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50 july 30 :: vol 28 no 48 :: 2014 NURSING STANDARD / RCN PUBLISHING

CONTINUING
PROFESSIONAL
DEVELOPMENT
CPD
Prevention of surgical site infection
NS754 Harrington P (2014) Prevention of surgical site infection.
Nursing Standard. 28, 48, 50-58. Date of submission: March 7 2014; date of acceptance: April 28 2014.
Abstract
Surgical site infection (SSI) is a common healthcare-associated
infection that can cause patients extreme pain and discomfort,
resulting in prolonged hospitalisation and additional costs to the NHS.
Multidisciplinary team working, combined with audit and surveillance,
early recognition of signs and symptoms of infection, and implementation
of evidence-based guidance are essential for reducing the incidence of
SSI. Nurses caring for patients in the pre, peri and post-operative period
have an important role in advising individuals about the risks associated
with SSI and how infection should be managed.
Author
Pauline Harrington
Surgical site infection surveillance manager, Public Health England, London.
Correspondence to: Pauline.Harrington@phe.gov.uk
Keywords
Healthcare-associated infection, infection prevention and control,
surgical site infection, wound care
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Surgical site infection
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Aims and intended learning outcomes
This article is aimed at nurses who care for
patients during the pre, peri and post-operative
periods. It is intended to provide information
on the risk of developing surgical site infection
(SSI) and on how it can be prevented and
managed. After reading this article and
completing the time out activities you should
be able to:
Recognise the signs and symptoms of SSI.
Understand the importance of SSI audit
and surveillance.
Describe measures that can be taken to
reduce the incidence of SSI.
Explain management strategies for patients
with SSI.
Discuss the role of the nurse in treating
patients with SSI.
Introduction
SSI accounts for an estimated 16% of all
healthcare-associated infections (HCAIs)
and can lead to increased antibiotic
consumption and healthcare costs, prolonged
recovery for patients, increased pain, anxiety,
further risk of complications and, in some
cases, death (National Audit Ofce (NAO)
2000, Health Protection Agency (HPA) 2012).
Patients who develop SSI after discharge from
hospital are at increased risk of readmission,
resulting in additional costs to the NHS.
Estimates suggest that it costs the NHS
700 million per year to treat patients with
SSI (Adams-Howell et al 2011). SSI can be
prevented with appropriate intervention,
and healthcare professionals have an
important role in this area. Guidance is
available to assist healthcare professionals
in the prevention, recognition and treatment
of SSI, and should be integrated into local
Prepare for revalidation:
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NURSING STANDARD / RCN PUBLISHING july 30 :: vol 28 no 48 :: 2014 51
policies so that every patient undergoing
surgery receives the best possible care.
SSI rates are often reported using the
cumulative incidence measure, which is
calculated as the number of new infections
divided by the population at risk over a dened
period of time, expressed as a percentage.
The infections included in this measure are
those detected during inpatient stay or on
readmission.
The incidence of SSI varies widely between
hospitals and between surgical categories in
NHS hospitals in England (Public Health
England (PHE) 2013a). This may be because
of differences in case ascertainment, clinical
practices and case mix. Categories with the
highest degree of wound contamination have
a higher incidence of infection. For example,
large bowel surgery has an incidence rate
for SSI of 10.6%, while categories generally
considered as associated with clean wounds,
such as knee and hip surgery are lower with
an SSI incidence of less than 1%.
Figure 1 shows the incidence of SSI for the
17 categories of surgery available at PHE.
Complete time out activity 1
Defnition of surgical site infection
An SSI is a wound infection that occurs
following surgery. Most surgical wounds
heal rapidly without complications; however,
some become infected. Such infection occurs
when microorganisms are introduced through
the surgical incision as a result of bacteria
or fungi migrating from the patients skin or
gastrointestinal tract (microora; endogenous
infection), direct transfer from surgical
instruments, equipment or hands of healthcare
workers, or via the airborne route (exogenous
infection) (Table 1).
When the microorganism gains entry to
the wound, it can multiply. The development
of an SSI is inuenced by the virulence of
the organism and the hosts ability to resist
infection. In some cases, bacteria can enter
the body and travel in the blood, then deposit
on prosthetic implants and multiply, causing
infection. This is called haematogenous seeding
(NAO 2000, Collier 2004, PHE 2013c).
