Reducing Surgical Site Infections Perioperatively Julia ... · Chlorhexidine is used due to its...

Running head: REDUCING SURGICAL SITE INFECTIONS

Reducing Surgical Site Infections Perioperatively

Julia Kim

KSL/OAK 5 Cohort

Samuel Merritt University

REDUCING SURGICAL SITE INFECTIONS

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Reducing Surgical Site Infections Perioperatively

Problem Identification

Infection that occur at or near surgical incisions within 30 days of an surgical

procedure are called surgical site infections and they contribute substantially to surgical

morbidity and mortality each year. “Surgical site infection (SSI) accounts for 15% of all

nosocomial infections and, among surgical patients, represents the most common

nosocomial infection. Postsurgical infection leads to increased length of postoperative

hospital stay, drastically escalated expense, higher rates of hospital readmission, and

jeopardized health outcomes” (Reichman & Greenberg, 2009). The first step in the

treatment of surgical site infections is in their prevention.

Background

Complications are unfortunately common after surgery, highlighting the need for

innovations that reduce postsurgical morbidity and mortality. “With some reports

estimating that as many as one-fourth of patients suffer postoperative complications”

(Liu, X.L., et al., 2017). There are psychological and social impact on not only the

patients, but also their family members. Thus, creating a need to develop new approaches

to optimizing surgical care preoperatively, intra-operatively, as well as post-operatively.

“Surgical site infections raise costs due to prolonged hospitalization, additional

diagnostic tests, therapeutic antibiotic treatment, and, rarely, additional surgery. In 2009,

it was estimated that SSI extended the length of hospital stay on average by 9.7 days and

increased costs by $20,842 per admission; this amounts to additional hospital costs


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exceeding $900 million, with hospital readmission due to SSI accounting for an

additional $700 million in health care spending” (Reichman & Greenberg, 2009).

Literature Review

One of the preventative measures currently being used is antisepsis prior to start

of surgery. There are some literature on chlorhexidine wipe cloths the night before

surgery as well as chlorhexidine as a prep in the operating room. “It is recommended that

prior to surgery, patients should shower with an antiseptic agent at least the night before

the operative day. Skin preparation in the operating room should be performed using an

alcohol-based agent unless contraindicated” (Berríos-Torres, S. I., et al., 2017).

Chlorhexidine is used due to its broad-spectrum antimicrobial activity and

excellent safety profile. “In health care settings, chlorhexidine has been used for several

decades for hand hygiene and for disinfection of the skin of patients before surgical

procedures and catheter insertion” (Donskey & Deshpande, 2016).

Another preventative for surgical site infection is prophylactic antibiotics within

60-120 minutes of incision time. Cefazolin is a first-generation cephalosporin, most often

chosen as a primary prophylactic antibiotic, “it is comparatively inexpensive, has

minimal side effects, and destroys the most potent aerobic gram-positive bacteria that

cause SSIs (ie, staphylococci, streptococci)” (Heuer & Kossick, 2017). “Redosing of

antibiotics should be performed if the surgical procedure exceeds 2 half-lives of the

antimicrobial or there is blood loss greater than 1,500 mL” (Heuer & Kossick, 2017).

Identified Community and Stakeholders


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The studied facility is a local community hospital in the Bay Area servicing a total

population of 529,908 with 66.41% being white, 18.22% Asian, and 22.95% being

Hispanic/Latino, and 19.38% of the population living in federal poverty level (2016

Community Health Needs Assessment, 2016). Surgical site infections have always been a

challenge since the beginning of surgery. The U.S. Centers for Disease Control and

Prevention (CDC) coined the term “surgical site infection” in 1992 to differentiate

infection from a surgical incision from infection of a traumatic wound (Reyes & Chang,

2011). Among all hospitalized patients, approximately 15% of all hospital-acquired

infections are as a result of surgical site infections. Surgical site infections are also the

third most common type of hospital-acquired infection in the United States (Reyes &

Chang, 2011). “Of the approximately 65 million patients who undergo surgery every year

that have an infection, 38% have an surgical site infection. Two-thirds of these are

confined to the incisional area, whereas one-third are within the organs or within deep

spaces accessed during the surgery” (Reyes & Chang, 2011). Also, when a patient with a

hospital-acquired infection dies, 77% of those were reported to be as a result of the

infection.

