This document discusses surgical site infections (SSIs). It notes that SSIs result in up to $10 billion in annual treatment costs in the US and outlines some of the impacts of SSIs, including increased length of hospital stay, morbidity, and mortality. The document then describes several evidence-based practices that can reduce SSIs when implemented as part of a care bundle, including proper administration of preoperative antibiotics, appropriate hair removal, and maintaining postoperative normothermia. It discusses these practices in further detail in sections on preoperative, intraoperative, and postoperative phases of care.

1. SURGICAL SITE
INFECTIONS
ME Macrae B.Cur 1et A III
University of Pretoria
Student No: 29606218
15 November 2011
Sandton MediClinic
Operating Theatre
ME MA C R A E B . C U R 1 E T A I I I

2. INTRODUCTION
 Definition of Surgical Site Infections
 The incidence of SSI’s
 SSI nosocomial infection
 Economic costs of SSIs
 Morbidity
 Mortality
 Re-admission Rate
 Length of stay
 Cost for patients
 Evidence-based care components
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3. IMPACT
 Despite the best efforts of healthcare facilities to maintain safe
surgical environments, surgical site infections result in up to $10
billion in treatment costs every year in the U.S. alone
 780,000 out of 30 million surgical procedures performed annually
in the U.S. result in SSI.1
 In the United Kingdom, the estimated direct costs for a patient
who has developed a surgical site infection are between €2,265
and €2,518.2
 According to a study in the Netherlands, SSIs result in 5.8 to 17
extra days of hospitalization.3
 In France, approximately 11% of surgical patients acquire a
surgical site infection.
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4. CARE BUNDLES
 A review of the medical literature shows that the following care
components reduce the incidence of SSI:
 Day of Surgery Admission
 Appropriate use of Antibiotics
 Appropriate hair removal
 Maintenance of post-operative glucose control (Major cardiac surgical
patients)
 Post-operative normothermia (All open abdominal surgery)
 The components, if implemented reliably, drastically reduce the
incidence of SSI and virtually eliminate instances of preventable
SSI
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5. PREOPERATIVE PHASE
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6. DAY OF SURGERY ADMISSION
(DOSA)
 DOSA – Obvious means of reducing preoperative hospital stay
 Guidelines for Prevention of SSI recommends this
 Category II – Supported by suggestive clinical or epidemiological
studies
 Encouraged to practice DOSA where possible
 Document reasons for not practicing DOSA
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7. PREOPERATIVE ANTIBIOTIC
PROPHYLAXIS
 Purpose is to reduce the impact of intraoperative microbial
contamination of a surgical site to a level that will not result in
infection
 Antibiotics Selection
 Consistent with national guidelines
 Special cases: Allergy, prolonged use
 Timely Administration
 Within one hour prior to surgery (Vancomycin or Fluoroquinolones: 2 Hours)
 Make sure all antibiotic is infused prior to inflation of cuff
 Dosage
 At least a full therapeutic dose
 Upper ranges for large patients and/or long operations
 Repeat doses for long operations (>4 Hours)
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8. RUN CHARTS
ON-TIME PROHYLACTIC ANTIBIOTIC
ADMINISTRATION
100% Goal
% OF PATIENTS
80%
Hospital
60%
Series 3
40%
Series 2
20%
0%
Jan-11 Feb-11 Mar-11 Apr-11 May-11
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9. PREOPERATIVE ANTIBIOTIC
PROPHYLAXIS
 Timely Discontinuation
 Confirmed efficacy of > 12 hours
 Efficacy of a single dose
 Shorter course has been as effective as the longer course
 No need to continue coverage beyond 24 Hours even with tubes and drains
postoperatively
 Lack of evidence preventing SSI’s if given after the end of the operation
 Increased use promotes antibiotic resistance
 Antibiotic Use : selection, dosage, timing, duration
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10. APPROPRIATE HAIR REMOVAL
Appropriate Inappropriate
No hair removal
Clipping
Depilatory use
Razors
X
 Influence of shaving on SSI
 Ensure adequate supply of clippers and train staff in proper use
 Use Reminders
 Educate patients not to self-shave preoperatively
 Remove all razors from the entire hospital
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11. INTRAOPERATIVE PHASE
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12. INTRAOPERATIVE PHASE
 Hand Decontamination
 Incise Drapes
 Do not use non-iodophor-impregnated drapes routinely
 Use of sterile gown and gloves
 Antiseptic Skin Preparation
 Prepare the skin at the surgical site immediately before incision
 Use an antiseptic (Aqueous or alcohol based)
 Preparation: povidone-iodine or chlorohexidine most suitable
 Diathermy
 Do not use diathermy for surgical incision to reduce the risk
 Wound dressings
 Cover surgical incisions with an appropriate interactive dressing
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13. PERIOPERATIVE NORMOTHERMIA
 Hypothermia reduces tissue oxygen tension by vasoconstriction
 Hypothermia reduces leukocyte superoxide production
 Hypothermia increases bleeding and transfusion requirement
 Hypothermia increases duration of hospital stay even in
uninfected patients
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X

14. POSTOPERATIVE PHASE
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15. DRESSING FOR WOUND HEALING
 Changing Dressings
 Use an aseptic non-touch technique for changing or removing surgical wound
dressing
 Post-Operative Cleansing
 Sterile saline for wound cleansing up to 48 Hours after surgery
 Advise patients they can shower safely after 48 Hours
 Wounds healing by primary intention
 Do not use topical antimicrobial agents to reduce risk of SSI
 Dressings for wound healing by secondary intention
 Refer to tissue viability nurse for advice on appropriate dressings for the
management of surgical wounds that are healing by secondary intention
 Do not use Eusol and gauze
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16. POST OPERATIVE SERUM GLUCOSE
DETERMINATION
 Hyperglycemia or and risk of SSI
 No increased risk
 Elevated HgbA1C
 Preoperative hyperglycemia
 Increased Risk
 Diagnosed Diabetes
 Undiagnosed Diabetes
 Post-operative glucose > 200mg% within 48 Hours
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17. CONCLUSION
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18. REFERENCES
 Cook, R. “Hospitals learn simple, cheap steps can prevent infections,” San Francisco
Chronicle, May 18, 2004; F1.
Coello R, Glenister H, Fereres J, Bartlett C, Leigh D, Sedgwick J, et al. The cost of infection in
surgical patients: a case–control study. J Hosp Infect 1993; 24(4):239–50., and Plowman
R, Graves N, Griffin MA, Roberts JA, Swan AV, Cookson, B, et al. The rate and cost of hospital–
acquired infections occurring in patients admitted to selected specialties of a district general
hospital in England and the national burden imposed. J Hosp Infect 2001; 47(3):198–209.
Geubbels EL, Mintjes–de Groot AJ, Van den Berg JM, de Boer AS. An operating surveillance
system of surgical site infections in the Netherlands: results of the PREZIES national surveillance
network. Prevenzxztie van Ziekenhuis infecties door Surveillance. Infect Control Hosp Epidemiol
2000; 21 (5): 107.
Source: Prevalence of nosocomial infections in France; results of the nationwide survey in 1996.
Journal of Hospital Infection. 2000; 46:186–193
 http://www.ncbi.nlm.nih.gov/pubmed/9527963
 Safer Systems – Saving Lives Preventing Surgical Site Infection – Version 4
http://www.health.vic.gov.au/sssl/downloads/prev_surgical.pdf Copyright State of
Victoria, Department of Human Services, 2005.
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