An SSI usually develops within 30 days of
surgery although, in some patients with a
prosthetic implant, SSI can occur up to one
year after surgery (PHE 2013c). Studies in
1 Make a list of
the endogenous and
exogenous risk factors
for developing SSI.
Could any of these
be prevented and, if
so, how? Speaking
to members of the
infection prevention
and control team may
help your decisions.
FIGURE 1
Cumulative incidence of surgical site infection by surgical category in NHS hospitals in England fom April 2008 to March 2013
Large bowel
Bile duct, liver and pancreatic surgery
Small bowel
Coronary artery bypass graft (CABG)
Cholecystectomy
Limb amputation
Vascular
Gastric
Cranial
Repair of neck of femur
Abdominal hysterectomy
Cardiac (non-CABG)
Reduction in long bone fracture
Spinal
Breast
Hip prosthesis
Knee prosthesis
0
Percentage of operations resulting in surgical site infection
2 4 6 8 10 12
10.6
6.5
6.4
4.4
4.2
3.3
2.8
2.7
1.6
1.5
1.5
1.3
1.2
1.0
0.7
0.6
1.1
(Public Health England 2013b)
52 july 30 :: vol 28 no 48 :: 2014 NURSING STANDARD / RCN PUBLISHING
CPD infection control
the United States have shown that there is a
long-term risk of developing SSI following
primary hip and knee replacements, with
one quarter of infections diagnosed between
two and ten years following surgery (Ong et
al 2009, Kurtz et al 2010). Clinicians should
bear the possibility of infection in mind
when treating patients who have unresolved
problems with their prosthesis.
Complete time out activity 2
Clinical signs of surgical site infection,
efects and classifcation
Following surgery, patients usually experience
pain, swelling and redness around the wound
as part of the normal wound healing process
(PHE 2013c). However, SSI may intensify
these symptoms (National Institute for
Health and Care Excellence (NICE) 2008).
SSIs are associated with redness, heat, pain,
swelling, temperature greater than 38 degrees
centigrade, purulent discharge, abscess and
cellulitis directly related to the surgical wound,
and dehiscence (Cutting and White 2004).
A study conducted by Cahill et al (2008)
investigated the long-term effect of SSI on
several quality-of-life measures in patients
undergoing knee and hip surgery. The results
showed that SSI signicantly affected patients
mobility, independent living and psychological
health. Another study conducted by Andersson
et al (2010) showed that patients with deep
SSI experienced physical, social, emotional
and economic problems. Therefore, it is
important that healthcare professionals
understand the seriousness of SSI and the
importance of prevention.
Complete time out activity 3
Some infections may be difcult to diagnose,
as there may not be obvious clinical signs
TABLE 1
Mode of infection spread
One-to-one
contact
Direct Direct physical contact (body surface to body surface) between infected
or colonised individual and susceptible host.
Examples of transmission: shaking hands, kissing, coitus.
Examples of infections: common cold, sexually transmitted diseases.
Precautions: hand hygiene, masks, condoms.
Indirect Infectious agent deposited onto an object or surface (fomite) surviving
long enough to transfer to another person who subsequently touches
the object.
Examples of transmission: not washing hands between patients,
contaminated instruments.
Examples of infections: respiratory syncytial virus, Norwalk, rhinovirus.
Precautions: sterilising instruments, disinfecting surfaces in school.
Droplet Contact, but transmission is through the air. Droplets are relatively large
(>5m) and projected up to about one metre.
Examples of transmission: sneezing, coughing, during suctioning.
Examples of infections: meningococcus, pertussis, respiratory viruses.
Non-contact
Airborne Transmission via aerosols (airborne particles <5m) that contain organisms
in droplet nuclei or in dust.
Examples of transmission: via ventilation system in a hospital.
Examples of infections: tuberculosis, varicella, measles, chickenpox, smallpox.
Precautions: masks, negative pressure rooms in hospitals.
Vehicle A single contaminated source spreads the infection (or poison) to multiple
hosts. This can be a common source or a point source.