Stakeholders such as surgeons, anesthesiologists, all other operating room team

members such as the circulating RN, surgical technician, as well as the medical

assistants, RNs, etc. in the preoperative stage, and lastly, the postoperative staff such as

the PACU RN, CNA/PCTs, etc. all have a role in working together to prevent surgical

site infections. Support should come from all team members including the assistant nurse

managers, department managers of all three departments, as well as the director, and all


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other auxiliary staff such as janitors, central supply to reach its full potential and be

effective in preventing surgical site infections. Every single person in the company has a

role that may or may not directly handle the patient, but in the end will impact the patient

experience in infection prevention.

Data Metrics and Benchmarks

Factors for perioperative surgical site infections are multifactorial, but some can

be seen, as shown in table 1, that systemic factors can be included when trying to prevent

or looking at association between other factors that cannot be necessarily be prevented in

such a short notice perioperatively.

Factors that can be prevented however are things like povidone-iodine and

chlorhexidine gluconate for preoperative as well as intraoperative preparation, which “are

equally effective at decreasing initial bacterial skin contamination; however, a 4%

concentration of chlorhexidine gluconate has been shown more effective at decreasing

the rates of intrasurgical wound contamination than povidone-iodine or triclocarban

soap” (Reyes & Chang, 2011). “In institutions where standardization is important to

implementation it may also make sense to have a preoperative bathing program that

includes chlorhexidine gluconate” (O'hara, Thom, & Preas, 2018, p. 608). Hospitals as

well as some private outpatient surgical centers have implemented preoperative

chlorhexidine bathing programs at home the night prior to scheduled surgery or in the

hospital prior to the surgery if the patient is in an inpatient setting, to try and prevent

surgical site infections every way possible.


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Another factor that can be utilized for prevention of surgical site infections is

prophylactic antibiotics intraoperatively up to 60-120 minutes before incision time.

Studies have shown that antibiotics given to patients up to 60-120 minutes (depending on

the antibiotic being given) reduces surgical site infections. The anesthesia provider

usually administers the antibiotic intravenously. If the surgical procedures is longer than

the half-life of the antibiotic, another dose usually is administered intravenously during

the procedure. “According to the Institute for Healthcare Improvement, an estimated 40%

to 60% of surgical site infections are preventable with appropriate use of prophylactic

antibiotics. Overuse, underuse, improper timing, and misuse of antibiotics occurs in 25%

to 50% of operations” (Rothrock & McEwen, 2011, p.260). Table 2 shows prophylactic

antibiotics in an orthopedic surgery and its timing, dosing, as well as duration of

antimicrobial use.

Table 3 shows a comparison of surgical site infections in gastrointestinal surgeries

of a local hospital with the state average. In gastrointestinal surgeries, the highest rate (or

below the national average) of the local hospital was small bowel surgeries as compared

with the state average number of one. (Cal Hospital Compare, 2018)

Table 4 also shows a comparison of surgical site infections in orthopedic surgeries

of the same local hospital as compared with the state average. In orthopedic surgeries, the

highest rate (or below the state average) of the local hospital was around laminectomies.

(Cal Hospital Compare, 2018)


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Cal Hospital Compare also looked at other specialities such as OB-GYN,

Cardiovascular & Thoracic, Gallbladder/Liver related, as well as organ transplant

surgeries, but not enough data were collected to come to a solid conclusion thus not rated

as compared with the state average (2018).

Caritas 5 and 7

Communication as well as teamwork among the operating room team as well as

perioperatively, such as preoperative and postoperative is crucial when it comes to patient

safety and preventing patient surgical site infections.

Caritas 5 of Jean Watson’s caring science theory talks about promoting and

accepting positive and negative feelings as you authentically listen to another’s story

(Watson Caring Science Institute, 2010). Communication between the team members of

preoperatively as well as with the patient and their families creates caring relationships

and allows the team to acknowledge that healing relationships is a personal inner journey

that will enhance the communication of all parties involved. Surgery of any kind is very

scary, and patients count on the nurse to be fully present with them at their most

vulnerable time in the hospital. Listening to and honoring another person’s feelings honor

the patient’s story, which holds meaning and importance for them and their healing. By

listening to another person’s story, it may be the greatest healing act nurses can offer.

Caritas 7 in Jean Watson’s 10 Caritas Processes is “Engaging in genuine

teaching-learning experience that attends to unity of being and meaning, attempting to

stay within others’ frame of reference” (Watson Caring Science Institute, 2010).


