The document discusses the prevalence and impact of surgical site infections (SSI), highlighting their association with increased patient morbidity, mortality, and healthcare costs. It outlines SSI classifications, risk factors, and prevention strategies, emphasizing the importance of proper hygiene, surgical techniques, and antibiotic use before and after surgery. Additionally, it introduces an SSI prevention bundle aimed at optimizing peri-operative care to minimize infection risks and improve patient outcomes.

1. ١

2. Healthcare Associated
Infections Due to SSI
290,485 infections
8,205 deaths
SSI
17%
Other
22%
PNEU
14%
BSI
14%
250,205 infections
35,967 deaths
UTI
33%
248,678 infections
30,655 deaths
561,667 infections
13,088 deaths
Klevens RM, et al. Public Health Reports. 2007
BSI
PNEU
SSI
UTI
Bloodstream Infection
Pneumonia
Surgical Site Infection
Urinary Tract Infection
٢

3. Impact of SSI
SSI are associated with:
Increased length of stay by 7-10 days
 Increased cost per episode of up to
$30,000
30,
 Increased readmission rate of up to
40%
40%
 Up to ~ 10 times increased risk of
death compared to surgical patients
without SSI
 77% attributable mortality
77%
 $10 billion in annual US healthcare
expenditure

٣

4. SSI is a Global Public Health
Priority
2nd Global Patient
Safety
Challenge
Clean surgery
 Safe anesthesia
 Safe operators
 Measurement and
quality assurance

٤

5. Surgical Site Classification
• No inflammation
• No involvement of pulmonary, GIT or
GU systems
• Primarily closed and when drain is
involved it is closed drainage
• Only blunt trauma are included in this
category
٥

6. Surgical Site Classification
cont……
• Pulmonary, GIT or GU system
involvement, but under controlled
conditions
• For example: biliary tract, appendix,
vagina, and oropharynx
• No break in the technique
٦

7. Surgical Site Classification
cont…
• Fresh open injuries
• Operation with major break in sterile
technique
• Spillage from GI tract
• Entry into the genitourinary tract with
infected urine
• Entry into the biliary tract with infected
bile
• Non-purulent inflamed surgical site
٧

8. Surgical Site Classification cont…
• Old traumatic wounds with retained
devitalized tissues, foreign body or
fecal contamination
• Surgical procedures involved bowl
perforation
• Surgical procedures involved pus
drainage
٨

9. Diagnosed when
you see
pus at the site
Purulent drainage from
the site or the drainage
Positive culture from
the fluid of the
drainage
The surgeon diagnose
infection
SS requires re-opening
٩

10. Sources of pathogens
Personnel
From the skin
Hands, hair, scalp, nose and mouth
S. aureus
Environment
Coagulase-negative staphylococci
Contaminated solutions, antiseptics
From the pulmonary system
or dressings
, GIT or GUS
Surfaces
Normal flora e.g. E. coli,
Air
Enterococci, P.
Ventilation system
aeruginosa …
Positive pressure
١٠

11. Staphylococcus
aureus
Coagulase-negative
staphylococci
Enterobacter spp.
Etiological Agent
Pseudomonas
aeruginosa
Enterococci
Escherichia coli
١١

12. Risk Factors
Surgical site classification
Prolonged preoperative stay
Preoperative shaving
Length of the operation
Surgical technique
Abdominal drains
١٢

13. SSI Prevention
Patient
• Co morbid conditions
• Immune status
• Colonization
Pathogen
• Degree of contamination
• Virulence
• Antimicrobial resistance
Procedure
• Duration
• Preparation
• Type and technique
• Equipment sterilization
• OR characteristics
١٣
• Introduction of foreign material