Examples of transmission point source: food-borne outbreak from
infected batch of food, cases typically cluster around the site (such as a
restaurant), intravenous (IV) uid, medical equipment.
Vector-
borne
Transmission by insect or animal vectors.
Example of transmission: mosquitoes.
Example of infection: malaria.
Precautions: window screens, bed nets, insect sprays.
(Adapted from University of Ottawa 2013)
2 What information
and advice might you
give to a surgical patient
following discharge
regarding observing for
signs and symptoms of
SSI and how to care for
the wound?
3 Carol is aged 80
years, has diabetes
and osteoarthritis and
has undergone a total
hip replacement. Five
days after surgery, she
experiences difculty
in walking, her hip is
swollen, and the area
surrounding the wound is
red and dehisced. Using
the SSI criteria in Table 2,
decide whether Carol has
a wound infection? Does
she have any risk factors
for developing SSI?
Explain the rationale for
your answer.
NURSING STANDARD / RCN PUBLISHING july 30 :: vol 28 no 48 :: 2014 53
such as heat and swelling, and may require
multidisciplinary discussions between surgeons,
microbiologists, infection control nurses and
radiologists. However, it is important that SSI is
diagnosed correctly and consistently, using the
three standard classications of SSI: supercial,
deep, and organ or space infections (Table 2).
Figures 2, 3 and 4 show respectively a
supercial wound infection, a deep incisional
wound infection with dehiscence, and a
deep incisional wound infection with
purulent drainage.
Risk factors
Several factors increase the risk of developing
SSI. These may be patient-related (endogenous)
or environmental (exogenous) (Barnard 2003,
Johns Hopkins Medicine 2010), as shown in
Table 3. Some risk factors are modiable, for
example obesity, malnutrition and tobacco
use. While not all risk factors are modiable,
understanding the role each plays in the
development of SSI will assist in implementing
appropriate prevention strategies.
Prevention of surgical site infection
To prevent SSI occurring, a full clinical
assessment is required to identify risk factors,
followed by measures to modify these risks
where possible. These measures should
be based on Department of Health (DH)
(2007) and NICE (2013) guidance, which
recommend that:
Patients should be encouraged to stop
smoking at least four weeks before surgery
to promote primary wound healing (when
the margins of the wound are brought
together with suturing, glue or clips).
Smoking causes blood vessels to constrict
and thus reduces the delivery of oxygen and
nutrients to promote wound healing.
Pre-operative showering to reduce bacterial
load on the skin.
Antibiotic prophylaxis, when recommended,
should be given within 60 minutes before
the incision and at the correct dose and
duration to protect against organisms likely
to cause infection.
If hair removal is required, it must be
performed as close to the incision as possible
TABLE 2
Criteria for defning surgical site infection (SSI)
Supercial incisional infection Deep incisional infection Organ or space infection
SSI that occurs within 30 days
of surgery, involves only the skin
or subcutaneous tissue of the
incision and meets at least one
of the following criteria:
1. Purulent drainage from
supercial incision.
2. Culture of organisms and
pus cells present in:
Fluid and/or tissue from
supercial incision, or
Wound swab from supercial
incision.
3. At least two symptoms of
inammation:
Pain, tenderness, localised
swelling, redness, heat.
And either:
i) Incision deliberately opened
to manage infection, or
ii) Clinicians diagnosis of
supercial SSI.
Note: stitch abscesses (minimal
inammation or discharge at suture
point) do not classify as SSI.
SSI involving the deep tissues
(fascia and muscle layers), within
30 days of surgery (or one year if
a prosthetic implant is in place),
where the infection appears to be
related to the surgical procedure
and meets at least one of the
following criteria:
1. Purulent drainage from deep
incision (not organ space).
2. Organisms from culture and
pus cells present in:
Fluid and/or tissue from deep
incision, or
Wound swab from deep incision.
3. Deep incision dehisced or
deliberately opened and patient
has at least one symptom of:
Fever, localised pain, tenderness.
4. Abscess or other evidence of
infection involving the deep
incision seen during re-operation
or by histopathological or
radiological examination.
5. Clinicians diagnosis of deep
incisional SSI.
