Surgical-site infections (SSIs)can lead to increased post-operative stays, higher

readmission rates and health-care costs, and poorer healthoutcomes. In a 2014 study, SSIstied with pneumonia as themost common infection in hos-pitals, accounting for 21.8% oftotal infections. These facts andfigures underscore theneed for robust SSIprevention strategies.Implementing evi-dence-based interven-tions can greatly re-duce SSI risk. (See Riskfactors for SSIs.)

Preventionguidelines The Healthcare Infec-tions Advisory Com-mittee publishedguidelines for SSI pre-vention in 1999. Theguidelines have been up-dated and are currently under-going final review.

In 2014, “A Compendium ofStrategies to Prevent Healthcare-Associated Infections in AcuteCare Hospitals: 2014 Update”was published as a collaborativeendeavor by the Society forHealthcare Epidemiology, Infec-tious Diseases Society of Ameri-ca, Association of Professionalsin Infection Control, AmericanHospital Association, and TheJoint Commission. This docu-ment outlines the following pre-vention practices:

• Give antibiotic prophylaxisaccording to guidelines. Limitpostoperative duration of an-tibiotic therapy.

• Don’t use razors to removehair at the operative site, and

limit hair removal to areaswhere hair may interfere withthe surgical incision.

• Control blood glucose in pa-tients scheduled for cardiacsurgery, those with diabetes,and those known to have elevated preoperative bloodglucose.

• During the perioperative peri-od, maintain body tempera-ture at 95.9° F (35.5° C) orhigher.

• Use an alcohol-based skinprep unless contraindicated.

• Use impervious wound pro-tectors for gastric and biliarysurgery.

• Perform SSI surveillance andprovide feedback on SSI ratesto surgeons and other stake-holders.

• Educate patients and families

about their role in SSI preven-tion.

• Develop policies, procedures,and protocols based on evi-dence-based standards, suchas those of the Centers forDisease Control and Preven-tion, Association of periOper-ative Registered Nurses

(AORN), and other pro-fessional societies.

Special approaches Besides these corestrategies, a recom-mended special ap-proach to SSI preven-tion involves screeningfor Staphylococcus au-reus and decolonizinghigh-risk patients withan anti-staphylococcalagent, particularly inthe orthopedic or car-diac setting.

Nurse’s role in SSIprevention As a nurse, your role in prevent-ing SSIs is comprehensive andspans the continuum of care.You play a crucial part in exe-cuting or promoting implemen-tation of evidence-based prac-tices. For example, providecounseling and education dur-ing the initial preoperative visit,especially related to smokingcessation and glucose control inpatients with diabetes. Encour-age patients to report new rash-es, breaks in skin integrity, andnew-onset respiratory infectionsbefore surgery. Although datasuggest the effectiveness of anti-septic showers or cloths is unre-solved, AORN recommends in-structing patients to bathe orshower with soap or an antisep-tic before surgery, noting that

Preventing surgical-site infections By Linda R. Greene, MPS, RN, CIC

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reducing skin microorganismsmay lower the risk of develop-ing an SSI. If the patient willuse a chlorhexidine antisepticfor preoperative skin cleaning,instruct him or her to latherwith the soap and leave it onthe skin for 2 minutes beforerinsing it off.

Interventions before,during, and after surgery SSI prevention requires actionand vigilance during the preop-erative, intraoperative, andpostoperative periods, as de-scribed below.

Preoperative interventions Validate and ensure that thepatient has followed all preop-erative instructions. Maintainthe patient’s body temperature;a low temperature may increasethe infection risk by causingvasoconstriction. Active warm-ing can reduce this risk. AORNrecommends warming patientsat risk for hypothermia at least15 minutes before anesthesiainduction.

Risk factors for hypothermiainclude certain types and ex-tents of surgery or anesthesia,low body weight, cool irriga-tions in body cavities, and bloodadministration. Cardiac surgerypatients and patients with dia-betes may be at risk for elevatedblood glucose during and aftersurgery. Current guidelines rec-ommend keeping the patient’sblood glucose level at 180mg/dL or lower; insulin via in-jection or I.V solution may berequired preoperatively.

Intraoperative interventions To ensure razors aren’t used toremove hair before surgery,many hospitals have eliminatedthem from the operating room(OR). Also, surgical prep mustbe applied correctly and al-lowed to dry before the initialincision.

The OR nurse is integral toensuring all skin antisepsis pa-

rameters are met. Unless con-traindicated, an alcohol-basedprep is recommended. General-ly, surgical antibiotic prophy-laxis is administered by anes-thesia before incision; somehealthcare organizations haveadded surgical prophylaxis totheir preoperative checklist. TheOR nurse should ensure pro-phylaxis guidelines are fol-lowed and the antibiotic is giv-en before incision. OR doorsmust remain closed during sur-gery and traffic flow must beminimized.

Postoperative interventions Postoperative wound care shouldbe managed closely. In thepostanesthesia care unit, checkall dressings for drainage andclosure. Hand hygiene and strictasepsis during dressing changesare critical. Monitor the patient’stemperature; as needed and or-dered, implement warming tech-niques. At discharge, carefullyreview postoperative instructionswith the patient.

Using the best availableevidence Implementing evidence-basedguidelines requires a coordinat-ed multidisciplinary approach.As we transition from silos ofcare to a collaborative ap-proach, nurses continue to play

a pivotal role in promoting andimplementing SSI preventionstrategies while bringing thebest available evidence to thebedside. �

Selected referencesAnderson DJ, Podgorny K, Berrios-TorresSI, et al. Strategies to prevent surgical siteinfections in acute care hospitals: 2014 up-date. Infect Control Hosp Epidemiol. 2014;35(6):605-27.

Association of periOperative RegisteredNurses (AORN). Recommended practicesfor environmental cleaning. In: Periopera-tive Standards and Recommended Prac-tices; 2014 Edition. Denver, CO: AORN,Inc.; 2014.

Magill SS, Edwards JR, Bamberg W, et al.;Emerging Infections Program Healthcare-Associated Infections and Antimicrobial UsePrevalence Survey Team. Multistate point-prevalence survey of health care-associatedinfections. N Engl J Med. 2014;370(13):1198-208.

Mangram AJ, Horan TC, Pearson ML, SilverLC, Jarvis WR. Hospital Infection ControlPractices Advisory Committee. Guideline forprevention of surgical site infection, 1999.Hospital Infection Control Practices Adviso-ry Committee. Infect Control Hosp Epidemi-ol. 1999;20(4):250-78.

Yokoe DS, Anderson, DJ, Berenholtz, SM, etal. A Compendium of Strategies to PreventHealthcare-Associated Infections in AcuteCare Hospitals: 2014 Update. May 1, 2014.www.shea-online.org/View/ArticleId/289/Compendium-of-Strategies-to-Prevent-Healthcare-Associated-Infections-in-Acute-Care-Hospitals-2014-Up.aspx

Linda R. Greene is manager of infection preventionat Highland Hospital, University of RochesterMedical Center, in Rochester, New York.

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Risk factors for SSIs Independent risk factors for surgical-siteinfections (SSIs) include diabetes,obesity, other comorbid conditions,and advanced age. These risk factorsare hard or impossible to modifyduring the perioperative period.

Modifiable risk factors includeimproper or inadequate handhygiene, surgical scrub, skinpreparation, antibiotic pro -phylaxis, traffic control, surgicalinstrument cleaning and sterili -zation, and environmentalcleaning of the operating room.