14. Prevention of SSI
Preoperative
Measures
Preoperative
stay
Host factors
Preoperative
shower
Hair removal
Preoperative
antibiotics
Postoperative Phase
Changing Dressings
Intraoperative
Postoperative Cleansing
Measures
Topical Antimicrobial
Preparation of the
Agents for Wound
incisional site
Healing by Primary
Surgical scrub
Intention
Barrier devices
Dressings for Wound
Masks, Caps,Gowns
Healing by Secondary
and drapes
Intention
Reduction of air-borne
Antibiotic Treatment of
contamination in the OR
Surgical Site Infection
Operative technique
and Treatment Failure
١٤

15. Risk Prevention

Patient Characteristics
–
–
–
–
–
–
Diabetes
Nicotine use
Steroid Use
Malnutrition
Prolonged Hospital Stay
PrePre-operative nares colonization with
Staph aureus
– Peri-operative Transfusions
Peri-
١٥

16. Risk Prevention

Operative Characteristics:
Preoperative Issues
–
–
–
–
–
Preoperative antiseptic showering
Preoperative hair removal
Patient skin prep in the OR
Preoperative hand/forearm antisepsis
Management of infected or colonized
surgical personnel
– Antimicrobial prophylaxis
١٦

17. Preoperative Preparation
١٧

18. Risk Reduction: Antimicrobial
PrePre-Operative Shower

Chlorhexidene Gluconate – Primary
choice

Iodophor

Hexachlorophene
١٨

19. Risk Prevention

Operative characteristics: Intra-operative issues
Intra– Operating Room environment
 Ventilation
 Environmental surfaces
 Microbial sampling – do not do routinely
 Conventional sterilization of surgical instruments
 Flash sterilization of surgical instruments
– Surgical attire and drapes
 Scrub suits
 Masks
 Surgical caps/hoods and shoe covers
 Sterile gloves
 Gowns and Drapes
– Asepsis and surgical technique
 Asepsis
 Surgical technique
١٩

20. Intraoperative - OR Environment

Ventilation
– Positive pressure to corridors
– A minimum of 20-25 air exchanges per
20hour
– Filter air
– Ceiling supply vents and exhaust near
floor

Humidity
– 30-60%
30-60%

Temp 68-73°F
68-73°
٢٠

21. Dress Codes & Drapes
 Gloves
 Masks
 Sterile
Gowns – determine the
level of impermeability needed
per procedure
 Shoe covers – not infection
prevention for SSI but prevents
blood contamination
 Drapes – impervious!
٢١

22. Cleaning, Disinfection &
Sterilization

Environmental cleaning
– EPA approved hospital disinfectant


Patient care equipment and instruments
Sterilization
– Sterilize all surgical instruments according to
published guidelines
– Perform flash sterilization only for patient care
items that will be used immediately
 Do not use flash sterilization for convenience
or for inventory control

Biological monitoring for sterilizers
– Rapid readouts
– 48 hour test
– Steris
٢٢

23. Gloving Aspects of Hand Hygiene


Wear gloves when
contact with blood or
other potentially
infectious materials,
mucous membranes,
& nonintact skin
could occur.
Change gloves during
patient care if
moving from a
contaminated body
site to a clean body
site.

Remove gloves after
caring for a patient.
– Do not wear the
same pair of gloves
for the care of more
than one patient,
– Do not wash gloves
between uses with
different patients.
٢٣

24. Sterile Technique





Adhere to principles of asepsis
Assemble sterile equipment and solutions
immediately prior to use.
Handle tissues gently, maintain homeostasis,
minimize devitalized tissues and foreign bodies
and eradicate dead space at the surgical site
Use delayed primary skin closure or an incision
open to heal by secondary intention if the
surgeon considers the surgical site to be
heavily contaminated
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.
٢٤

25. Risk Prevention

Postoperative Issues
– Incision care
 Protect
with a sterile dressing for 24 to 48
hours postoperatively an incision that has
been closed primarily.
 Wash hands before and after dressing
changes any contact with surgical site
 When an incision dressing must be changed,
use sterile technique.
– Discharge planning
 Educate
the patient and family regarding
proper incision care, symptoms of SSI, and
٢٥
the need to report those symptoms