SSI involving the organ or
space (other than the incision)
opened or manipulated during
the surgical procedure, that
occurs within 30 days of
surgery (or one year if a
prosthetic implant is in place),
where the infection appears
to be related to the surgical
procedure and meets at least
one of the following criteria:
1. Purulent drainage from
drain (through stab wound)
into organ or space.
2. Organisms from culture
and pus cells present in:
Fluid and/or tissue from
organ or space, or
Swab from organ or space.
3. Abscess or other evidence of
infection in organ or space
seen during re-operation
or by histopathological or
radiological examination.
4. Clinicians diagnosis of
organ or space infection.
Note: an infection involving both supercial and deep incisional = deep incisional
54 july 30 :: vol 28 no 48 :: 2014 NURSING STANDARD / RCN PUBLISHING
CPD infection control
using clippers to prevent any break in the
skin and the potential for microorganisms
to gain access to the wound.
Blood glucose control should be maintained
below 11mmol/L in patients with diabetes.
Body temperature should be maintained
above 36C before, during and after surgery
to prevent vasoconstriction.
Skin preparation should be carried out in
theatre using a recommended antiseptic to
remove soil and transient organisms.
The hands of those present in the operating
theatre should be decontaminated. A sterile
theatre environment should be maintained
by limiting the number of people in the
theatre during surgery and ensuring that
staff who are present wear appropriate
theatre clothing.
SSI surveillance should be conducted along
with feedback of results to staff involved in
patient care.
Role of surveillance
Haley et al (1985) showed that establishing an
infection control programme which includes
feedback on SSI rates to surgeons can lower
the overall rate of SSI by as much as 35%.
Two European studies have also shown similar
ndings (Gastmeier et al 2006, Astagneau
et al 2009). The national SSI surveillance
programmes in the UK provide effective
frameworks for hospitals to reduce SSI by
monitoring patients following surgery. Such
monitoring helps hospitals identify any
problems with their rates of SSI.
The aim of SSI surveillance is to enhance
the quality of patient care by encouraging
hospitals to use the data to compare their rates
of SSI over time and against a benchmark.
However, if the surveillance of SSI is to provide
comparable and valid data, it is crucial the
methods used are standardised. Data derived
from surveillance can then be used by hospitals
to review and guide clinical practice. There are
several benets to conducting SSI surveillance.
It enables proactive early intervention, reduces
preventable harm to patients, reduces the
additional length of hospital stay, and promotes
compliance with care bundles.
A national SSI surveillance programme in
England was launched in 1997 by the Public
Health Laboratory Service now hosted by PHE.
Scotland (Health Protection Scotland), Wales
(Public Health Wales) and Northern Ireland
(Public Health Agency) have similar surveillance
programmes. PHE identies 17 categories
of surgery in which hospitals can undertake
surveillance, four of these are orthopaedic
categories mandated by the DH. NHS trusts
are asked to undertake surveillance in one of the
four orthopaedic categories in each nancial year
(PHE 2013b). Hospitals may choose to conduct
surveillance in as many categories as they wish
FIGURE 2
Superfcial wound infection
FIGURE 3
Deep incisional wound infection with
dehiscence
FIGURE 4
Deep incisional wound infection with
purulent drainage
NURSING STANDARD / RCN PUBLISHING july 30 :: vol 28 no 48 :: 2014 55
and can also conduct in-house surveillance in
categories not identied by PHE.
PHE provides training on SSI surveillance
methodology for hospital surveillance staff, to
equip them to conduct surveillance effectively
while ensuring comparability of data. A protocol
outlining SSI denitions and methodology
is provided to all hospitals participating in
surveillance to use as a guide or point of
reference (PHE 2013c). At the end of each
surveillance period, hospitals are able to generate
their reports and identify their rates of SSI.
Some surgical teams are able to reduce
the hospitals SSI rates by planning relatively
simple and inexpensive interventions such
as auditing the patients journey to identify
any breaches in infection control or failure to
comply with SSI guidelines (Adams-Howell
et al 2011). A report including data from the
17 categories of surveillance identied by PHE
is published each year. Named trust-level data
for the four orthopaedic mandatory categories
are reported publicly as an annex in the main
report (PHE 2013b).
