operating field at a uniform
velocity, sweeping away particles in
its path. Laminar airflow can be
directed vertically or horizontally,
and recirculated air is usually
passed through a high efficiency
particulate air (HEPA) filter (Mangram,
et al., 1999). Do not use UV
radiation to prevent SSI (Anonymous,
2003).
The temperature of an operating room
should be between 68-73F, and have
a relative humidity 30%-60% (Mangram,
et al., 1999). Do not use tacky mats
at entrance to the ORs (Anonymous,
2003).
Surgical team members should wear a
“scrub suit” that consists of pants
and a shirt. Policies for
laundering, wearing, covering, and
changing scrub suits vary greatly.
Some policies restrict the
laundering of scrub suits to the
facility, while other facilities
have policies that allow laundering
by employees. The Association of
Operating Room Nurses recommends
that scrub suits be changed after
they become visibly soiled and that
they be laundered only in an
approved and monitored laundry
facility. Additionally, OSHA
regulations require that garment
penetrated by blood or other
potentially infectious materials
should be removed immediately or as
soon as feasible. There are no
well-controlled studies evaluating
scrub suit laundering as an SSI risk
factor. Some facilities have
policies that restrict the wearing
of scrub suits to the operating
suite, while other facilities allow
the wearing of cover gowns over
scrub suits when personnel leave the
suite (Mangram, et al., 1999).
Wearing a surgical mask during an
operation to prevent potential
microbial contamination of incisions
is a longstanding surgical
tradition. A mask can be beneficial
since it protects the wearer’s nose
and mouth from inadvertent splashes
of blood and other body fluids. OSHA
regulations require that masks in
combination with protective eyewear,
such as goggles or glasses with
solid shields, or chin-length face
shields be worn whenever splashes,
spray, spatter, or droplets of blood
or other potentially infectious
material may be generated and eye,
nose, or mouth contamination can be
reasonably anticipated. However,
some studies have raised questions
about the efficacy and cost-benefit
of surgical masks in reducing SSI
risk (Mangram, et al., 1999).
Surgical caps/hoods are inexpensive
and reduce contamination of the
surgical field by organisms shed
from the hair and scalp. SSI
outbreaks have occasionally been
traced to organisms isolated from
the hair or scalp, even when
personnel wore caps. The use of shoe
covers has never been shown to
decrease SSI risk or to decrease
bacteria counts on the operating
room floor. Shoe covers may,
however, protect surgical team
members from exposure to blood and
other body fluids during an
operation. OSHA regulations require
that surgical caps or hoods and shoe
covers or boots be worn in
situations when gross contamination
can reasonably be anticipated (Mangram,
et al., 1999).
Sterile gloves are put on after
donning sterile gowns. A strong
theoretical rationale supports the
wearing of sterile gloves by all
scrubbed members of the surgical
team. Sterile gloves are worn to
minimize transmission of
microorganisms from the hands of
team members to patients and to
prevent contamination of team
members’ hands with patients’ blood
and body fluids. If the integrity of
a glove is compromised it should be
changed as promptly as safety
permits. Wearing two pairs of
gloves, double-gloving, has been
shown to reduce hand contact with
patients’ blood and body fluids when
compared to wearing only a single
pair (Mangram, et al., 1999).
Sterile surgical gowns and drapes
are used to create a barrier between
the surgical field and potential
sources of bacteria. All scrubbed
surgical team members wear gowns and
drapes are placed over the patient.
There are limited data that can be
used to understand the relationship
of gown or drape characteristics
with SSI risk. The wide variation in
the products and study designs make
interpretation of the literature
difficult (Mangram, et al., 1999).
Gowns and drapes are classified as
disposable or reusable. Regardless
of the material used to manufacture
gowns and drapes, these items should
be impermeable to liquids and
viruses. Only gowns reinforced with
films, coatings, or membranes meet
standards developed by the American
Society for Testing and Materials.
However, such “liquid-proof” gowns
may be uncomfortable because they
also inhibit heat loss and the
evaporation of sweat from the
wearer’s body. These factors should
be considered when selecting gowns (Mangram,
et al., 1999).