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Speaking to patients and their family members as well as the team members in a calm and

quiet manner shows respect for the other person, allowing caring moments of openness

and readiness to both teach and learn from each other staying in the others’ frame of

reference. Being in a calm state shows the other person that they too, can be in a calm

state. If they see that the nurse is in a frantic state, feeling rushed to get things done

quickly, the patient and their family members will truly see this in the nurse’s actions

thus also feeling rushed and frantic, not conducive to a good learning environment.

Asking open-ended questions encourages members of each discipline to communicate

authentically and respectfully.

Teamwork

The group that was formulated for this quality improvement project consisted of

five scholars: Martin, Kathy, Djenne, Sharon, and myself. Although all five of the

scholars worked in different facilities and units within the company, it was possible to

meet in person as well as text and email throughout this project to come together and

share various articles as well as ideas for the paper as well as the group presentation. The

app GroupMe was utilized for texting as well as traditional texting, electronic mail was

frequently used to share articles, as well as Google Docs, Google Slides/Presentation, and

of course, face to face time in person was another way ideas were shared and exchanged.

Each group member’s strengths were taken into consideration when deciding each role

for group presentations and preparation work. This was an excellent manifestation of

ideas being exchanged with each member having come from different departments,

backgrounds, as well as experiences. Various articles were shared amongst the group


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members to allow for better flow of ideas for the group project as well as the individual

paper. The author’s personal contribution were making the PowerPoint presentation

esthetically pleasing to the eye for presentation, making sure the project was within APA

guidelines, editing for grammar, spelling, punctuation as well as contribution to various

slides, including references, and seeing the whole picture. All of this was done with the

acknowledgement and verification from the team, making sure all voices were heard

throughout the team effort. Some lessons learned were that all group members involved

had different schedules regarding work and family and some group members waited until

the last minute to contribute to the project. In the end, the group as a whole pulled

through with equal teamwork, cooperation, and innovative thinking to make for an

excellent group project.

Discovery Interview Findings

Discovery interviews were conducted in October of 2018 focusing on preventing

surgical site infections at a Northern California hospital. These discovery interviews were

an excellent opportunity to expand on current research knowledge and to explore what

experts in the field had to say regarding this issue. Interviews were conducted on a

surgeon, operating room technician, and a registered nurse regarding prevention of

surgical site infections and responses were various but had some underlying themes that

matched each role interviewed involved in the operating room.

After the interviews with a surgeon, OR tech, and a registered nurse, there was a

conclusion made that the author was on the right track with ideas regarding the quality


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improvement project. It was all about prevention of infections before surgery, during

surgery, and after surgery that pulls all of this together, working as a team, to prevent

SSIs. A theme that was noticed was that the surgeon had no preference on betadine vs.

chlorhexidine intra-operative prep, only dependent on where the prep was going; but

mostly chlorhexidine is used for body prep (except for vaginal prep), and betadine being

used for the face. Another theme that was noticed was the after-care of patients of

surgeries were very important--the post-operative care the patient receives or practice at

home after discharge makes a big difference. Thorough patient education is very

important to prevent infections of any kind; what to watch for, what to expect, and what

to do when they think that something is wrong.

What was found was that the surgeon will do things or order to have things done

preoperatively, and dependent on the surgery being performed by that surgeon, the

patient will do a chlorhexidine bath the night before as well as the morning of. For

example, the surgeon has patients who undergo an abdominoplasty do a chlorhexidine

bath the night before and the morning of the surgery, but no other cases warranted this

chlorhexidine bath. His words were that there were “no real clinical evidence” to strongly

suggest that these chlorhexidine baths work, but he likes to feel better about it at the end

of the day, and that there were SSI bundles in place.

The registered nurse that was interviewed was strongly opinionated about the

post-operative care that the patient will practice at home has a lot to do with what

outcomes they will have in preventing infections. The surgeon does a lot of techniques

that have been well studied through peer reviewed journals to prevent SSIs and other


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complications intraoperatively such as a “no-touch” technique when inserting breast

implants, using a funnel during implant insertion, using triple antibiotic as irrigation,

having the implants soak in that irrigation before insertion, and other surgeons that the

author has seen will use betadine as irrigation instead of triple antibiotic (consisting of

cefazolin, gentamicin, and bacitracin). In making sure that everything is sterile before

implant insertion, incision, etc. intraoperatively, the surgeons are ensuring that all

infections are being prevented as well as other complications; also mentioned was

normothermia of patient’s body temperature throughout the surgery to prevent infections

or complications.