Multidisciplinary teamwork is essential in
preventing and managing SSI and in ensuring
effective surveillance. The multidisciplinary
team should include surgeons, anaesthetists,
theatre managers, microbiologists, infection
control nurses, audit and surveillance staff,
administrative staff and ward staff. The
roles in the team are different, ranging from
co-ordination of the surveillance, data
collection, clinical care, infection prevention
advice, microbiological testing, reporting of
results and advice on treatment. A cohesive
multidisciplinary team will analyse the reports
and communicate results to all team members,
reviewing local policies and procedures to
ensure patient safety is not compromised.
Strong leadership, knowledge of SSI, effective
communication and multidisciplinary working
are essential for a successful surveillance
programme and reduction of SSI. A champion
who is well known, driven and respected is
required to engage the main surgical staff
(surgeons, anaesthetists, theatre managers and
ward staff) to create and maintain a culture that
makes SSI surveillance a priority and places
patient safety rst (Adams-Howell et al 2011).
Complete time out activity 4
Treatment
Most SSIs can be treated with antibiotic
therapy; however, treatment should be
discussed with the surgeon and microbiologist
so that patients are prescribed an antibiotic that
provides protection against the likely causative
organisms. Local resistance patterns and the
results of microbiological tests must also be
considered when choosing an antibiotic to treat
the infection.
Patients with infections involving the deeper
tissues may need to undergo further surgery to
manage the infection. For example, surgical
debridement or replacement of an infected
prosthetic implant may be necessary (Smith
et al 2013). Tissue viability specialist nurses can
advise on types of dressings to be used to treat
infected wounds and how frequently dressings
should be changed. It is important to consider
TABLE 3
Risk factors for surgical site infection
Endogenous risk factors Exogenous risk factors
Extremes of age: older adults and
neonates.
Immunosuppression.
Alcoholism.
Pre-existing infection at another site.
Diabetes mellitus.
Hypothermia.
Poor nutrition or physical status.
Obesity.
Shock.
Length of pre-operative stay.
Previous radiotherapy or chemotherapy.
Skin disease in the area of the wound,
for example psoriasis.
Smoking and use of tobacco products.
Contaminated or dirty surgical procedure, or poor
surgical instrument processing.
Operations that last longer than predicted.
Surgical scrub that is not applied for the
recommended time.
Excessive movement of staff in theatre.
Foreign material in the surgical site.
Staff with skin infections.
Type of surgery some operations carry high risk
of infection, for example colorectal surgery and
complexity of the procedure.
Surgical drains.
Surgical technique laparoscopic procedures carry
a lower risk of infection than open techniques.
Transplant or implant operations.
(Barnard 2003, Johns Hopkins Medicine 2010)
4 Investigate
whether the healthcare
setting where you work
collects information on
SSI incidence. What,
if any, methods of
surveillance are used?
Discuss with colleagues
the importance of SSI
audit and surveillance
in the prevention and
reduction of SSI.
56 july 30 :: vol 28 no 48 :: 2014 NURSING STANDARD / RCN PUBLISHING
CPD infection control
factors that could promote wound healing, for
instance the role of diet and exercise in recovery
from surgery. Exercise helps to increase tissue
perfusion, and oxygen plays a crucial role
in the formation of collagen, the growth of
new capillaries, and the control of infection
(Whitney 1990).
Wound care
The evidence for optimal choice of dressing
is based on chronic wounds and not surgical
wounds. However, an interactive dressing is
recommended for protecting surgical wounds
(DH 2007). Interactive dressings create a moist
wound environment and interact with the
wound to enhance wound healing by reducing
colonisation count and level of exudate,
improving wound bed moisture retention,
wound collagen matrix, and removing cellular
products or providing protection for the new
cells (Swezey 2010).
NICE (2008) guidelines on the prevention
and treatment of surgical site infection and
the DH (2007) High Impact Intervention
care bundle recommend dressings applied in
theatre should remain in situ for at least 48
hours before removal, to prevent the entry
of microorganisms and promote healing.
Dressings should be removed before this
time only if there is excessive leakage from
the dressing. Nurses should ensure that any
signs and symptoms of infection in patients
are discussed with surgeons responsible for
the care of these patients to ensure timely and
appropriate treatment. Patients who are at
high risk of developing SSI after surgery or
those who develop serious infections should
be referred to the tissue viability specialist for
wound management.
