You may have heard “The operation was a success, but the patient died” as the punch line of an old joke, but, sadly, it is too often true. Surgical-site infection (SSI) can be a life threatening complication following a successful operation.

In a study by Leape et al, it was reported that 14% of all adverse events in hospitalized patients were due to SSIs. (1) The Centers for Disease Control and Prevention (CDC)’s “Guideline for Prevention of Surgical Site Infection, 1999,” noted that SSIs were the “third most frequently reported nosocomial infection, representing 14% to 16% of all nosocomial infections among hospitalized patients.” (2) The guideline also stated that hospitals in the CDC’s National Nosocomial Infection Surveillance System who conducted SSI surveillance from 1986 to 1996 reported 15,523 SSIs resulting from 593,344 operations. SSIs were the most common nosocomial infection among surgery patients, accounting for 38% of infections. Of these, two thirds of the infections were confined to the incision, with one third affecting organs or spaces accessed during the operation. The deaths of 77% of the patients with SSI were reportedly related to the infection.

Patients experiencing SSI have their hospital stay prolonged by 7.3 days on average, to the tune of $3,152 in extra charges. (2,3) Studies by Boyce et al (4) and Poulsen et al (5) also associate increased length of hospital stay and cost with SSIs. Patients who develop an SSI need, on average, 4.6 more ambulatory-care visits than do patients who escape SSI. (6,7) Clearly, SSIs cause substantial morbidity and mortality and create a financial burden on already stressed budgets of healthcare systems.

Certain interventions can reduce SSI rates. Method of hair removal, use of appropriate antiseptics to prepare the operative site and for surgical hand scrubs, and the timing of antibiotic prophylaxis should be reviewed to ensure that practices deviating from standard guidelines are not contributing to elevated rates. (7)

Vicki Brinsko, Infection Control Coordinator, Vanderbilt University Medical Center, Nashville, Tennessee, related how their department made a matrix, basically a check list, comprised of the CDC’s recommendations outlined in the SSI guide line. (2) Brinsko explained, “When there is a rise in SSIs, a meeting is called, and we go over the matrix to make sure we are in compliance with the guidelines.” Vanderbilt has the necessary steps in place to prevent SSIs, as much as it is within their power. Even religiously using the guidelines will not completely stop SSIs because the infections are transmitted by colonized healthcare workers, and the colonizing germs are endemic to hospitals and other healthcare facilities. The most that can be hoped for is to hold them down. The CDC SSI guidelines are very specific about measures to take to reduce the incidence of SSI.

Timing of Administration of Antibiotics

Often,” Brinsko said, “it’s a matter of the timing of administration of antibiotics being off. The CDC recommends antibiotics be given to patients 30 minutes before ‘cut time,’ so that the antibiotic has time to work. Delaying administration of antibiotics can easily be come a problem. Sometimes nurses are assigned the task of administering antibiotics, sometimes anesthetists are assigned to do it, and no matter who delivers the antibiotics, there can be reasons it’s delayed. If a previous operation has run longer than expected, for example, that can delay the patient in getting to the operating room, so antibiotics may not be given within the recommended time period.” Brinsko also pointed out that “If cutting comers has been a problem, it will be revealed during the investigation of an outbreak.”

Limiting Room Traffic

Another area that Brinsko and her team track is traffic in a room. Each time a door is opened, a way is provided for organisms to enter. “You’d be surprised how many times a door is opened as healthcare personnel gather items, such as intravenous fluid solutions, when preparing for surgery; so, we put counters on the door.”

Skin Preparation and Hand Cleansing

“Artificial nails are a hot issue. The Association of periOperative Registered Nurses (AORN) says not even to use nail polish, but everybody loves artificial nails. They look great, but if you are in health care and touch patients, especially in the operating room or intensive care unit, do not wear them. Bacteria and fungi, particularly, can grow in the spaces between the nail and the tip of the finger, and scrubbing can’t get rid of these organisms. Operating nurses have to be very cognizant of nail cleansing.”

“Skin preparation also is very important, explained Brinsko. “The CDC recommends clipping rather than shaving hair to cut down on infection.” Shaving can cut the skin, giving bacteria an opportunity to infect. “Surgical skin prep solutions should be applied in an aseptic fashion, as recommended by AORN.”