AORN makes no official
recommendation about the length of
the drape that extends over the edge
of the sterile back table. The
draped table is sterile only at the
top surface and drapes extending
below the table level are considered
unsterile. The length of the drape
extending over the edge of a draped
surface becomes irrelevant in terms
of sterility because any portion of
the drape beyond the flat surface is
contaminated. After a drape is
placed, it should not be shifted or
moved so that part of the drape that
was below the table level is not
moved inadvertently to the top,
because this compromises the sterile
field (Peterson, 2003).
|
The Association for the Advancement of Medical
Instrumentation set the following parameters for
flash sterilization cycles (Mangram, et al.,
1999). |
Gravity-Displacement Minimum Exposure Time and
Temperature
Nonporous items 3 min at 132C (270F)
Nonporous and porous items 10 min at 132C
(270F)
Prevacuum Minimum Exposure Time and Temperature
Nonporous items 3 min at 132C (270F)
Nonporous and porous items 4 min at 132C
(270F) |
Rigorous adherence to the principles
of asepsis by all scrubbed personnel
is the foundation of surgical site
infection prevention. Others who
work in close proximity to the
sterile surgical field, such as
anesthesia personnel, must also
abide by these principles. SSIs have
occurred in which anesthesia
personnel were implicated as the
source of the pathogen.
Anesthesiologists and nurse
anesthetists perform a variety of
invasive procedures such as
placement of intravascular devices
and endotracheal tubes, and
administration of intravenous drugs
and solutions. Lack of adherence to
the principles of asepsis during
such procedures, including use of
contaminated syringes and
contaminated infusion pumps, and the
assembly of equipment and solutions
in advance of procedures, have been
associated with outbreaks of
postoperative infections, including
SSI (Mangram, et al., 1999).
Excellent surgical technique is
widely believed to reduce the risk
of SSI. Such techniques include
maintaining effective hemostasis
while preserving adequate blood
supply, preventing hypothermia,
gently handling tissues, avoiding
inadvertent entries into a hollow
viscus, removing devitalized (e.g.,
necrotic or charred) tissues, using
drains and suture material
appropriately, eradicating dead
space, and appropriately managing
the postoperative incision (Mangram,
et al., 1999).
Any foreign body, including suture
material, a prosthesis, or drain,
may promote inflammation at the
surgical site and may increase the
probability of SSI. Extensive
research compares different types of
suture material and their presumed
relationships to SSI risk. In
general, monofilament sutures appear
to have the lowest
infection-promoting effects. Drains
placed through an operative incision
increase incisional SSI risk. Many
authorities suggest placing drains
through a separate incision distant
from the operative incision. It
appears that SSI risk also decreases
when closed suction drains are used
rather than open drains. Closed
suction drains can effectively
evacuate postoperative hematomas or
seromas, but timing of drain removal
is important. Bacterial colonization
of initially sterile drain tracts
increases with the duration of time
the drain is left in place (Mangram,
et al., 1999).
Hypothermia in surgical patients,
defined as a core body temperature
below 36C, may result from general
anesthesia; exposure to cold, or
intentional cooling such as is done
to protect the myocardium and
central nervous system during
cardiac operations. In one study of
patients undergoing colorectal
operations, hypothermia was
associated with an increased SSI
risk. Mild hypothermia appears to
increase incisional SSI risk by
causing vasoconstriction, decreased
delivery of oxygen to the wound
space, and subsequent impairment of
function of phagocytic leukocytes.
In animal models, supplemental
oxygen administration has been shown
to reverse the dysfunction of
phagocytes in fresh incisions. In
recent human experiments, controlled
local heating of incisions with an
electrically powered bandage has
been shown to improve tissue
oxygenation (Mangram, et al., 1999).
The type of postoperative incision
care is determined by whether the
incision is closed primarily, left
open to be closed later, or left
open to heal by second intention.
When a surgical incision is closed
primarily, as most are, the incision
is usually covered with a sterile
dressing for 24 to 48 hours. Beyond
48 hours, it is unclear whether a
dressing must cover an incision or
whether showering or bathing is
detrimental to healing. When a
surgical incision is left open at
the skin level for a few days before
it is closed, delayed primary
closure, a surgeon has determined
that it is likely to be contaminated
or that the patient’s condition
prevents primary closure. When such
is the case, the incision is packed
with a sterile dressing. When a
surgical incision is left open to
heal by second intention, it is also
packed with sterile moist gauze and
covered with a sterile dressing. The
American College of Surgeons, CDC,
and others have recommended using
sterile gloves and equipment
(sterile technique) when changing
dressings on any type of surgical
incision (Mangram, et al., 1999).