Infection control measures
Hand decontamination is essential in reducing
the risk of SSI both during surgery and when
carrying out wound care. Dressings should
be changed by nurses who have been trained
and are competent in carrying out aseptic
non-touch technique (ANTT). ANTT is a
clinical practice framework for ensuring high
standards of aseptic technique and has helped
in reducing HCAIs (Rowley and Clare 2009).
NICE (2008) recommends an aqueous
antiseptic solution (povidone-iodine)
for use by the surgical team for hand
decontamination before surgery, while the
Centers for Disease Control and Prevention
(2002) recommend the use of an antimicrobial
soap such as chlorhexidine or povidone-iodine,
which should be used for between two and
six minutes. The World Health Organization
(WHO) (2009a) recommends a suitable
antimicrobial soap or alcohol-based hand rub
be used before sterile gloves are worn.
NICE (2008) suggests that patients skin
should be prepared for surgery using an
antiseptic that is an aqueous or alcohol-based
preparation such as povidone-iodine or
chlorhexidine. However, the DH (2007)
High Impact Intervention care bundle
recommends 2% chlorhexidine gluconate
and 70% isopropyl alcohol solution, and
one study has shown that 2% chlorhexidine
gluconate and 70% isopropyl alcohol solution
is more effective in reducing microbial load
(Hibbard 2005). If the patient has sensitivity
to this solution, then povidone-iodine
application should be used.
Complete time out activity 5
Role of the nurse in preventing surgical
site infection
Nurses need to be knowledgeable about the
cause, effect and management of SSI to ensure
optimum patient outcomes following surgery.
This can be obtained by reading literature
on the topic, and working closely with the
infection control and audit and surveillance
teams. There is a range of guidance available
to assist nurses in preventing SSI, including the
High Impact Intervention care bundle (DH
2007), SSI quality standards (NICE 2013) and
the WHO (2009b) Surgical Safety Checklist.
NICE (2008) guidance for the prevention and
management of SSI outlines three phases: pre-
operative, intra-operative and post-operative
care (Box 1).
The WHO (2009b) Surgical Safety
Checklist is intended to be used as a tool
by clinicians to improve safety during
surgical operations, and reduce unnecessary
deaths and complications. It has introduced
organisational guidelines to reduce patient
harm and decreased complications resulting
from surgery. WHO (2009b) states that
at least half-a-million deaths per year
worldwide would be prevented with effective
implementation of the checklist. The checklist
covers tasks that should be carried out
before induction of anaesthesia, before skin
incision and before the patient leaves the
operating theatre. It is important to ensure
the checklist is not used as a tick-box exercise
and that the actions are implemented. This
can be achieved through educating staff
5 Suppose you are
a nurse working on a
gynaecology ward and
have expressed concern
to your manager
about a number of
women who have
developed infections
in their wounds
following abdominal
hysterectomies. Your
manager suggests you
set up a surveillance
programme to monitor
the situation. What
considerations are
important when
planning a surveillance
programme for SSI?
Describe how you intend
to use the results of the
surveillance.
NURSING STANDARD / RCN PUBLISHING july 30 :: vol 28 no 48 :: 2014 57
who are responsible for the care of patients
undergoing surgery and by conducting audits
to assess compliance.
The DH (2007) High Impact Intervention
for SSI aims to ensure appropriate and
high-quality patient care is provided. It is
designed to support cycles of review and
continuous improvement in surgical care
settings. The care bundle is based on
NICE (2008) guidelines for the prevention
and treatment of SSIs, expert advice, and
other international and national infection
control best practice; it also supports the
implementation of the WHO (2009b) checklist.
Implementing quality standards
NICE (2013) has developed evidence-based
quality statements for SSI. These statements
contain seven main interventions, which
hospitals should implement to reduce the
risk of SSI. Some of these statements can
be nurse-led, for example statement 1,
Personal preparation for surgery; statement 4,
Minimisation of transfer of microorganisms
by staff; statement 5, Patients and carers
information and advice on wound care;
and statement 7, Surveillance and feedback
of results. Statements 1 and 5 are based on
providing patients and carers with information
about what they could do to prepare for
surgery and how to recognise problems with
their wounds. Nurses should ensure patients
and carers understand their role in prevention
and early recognition of problems with their
wounds and know what actions to take.
