In the early days of surgery, it was common for patients to develop serious, even deadly infections after surgical procedures. Fortunately, pioneering surgeons discovered relationships between certain risk factors and the infections they caused. Ignaz Semmelweis, an obstetrical surgeon from Austria, noted that large numbers of his maternity patients were dying of "puerperal sepsis," an illness now known to be caused by Streptococcal infection. Semmelweis implemented the first surgical hand antisepsis program by requiring medical students to wash their hands in a chlorine solution between conducting autopsies and deliveries. These efforts yielded a sustained reduction in postpartum deaths from 16% to less than 2%.1 Sometime later, following the work of Louis Pasteur, Joseph Lister proposed that microbes from the air were likely the cause of most postoperative infections and began using carbolic acid-soaked cloth on wounds after surgery. His efforts also produced astounding improvements in postoperative morbidity and mortality.2

The burden of SSIs

Despite the fact that hospital infection prevention and control programs have improved outcomes significantly for surgical patients, the recent history of progress appears bleak. From 1986 to 1996, the National Nosocomial Infections Surveillance (NNIS) database, created by the CDC, compiled data on about 600,000 surgeries performed in select U.S. hospitals. Of those, about 38% resulted in a surgical-site infection (SSI). In fact, SSIs were the most common nosocomial, or hospital-acquired infection (HAI), with 77% of deaths in surgical patients attributed to infection.3

By 1999, improvements in OR ventilation, sterilization, barriers, surgical technique, and antimicrobial prophylaxis resulted in a further decrease in SSIs. Postoperative SSI was then the third most frequent HAI with about 15% of surgical patients acquiring an infection.3 Then, in 2002, CDC estimates placed the burden of SSI at about 20%.4 Naturally, increased costs of care accompany any hospital complications. In 2003, a study at Brigham and Women's hospital revealed an increase in overall hospital charges from $2,079 to $7,925 for patients with SSIs compared with those who didn't develop a SSI. In addition, radiology charges were about double, ED charges triple, and antibiotic charges were five times that of noninfected patients.5

The Centers for Medicare and Medicaid Services (CMS) will no longer pay hospitals for the additional days required to treat Medicare patients with hospital-acquired infections.6 This latest move by CMS underscores the fact that hospitals can do a better job of preventing infections for surgical patients, and all perioperative nurses should be doing everything possible to achieve this goal. A good place to begin is by implementing evidence-based practices that address common risk factors. In the past, OR staff have done a great job addressing risks associated with surgical asepsis, sterilization, ventilation, barriers, and surgical technique. Now, the host factors must be addressed.

Following the lead from the CMS' Surgical Care Improvement Project (SCIP), the Institute for Healthcare Improvement's (IHI) "5 Million Lives" campaign has challenged U.S. hospitals to reliably implement several measures proven to reduce postsurgical complications.7 A few of those will be discussed here.

Antimicrobial prophylaxis

Because there are so many contributing factors from both the patient and the OR environment, one of the most important pieces of the infection prevention puzzle is the proper administration of prophylactic antibiotics. A landmark study by Classen et al. showed that administering one dose of antibiotics within 1 hour of the surgical incision significantly reduced the incidence of SSIs.8 Prolonged cases (those lasting longer than 4 hours) should include a redose of the antibiotics every 4 hours.3 These important research findings have been included in the CDC's "Guideline for the Prevention of Surgical Site Infections" since 1999. They're also included in SCIP and IHI measures for improving surgical care.

Implementing an effective, preoperative prophy lactic antibiotic program involves multidisciplinary efforts. It's imperative that ownership of administration and documentation of the antibiotic dose are clearly defined in each institution. Incorporating the antibiotic administration into the time out before incision is one way to ensure that the dose is on board prior to the initial incision. Additionally, it may be helpful to provide a list of antibiotic choices according to operative procedure such as, vascular, colon, orthopedic cases, and so on in each OR to ensure appropriate coverage is given according to risk.

Patient characteristics

Patients themselves may bring significant risk to the OR depending on existing comorbidities. A thorough preoperative history of illness should be obtained so that appropriate interventions can be planned. Surgical wound healing can be significantly impaired by lack of adequate nutrition and circulation. The effects of diabetes, hypertension, smoking, obesity, and other conditions affecting the vasculature present increased risk of infection.

The source of most SSIs is actually the patients' own skin flora.3 Many studies have indicated a relationship between nasal carriage of Staphylococcus aureus and subsequent postoperative wound infections.9

Chronically elevated blood glucose levels have also been associated with an increased risk of SSI.10 Maintaining control of blood glucose levels has been shown to reduce the risk of SSI in cardiothoracic surgery patients.11 Current SCIP recommendations for glucose control in patients with diabetes undergoing major operative procedures include maintaining a serum blood glucose of 200 mg/dL or less beginning 24 hours before surgery and lasting until 48 hours after surgery.12

In 2004, a large prospective study of surgical patients indicated that male gender, obesity, and a history of stroke were risk factors for nasal carriage of S. aureus.13 For this reason, the importance of a preoperative antiseptic shower can't be overemphasized. The patient should receive clear instructions well in advance of the surgery, regarding when and where to obtain the antiseptic product and how to use it. Chlorhexidine gluconate-containing products provide a residual effect when used repeatedly. The CDC recommends an antiseptic shower at least the night before surgery. Repeating the shower the morning of the surgery may add even greater benefit to reducing microbial load on the skin.3OR

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