The Guideline for Prevention of
Surgical Site Infection, 1999,
provides recommendations concerning
reduction of surgical site infection
risk. Each recommendation is
categorized on the basis of existing
scientific data, theoretical
rationale, and applicability.
Category I recommendations,
including IA and IB, are those
recommendations that are viewed as
effective by the Hospital Infection
Control Practices Advisory Committee
of the National Center for
Infectious Diseases and experts in
the fields of surgery, infectious
diseases, and infection control.
Both Category IA and IB
recommendations are applicable for,
and should be adopted by, all
healthcare facilities; IA and IB
recommendations differ only in the
strength of the supporting
scientific evidence.
Category II recommendations are
supported by less scientific data
than Category I recommendations;
such recommendations may be
appropriate for addressing specific
nosocomial problems or specific
patient populations. No
recommendation is offered for some
practices, either because there is a
lack of consensus regarding their
efficacy or because the available
scientific evidence is insufficient
to support their adoption. For such
unresolved issues, practitioners
should use judgment to determine a
policy regarding these practices
within their organization.
Category IA. Strongly recommended
for implementation and supported by
well-designed experimental,
clinical, or epidemiological
studies.
Category IB. Strongly recommended
for implementation and supported by
some experimental, clinical, or
epidemiological studies and strong
theoretical rationale.
Category II. Suggested for
implementation and supported by
suggestive clinical or
epidemiological studies or
theoretical rationale.
No recommendation; unresolved issue.
Practices for which insufficient
evidence or no consensus regarding
efficacy exists.
Practices required by federal
regulation are denoted with an
asterisk (*).
Preoperative Recommendations
Preparation of the patient
1.
Whenever possible, identify and
treat all infections remote to the
surgical site before elective
operation and postpone elective
operations on patients with remote
site infections until the infection
has resolved. Category IA
2.
Do not remove hair preoperatively
unless the hair at or around the
incision site will interfere with
the operation. Category IA
3.
If hair is removed, remove
immediately before the operation,
preferably with electric clippers.
Category IA
4.
Adequately control serum blood
glucose levels in all diabetic
patients and particularly avoid
hyperglycemia perioperatively.
Category IB
5.
Encourage tobacco cessation. At
minimum, instruct patients to
abstain for at least 30 days before
elective operation from smoking
cigarettes, cigars, pipes, or any
other form of tobacco consumption
(e.g., chewing/dipping). Category IB
6.
Do not withhold necessary blood
products from surgical patients as a
means to prevent SSI. Category IB
7.
Require patients to shower or bathe
with an antiseptic agent on at least
the night before the operative day.
Category IB
8.
Thoroughly wash and clean at and
around the incision site to remove
gross contamination before
performing antiseptic skin
preparation. Category IB
9.
Use an appropriate antiseptic agent
for skin preparation. Category IB
10.
Apply preoperative antiseptic skin
preparation in concentric circles
moving toward the periphery. The
prepared area must be large enough
to extend the incision or create new
incisions or drain sites, if
necessary. Category II
11.
Keep preoperative hospital stay as
short as possible while allowing for
adequate preoperative preparation of
the patient. Category II
12.
No recommendation to taper or
discontinue systemic steroid use
(when medically permissible) before
elective operation. Unresolved issue
13.
No recommendation to enhance
nutritional support for surgical
patients solely as a means to
prevent SSI. Unresolved issue
14.
No recommendation to preoperatively
apply mupirocin to nares to prevent
SSI. Unresolved issue
15.
No recommendation to provide
measures that enhance wound space
oxygenation to prevent SSI.
Unresolved issue
Hand/forearm antisepsis for surgical
team members
1.
Keep nails short and do not
wear artificial nails. Category IB
2.
Perform a preoperative
surgical scrub for at least 2 to 5
minutes using an appropriate
antiseptic. Scrub the hands and
forearms up to the elbows. Category
IB. However, in October 2002, the
CDC updated its hand hygiene
recommendations and essentially
abolished the traditional long
presurgical scrub. For surgical hand
antisepsis, the new guideline
recommends using either an
antimicrobial soap or an
alcohol-based hand rub with
persistent activity. Washing with
regular soap is still necessary
before using alcohol rub products,
because alcohol rub products are not
cleaning agents and don't remove
surface dirt. No recommendation on
the use of brushes was made (Maithias,
2003).
