Posted on March 18, 2016
A special report published in the December AORN journal1 and made available to all infection preventionists (IPs), examines several interventions, some of which you may have already implemented:
Nasal Antisepsis Before Surgery – MRSA/MSSA Decolonization Protocols: These protocols have been instituted by many facilities but the procedures can vary based upon your risk assessment.
Do you screen patients to determine if they are colonized with MRSA and/or MSSA?
Do you only screen patients undergoing certain procedures?
If the screen is negative, do you stop there?
If the screen is positive, do you proceed with a decolonization plan which includes utilization of mupirocin or nasal povidone-iodine and CHG-based skin cleanser, then provide instructions for use of both?
How does the clinical staff ensure compliance?
The momentum is building to incorporate antimicrobial stewardship programs (ASP) into every healthcare facility. Having an ASP will help ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration.2
ASPs are applicable to SSI prevention by helping surgeons and all clinicians involved in the patient’s care ensure that antibiotic prophylaxis is appropriate.
Wound Edge Protectors
It has been reported that wound edge protectors (WEPs) can help reduce SSI rates in open abdominal, urology, and orthopedic procedures.3-7 WEPs are made to protect the wound edges from contamination by skin flora, bowel contents, or trauma during surgery. Single-ring wound protectors have been available since the 1960s but a newer, dual-ring protector has been on the market since 2002.
Wound Closure and Postoperative Dressings
Currently, there is not a standard guideline for surgical wound closure or postop wound dressings,1 even though there are many wound closure and dressing products designed to reduce SSI risk.
Glue can be used as a wound closure device to help protect the patient from an SSI.8
Negative pressure, antimicrobial-impregnated, silver and polyhexamethylene biguanide (PHMB), a derivative of CHG, dressings are also available.
Guidelines for Temperature and Humidity
Many hospitals have been cited by regulatory agencies for issues related to temperature and humidity in the Operating Room (OR) and Sterile Processing Departments (SPD), although the effects of temperature and humidity on patient outcomes are not quite so clear. However, these adverse events have been documented:1
For certain procedures, low patient core temperatures have been associated with an increased likelihood of SSIs.
Extremely hot ORs may cause sweating by the surgical team and perspiration may contaminate sterile items or the sterile field.
Extremely low humidity and flammable gases have been associated with an increased risk of fire.
Extremely high humidity for prolonged periods has been linked to increased fungal growth.
Certain key items such as rapid biological indicators do not operate. consistently when used in climate conditions outside those delineated in the manufacturer’s instructions for use.
Climactic variation between hot items being moved from a sterilizer and the outside area may lead to “wet loads.”
The Association for the Advancement of Medical Instrumentation (AAMI), Association of Operating Room Nurses (AORN), American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), and Facility Guidelines Institute (FGI) groups have their own guidelines based on their particular areas. ASHRAE and FGI are geared toward building design while AAMI and AORN focus on daily clinical operations. However, they began working together to coordinate their guidelines and have provided joint interim information for heating, ventilation and air conditioning in the OR.9
We have lists, bundles, products, and committees to help us in our efforts to prevent SSIs. But how do you get along with your OR team? Do you make OR rounds? Do the staff know you? How often do you visit to the OR? Do you provide the OR staff with continuing education? Does the front line staff know what the SSI rates are for the procedures with which they assist?
Sometimes the best way to find out what is causing a problem is talking to the OR nurses, techs, PAs, NPs, and surgeons. All of this takes time, but do you make the time to be proactive in preventing SSI rather than reactive to adverse events once they occur?
Centers for Disease Control and Prevention. Core Elements of Hospital Stewardship Programs. Accessed January 25, 2016 http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
Mihaljevic AL, Muller TC, Kehl V, Friess H, Kleeff J. Wound edge protectors in open abdominal surgery to reduce surgical site infections: a systematic review and meta-analysis. PLoS One. 2015; 10(3):e01211.
Gheorghe A, Calvert M, Pinkney TD, et al; West Midlands Research Collaborative; ROSSINI Trial Management Group. Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection in patients undergoing open abdominal surgery. Ann Surg. 2012;255(6):1017-1029.
Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG. Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg. 2012;256(1):53-59.
Green C, Molony D, Cashman J, Burke T, Masterson E. Another string….but no bow. Acta Orthop Belg. 2011;77(2):258-259.
Biewenga ED, Choe C, Chang J, Rhee EY. An innovative wound retractor/protector for prosthetic urologic surgery. Curr Urol. 2013;6(4):205-208.
Grimaldi L, Cuomo R, Brandi C, Botteri G, Nisi G, D’Aniello C. Octyl-2-cyanoacrylate adhesive for skin closure: eight year experience. In Vivo. 2015;29(1):145-148.
Joint Interim Guidance: HVAC in the Operating Room and Sterile Processing Department. Association for Professionals in Infection Control and Epidemiology. http://www.apic.org/Resource_/TinyMceFileManager/HVAC-Interim-Position-Statement_1_1.pdf Accessed January 25, 2016.