26. WHAT IS A BUNDLE?
A bundle is a structured way of improving
processes of care and patient outcomes.
It is a small straightforward set of
practices – generally three to five that when
performed collectively, reliably and
continuously, have been proven to improve
patient outcome.
٢٦

27. Surgical Site Infection Prevention
Bundle
The Bundle
1. If at all possible avoid hair removal; if hair removal is
necessary, avoid the use of razors
2. Ensure prophylactic antibiotic was prescribed as per local
antibiotic policy guideline, for the specific operation category &
Ensure the antibiotic was been administered within 60 minutes
prior to the operation.
3. Ensure the patient’s body temperature was normal throughout
the operation (excludes cardiac patients).
4. Ensure the surgical scrub & preparation of incision site was
done.
5. Ensure the patient’s blood glucose level was normal throughout
the operation (diabetic patients only).
٢٧

28. Surgical Site Infection Prevention Bundle –Standard Operating Procedure
Statement
Surgical site infections arise when the host’s defences are overwhelmed by micro-organisms
that come from the patient, disseminated from staff in the operating theatre or from
inadequately decontaminated instruments.
Procedures undertaken in the ward pre and post operatively, and in the theatre perioperatively must be designed to negate, or minimise as far as is possible, the risk of surgical
site infection.
Objectives
Objectives:
1.To optimise peri-operative care minimising the risk of surgical site infections.
2.To be able to demonstrate quality peri-operative care in OUR clinical area
Requirement
s
Before the SSI prevention bundle is performed.
Signed commitment from the clinical team: consultants; junior doctors, ward manager and
nurse team to optimising SSI prevention care.
The data required for this bundle should be collected and documented on every patient.
Analysis of compliance can be through the analysis of data (if there is ongoing surveillance),
or via a weekly analysis of a selection of patients’ peri-operative records
Procedure
For weekly analysis review of notes
1.Perform hand hygiene.
2.On each ward select notes from 7 patients who underwent operations.
3.Check to see if the appropriate bundle criteria were recorded in the patients’ notes.
4.Record findings on the SSI bundle prevention data collection sheet.
After care
Complete form.
Give it to:
٢٨
Discuss and display the data when it has been returned.(Keep bundle forms for xx time).

29. Date:
Location:
Observer:
(See overleaf for qualifying information)
Patient
1
Patient
2
Patient
3
Patient
4
Patient
5
Patient
6
Patient
7
1.If at all possible avoid hair removal; if hair removal is necessary,
avoid the use of razors $
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
1.Prophylactic antibiotics were prescribed as per the local antibiotic
policy/SIGN guideline for the operation category.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1.The antibiotic was administered 60 minutes prior to the start of the
operation.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1.The patient’s body temperature was normal (36-37C) throughout
the operation. $$
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
1.If diabetic, the patient remained normoglycaemic during the
operation. $$$
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
1.The surgical scrub & preparation of incision site were done
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
٢٩ N/A

30. Summary Table of SSI Prevention Bundle Findings
Comment
(if required)
Total number of patients’ case notes reviewed
(should be 7)
No.
Total number of patients requiring hair removal that operation sites were clipped.
Total number of patients who were given the right antibiotics
Total number of given antibiotics within 60 minutes of the start of the operation.
Total number of patients who were normothermic throughout the operation.
Total number of diabetic patients who were normoglycaemic throughout the operation.
All or None Table – Was SSI prevention Optimal
Tick if achieved
100% of patients requiring hair removal, hair was clipped.
100% of patients were given the correct antibiotics
100% of patients were given antibiotics within 60 minutes of the operation
100% of patients were normothemic throughout the operation
100% of diabetic patients were normoglycaemic throughout the operation.
٣٠
100% of OR staff don surgical scrub & well prepared the incision site.

31. ٣١