3.
After performing the surgical
scrub, keep hands up and away from
the body (elbows in flexed position)
so that water runs from the tips of
the fingers toward the elbows. Dry
hands with a sterile towel and don a
sterile gown and gloves. Category IB
4.
Clean underneath each
fingernail prior to performing the
first surgical scrub of the day.
Category II
5.
Do not wear hand or arm
jewelry. Category II
6.
No recommendation on wearing
nail polish. Unresolved Issue
Management of infected or colonized
surgical personnel
1.
Educate and encourage
surgical personnel who have signs
and symptoms of a transmissible
infectious illness to report
conditions promptly to their
supervisory and occupational health
service personnel. Category IB
2.
Develop well-defined policies
concerning patient-care
responsibilities when personnel have
potentially transmissible infectious
conditions. These policies should
govern (a) personnel responsibility
in using the health service and
reporting illness, (b) work
restrictions, and (c) clearance to
resume work after an illness that
required work restriction. The
policies also should identify
persons who have the authority to
remove personnel from duty. Category
IB
3.
Obtain appropriate cultures
from, and exclude from duty,
surgical personnel who have draining
skin lesions until infection has
been ruled out or personnel have
received adequate therapy and
infection has resolved. Category IB
4.
Do not routinely exclude
surgical personnel who are colonized
with organisms such as S. aureus
(nose, hands, or other body site) or
group A Streptococcus, unless such
personnel have been linked
epidemiologically to dissemination
of the organism in the healthcare
setting. Category IB
Ventilation (Anonymous, 2003)
1.
Maintain positive-pressure ventilation in the operating room with
respect to the corridors and adjacent areas. Category IB
2.
Maintain a minimum of 15 air changes per hour, of which at least
3 should be fresh air. Category IB
3.
Filter all air, recirculated and fresh, through the appropriate filters per
the American Institute of Architects’ recommendations. Category IB
4.
Introduce all air at the ceiling, and exhaust near the floor. Category IB
5.
Do not use UV radiation in the operating room to prevent SSI.
Category IB
6.
Keep operating room doors closed except as needed for passage of equipment,
personnel, and the patient. Category IB
7.
Consider performing orthopedic implant operations in operating rooms
supplied with ultraclean air. Category II
8.
Limit the number of personnel entering the operating room to necessary
personnel. Category II
Cleaning and disinfection of
environmental surfaces
1.
When visible soiling or contamination with blood or other body fluids of
surfaces or equipment occurs during an operation, use an EPA-approved
hospital disinfectant to clean the affected areas before the next operation.
Category IB*
2.
Do not perform special cleaning or closing of operating rooms after
contaminated or dirty operations. Category IB
3.
Do not use tacky mats at the entrance to the operating room suite or
individual operating rooms for infection control. Category IB
4.
Wet vacuum the operating room floor after the last operation of
the day or night with an EPA-approved hospital disinfectant. Category II
5.
No recommendation on disinfecting environmental surfaces or equipment used
in operating rooms between operations in the absence of visible soiling.
Unresolved issue
6.
After the last surgical procedure of the day or night, wet vacuum or mop OR
floors with a single-use mop and an EPA-registered hospital disinfectant. IB
(Anonymous, 2003).
Microbiologic sampling
1.
Do not perform routine environmental sampling of the operating room. Perform
microbiologic sampling of operating room environmental surfaces or air only
as part of an epidemiologic investigation. Category IB
Sterilization of surgical
instruments
1. Sterilize all surgical instruments
according to published guidelines.
Category IB
2.
Perform flash sterilization only for patient care items that will be used
immediately (e.g., to reprocess an inadvertently dropped instrument). Do not
use flash sterilization for reasons of convenience, as an alternative to
purchasing additional instrument sets, or to save time. Category IB
Recommendations: Water Automatic endoscope reprocessors (Anonymous, 2003).
1. Clean, disinfect, and maintain
automatic endoscope reprocessor (AER) equipment according to the
manufacturer's instructions and relevant scientific literature to prevent
inadvertent contamination of endoscopes and bronchoscopes with waterborne
microorganisms. IB
2.