The OR technician felt like she was an integral part of the SSI prevention as well

to make sure sterility is kept at all times. When she had any inkling that there was any

break in sterility, she would speak up, even if she knew the surgeon may not be happy

that his instrument that he was using was contaminated and may delay the case for a bit

to reprocess and she would alert the circulating RN that that instrument needed to be

sterilized and reprocessed.

Caritas Processes 6 and 8

Caritas process 6 is defined as “creatively using self and all ways of knowing as

part of the caring processes; engaging in artistry of caring-healing practices” (Watson,

2007). This caritas can also be interpreted in other systems as using “creative

problem-solving, and sometimes scientific problem solving, to meet the needs of others”

(Watson, 2007). Caritas process 6 was incorporated into the surgical site infection

prevention project in both scientific and artistic problem solving utilizing caring


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moments, treating each patient as a whole human being, not with just a medical record

number or as a subject in a trial. Caritas process 6 was also utilized in a scientific

approach with all of the knowledge obtained by the various research articles and change

models being rolled out in various health-care settings. There were acknowledgments and

integration of an awareness that the presence of oneself is an effective element of the plan

of care for others. There were using of self to create healing environments via authentic

presence, intentional touch as well as voice. Appropriate eye contact as well as smiling

and positive gestures and active listening were utilized during this time with patients and

their families as well. There was also encouragement of others to ask questions (Watson,

2007). All of the aesthetics, ethical, empirical, personal, and metaphysical ways of

knowing with creative, imaginative, and critical thinking are essential to patient care and

in preventing infections in post surgical patients.

Caritas process 8 is defined as “creating a healing environment at all levels,

whereby wholeness, beauty, comfort, dignity, and peace are potentiated” (Watson, 2007).

Creates caring intentions. By promoting this caring relationship, this creates a space for

the patient (other) to generate his/her own wholeness and healing. Nurses creating a

healing environment thus creates a space for human connections to naturally occur. This

in turn participates in caring-healing consciousness. This is essential in patient healing

and thus reducing surgical site infections.

Interprofessionalism Analysis


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After thorough research regarding the topic of surgical site infections, it was

found that it is the responsibility of all healthcare team members involved to solve this

problem. “Leading international organizations, such as the World Health Organization,

acknowledge that collaborative practice is essential for achieving a concerted approach to

providing care that is appropriate to meet the needs of patients, thus optimizing individual

health outcomes and overall service delivery of health care” (Gillespie, et al., 2015).

The current state as researched by the article by Gillespie, et al. concludes that

“patient-centered interventions aimed at increasing patient participation in SSI prevention

and evaluating the contributions of allied health professionals in team-based SSI

prevention requires future research” (2015). Although this particular article shows that

this should be further researched, it is always better to have all hands on deck when

providing patient care and ensuring safety. Every team member involved matters to the

patient’s well-being. All team members from the medical assistants or patient care

technicians, to the circulating RNs, to the surgeons and anesthesiologists.

The ideal future state of interprofessionalism would be that all disciplinary teams

would work together harmoniously to ensure patient safety and reduction of infections,

such as surgical site infections. Healthcare providers are working towards one goal -

which is the patient’s safety.

Interprofessionalism would make a difference by mingling all staff comprised of

nursing and medical department managers, nurse educators, nurses from the operative

room or acute surgical units, physicians practicing in anesthesia, surgery, or infectious


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diseases, pharmacists, patients, and patient care technicians. All health care professionals

involved would be very important in the sole purpose of maintaining patient safety and

preventing surgical site infections.


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References

2016 Community Health Needs Assessment. (2016, December 21). Retrieved from

https://share.kaiserpermanente.org/wp-content/uploads/2016/12/2016-KFH-Redwood-

City-CHNA_Final.pdf

Anderson, D., Podgorny, K., Berríos-Torres, S., Bratzler, D., Dellinger, E., Greene, L., . . . Kaye,

K. (2014). Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014

Update. Infection Control and Hospital Epidemiology, 35(6), 605-627.

doi:10.1086/676022

Berríos-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R.

R.,...Schecter, W. P. (2017). Centers for Disease Control and Prevention Guideline for the

Prevention of Surgical Site Infection. JAMA Surg. 2017;152(8):784–791.

doi:10.1001/jamasurg.2017.0904

Cal Hospital Compare. (2018). Retrieved July 13, 2018, from

http://calhospitalcompare.org/hospital/?id=106410804

CDC. Healthcare-associated Infections. (2012, May 17). Retrieved from

https://www.cdc.gov/hai/ssi/ssi.html

Donskey, C. J., & Deshpande, A. (2016). Effect of chlorhexidine bathing in preventing infections

and reducing skin burden and environmental contamination: A review of the literature.