Patients should be made aware pre-operative
shaving should not be carried out; showering
before surgery is important and that keeping
warm before surgery will help to reduce
the risk of developing SSI. Nurses have a
responsibility to ensure all the standards are
met. This can be achieved by conducting audits
and providing feedback to all involved in the
care of patients undergoing surgery.
There are other considerations that should be
taken into account to assist in reducing SSI, for
example nutrition to encourage wound healing
(Gherini et al 1993, Thompson and Fuhrman
2005). Nutrition has a crucial role in how
fast the wound heals, how strong the wound
tissue becomes, the duration of the recovery
period and how well the body ghts infection.
Protein helps repair the damaged tissue and
increase the wound tensile strength. Vitamins
A, C and E and selenium act as scavengers to
remove necrotic tissue and inactivate bacteria
that occur in the inammatory stage of wound
healing. Vitamin C increases the strength of
the wound as it heals, and it helps with the
creation of collagen in the skin. Collagen is
important in the creation of new blood vessels,
and helps with iron absorption. Zinc helps the
body synthesise proteins and develop collagen
(Johnston 2007).
It is important that surgical wounds are kept
clean and special attention is paid to prevent
wounds becoming contaminated with faecal
matter or urine in patients who have difculty
maintaining continence. There is the potential
for tissue damage and for the wound to become
infected if there is contamination with urine
or faeces (Gray 2007). Patients and carers
should be provided with written information
on wound care, how to recognise problems
with the wound and who to contact if there
are concerns regarding the wound following
discharge from hospital (NICE 2013).
BOX 1
Preventing surgical site infections
Pre-operative phase
Do not use hair removal routinely to reduce the
risk of surgical site infection.
If hair has to be removed, use electric clippers
with a single-use head on the day of surgery.
Do not use razors for hair removal, because they
increase the risk of surgical site infection.
Give antibiotic prophylaxis to patients before:
Clean surgery involving the placement of a
prosthesis or implant.
Clean-contaminated surgery.
Contaminated surgery.
Do not use antibiotic prophylaxis routinely for
clean, non-prosthetic, uncomplicated surgery.
Use the local antibiotic formulary and consider
potential adverse effects when choosing specic
antibiotics for prophylaxis.
Consider giving a single dose of antibiotic
prophylaxis intravenously when commencing
anaesthesia. Provide prophylaxis earlier
for operations that involve a tourniquet.
Intra-operative phase
Prepare the skin at the surgical site immediately
before incision using an antiseptic (aqueous or
alcohol-based) preparation: povidone-iodine or
chlorhexidine are most suitable.
Cover surgical incisions with an appropriate
interactive dressing at the end of the operation.
Post-operative phase
Refer to a tissue viability nurse (or another
healthcare professional with tissue viability
expertise) for advice on appropriate dressings
for the management of surgical wounds that
are healing by secondary intention.
(NICE 2008)
58 july 30 :: vol 28 no 48 :: 2014 NURSING STANDARD / RCN PUBLISHING
CPD infection control
Conclusion
The risk of developing an SSI depends on
patient-related and environmental factors.
Measures can be taken to minimise the risk
of these infections occurring. However, some
patients may still develop SSI, and for those
patients, early detection through surveillance,
feedback of data to surgeons and appropriate
treatment are crucial.
Nurses have a pivotal role in preventing
SSI and ensuring optimum patient outcomes
by implementing evidence-based guidance,
followed by audits to ensure compliance.
The implementation of the Surgical Safety
Checklist, High Impact Intervention care
bundle, NICE guidance on the prevention and
treatment of SSI and NICE quality standards
can help to prevent SSI, reduce length of
recovery following surgery and save lives, if
implemented correctly and consistently NS
Complete time out activity 6
Acknowledgements
The author wishes to thank colleagues Theresa
Lamagni, Catherine Wloch and Suzanne
Elgohari for their contributions to this article.
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6 Now that you have
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