To rinse disinfected endoscopes and bronchoscopes, use water of the highest
quality practical for the system's engineering and design (e.g., sterile
water or bacteriologically filtered water [water filtered through 0.1 to 0.2
[mu]m filters]). IB
3.
Dry internal channels of the reprocessed endoscope or bronchoscope using a
proven method (e.g., 70% alcohol followed by forced-air treatment) to lessen
potential for proliferation of waterborne microorganisms and to help prevent
biofilm formation. IB
Surgical attire and drapes
1.
Wear a surgical mask that fully covers the mouth and nose when
entering the operating room if an operation is about to begin or already
under way, or if sterile instruments are exposed. Wear the mask throughout
the operation. Category IB*
2.
Wear a cap or hood to fully cover hair on the head and face when entering
the operating room. Category IB*
3.
Do not wear shoe covers for the prevention of SSI. Category IB*
4.
Wear sterile gloves if a scrubbed surgical team member. Put on gloves after
donning a sterile gown. Category IB*
5.
Use surgical gowns and drapes that are effective barriers when wet (i.e.,
materials that resist liquid penetration). Category IB
6.
Change scrub suits that are visibly soiled, contaminated, and/or penetrated
by blood or other potentially infectious materials. Category IB*
7.
Employers must launder workers' personal protective garments or uniforms
contaminated with blood or other potentially infectious materials
(Anonymous, 2003). No recommendations on how or where to launder scrub
suits, on restricting use of scrub suits to the operating suite, or for
covering scrub suits when out of the operating suite. Unresolved issue *
8.
Use sterilized textiles, surgical drapes, and gowns for situations requiring
sterility. IB (Anonymous, 2003)
9.
No recommendation regarding using disposable fabrics versus durable goods.
Unresolved issue (Anonymous, 2003).
Asepsis and surgical technique
1.
Adhere to principles of asepsis when placing intravascular devices (e.g.,
central venous catheters), spinal or epidural anesthesia catheters, or when
dispensing and administering intravenous drugs. Category IA
2.
Assemble sterile equipment and solutions immediately prior to use. Category
II
3.
Handle tissue gently, maintain effective hemostasis, minimize devitalized
tissue and foreign bodies (i.e., sutures, charred tissues, necrotic debris),
and eradicate dead space at the surgical site. Category IB
4.
Use delayed primary skin closure or leave an incision open to heal by second
intention if the surgeon considers the surgical site to be heavily
contaminated (e.g., Class III and Class IV). Category IB
5.
If drainage is necessary, use a closed suction drain. Place a drain through
a separate incision distant from the operative incision. Remove the drain as
soon as possible. Category IB
1.
Protect with a sterile dressing for 24 to 48 hours postoperatively an
incision that has been closed primarily. Category IB
2.
Wash hands before and after dressing changes and any contact with the
surgical site. Category IB
3.
When an incision dressing must be changed, use sterile technique. Category
II
4.
Educate the patient and family regarding proper incision care, symptoms of
SSI, and the need to report such symptoms. Category II
5.
No recommendation to cover an incision closed primarily beyond 48 hours, nor
on the appropriate time to shower or bathe with an uncovered incision.
Unresolved issue
Anonymous. (2003). CDC issues
new environmental guidelines. OR Manager. 19(8), 20. Retrieved 1/4/04 from
ProQuest.
Conner, R. (2003). Fire
blankets, alcohol-based hand scrubs, peel pouch indicators, aseptic
technique definitions, shaving. AORN Journal. 78(3), 483. Retrieved 1/4/04
from ProQuest.
Mangram, A., Horan, T.,
Pearson M., Silver, L., and Jarvis W. (1999). Guidelines for prevention of
surgical site infection. Infection Control and Hospital Epidemiology, 20(4),
247 Retrieved 1/4/04 from
http://www.cdc.gov/ncidod/hip/SSI/SSI_guideline.htm.
Maithias, J. (2003). New
alcohol-based hand rubs catch on quickly with staff, MDs. OR Manager, 19(1),
1-3. Retrieved 1/4/04 from ProQuest.
Peterson, C. (2003). Clinical
issues: Table overhang, hypothermia, separating sponges, skin lacerations
when scrubbing, wound classification, forced air warming. AORN Journal,
78(1), 123. Retrieved 1/4/04 from ProQuest.
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