American Journal of Infection Control, 44(5). doi:10.1016/j.ajic.2016.02.024

Ellingson, K., Haas, J., Aiello, A., Kusek, L., Maragakis, L., Olmsted, R., . . . Yokoe, D. (2014).

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. Infection

Control and Hospital Epidemiology, 35(8), 937-960. doi:10.1086/677145


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Gillespie, B. M., Kang, E., Roberts, S., Lin, F., Morley, N., Finigan, T., Homer, A., …

Chaboyer, W. (2015). Reducing the risk of surgical site infection using a multidisciplinary

approach: an integrative review. Journal of multidisciplinary healthcare, 8, 473-87.

doi:10.2147/JMDH.S73565

Heuer, A., & Kossick, M. A. (2017). Update on Guidelines for Perioperative Antibiotic Selection

and Administration From the Surgical Care Improvement Project (SCIP) and American

Society of Health-System Pharmacists. AANA Journal, 85(4), 293-299.

Hospital Compare Quality of Care Profile Page. (n.d.). Retrieved July 13, 2018, from

https://www.medicare.gov/hospitalcompare/profile.html

Kim, Julia. (2018, October 28). Personal interview with multidisciplinary team

Liu, X.L., Rosas, E., Hwang, J.C., Cain, E., Foss-Durant, A., Clopp, M….Parodi, S. (2017). The

Kaiser Permanente Northern California enhanced recovery after surgery program: Design,

development, and implementation. Perm J 2017;21:17-003. doi:

https://doi.org/10.7812/TPP/17-003.

O'hara, L. M., Thom, K. A., & Preas, M. A. (2018). Update to the Centers for Disease Control

and Prevention and the Healthcare Infection Control Practices Advisory Committee

Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and

strategies for implementation. American Journal of Infection Control, 46(6), 602-609.

doi:10.1016/j.ajic.2018.01.018

Reichman, D. E., & Greenberg, J. A. (2009). Reducing Surgical Site Infections: A Review.

Reviews in Obstetrics and Gynecology, 2(4), 212–221.

Reyes, G. E., & Chang, P. S. (2011). Prevention of Surgical Site Infections: Being a Winner.


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Operative Techniques in Sports Medicine, 19(4), 238-244. doi:10.1053/j.otsm.2011.02.005

Rothrock, J. C., & McEwen, D. R. (2011). Alexander's care of the patient in surgery. Elsevier.

Watson Caring Science Institute. (2010). Core concepts of Jean Watson’s theory of human

caring/caring science. Retrieved from

https://www.watsoncaringscience.org/files/Cohort%206/watsons-theory-of-human-

caring-core-concepts-and-evolution-to-caritas-processes-handout.pdf


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Tables

Table 1

Systemic Factors Associated With Increased Risk of Surgical Site Infection

Advanced age

Alcoholism

Coagulopathies

Colonization with pathogens resistant to antimicrobial agents

Diabetes mellitus

Hemoglobinopathy

Hypoxia

Immune deficiency

Malnutrition

Nicotine use

Obesity

Parenteral drug abuse

Skin colonization with bacterial pathogens

(Reyes & Chang, 2011)


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Table 2

Recommendation for the Use of Prophylactic Antibiotics in Orthopedic Surgery

Choice of antimicrobial agent

Cephalosporin (cefazolin, cefuroxime)

If beta-lactam allergy: use clindamycin or vancomycin

If infected or colonized with MRSA: use vancomycin

Timing of administration

Start up to 60 min before incision: cefazolin, cefuroxime, clindamycin

Start up to 120 min before incision: vancomycin

Dosing

Cefazolin, 1-2 g (2 g for patient weighing >80 kg)

Cefuroxime, 1.5 g

Vancomycin and clindamycin dosing based on patient mass

Pediatric dosing based on patient mass

Duration of antimicrobial use

Single preoperative dose

Redose antimicrobial intraoperatively for prolonged procedure or significant blood loss

(Reyes & Chang, 2011)


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Table 3

State Benchmarks for Gastrointestinal Surgical Site Infections



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Table 4

State Benchmarks for Orthopedic Surgical Site Infections


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