“Preventing Surgical Site Infections” by Debra Morrow, RN for OPENPediatrics

“Preventing Surgical Site Infections” by Debra Morrow, RN for OPENPediatrics


The purpose of this video is to provide general
information and education about the care of a critically ill child. It is in no way a substitute for the independent
decision-making and judgment by a qualified health care professional. The information contained in this video should
not be used to make a diagnosis, or to overrule the advice of a qualified health care provider,
nor should it be used to provide advice for emergency medical treatment. Prevention of Surgical Site infections, by
Deb Morrow Hi, I’m Deb Morrow, a Staff Nurse III and the Infection Prevention Coordinator
for the Cardiovascular Intensive Care Unit at Children’s Hospital Boston. Today I’d like to share with you some strategies
that we have implemented a Children’s Hospital for preventing surgical site infections. Epidemiology. The prevalence of surgical site infections
varies by country and type of surgery. In the United States, surgical site infections
account for about 31% of all healthcare associated infections. Surgical site infections lead to an average
increase in length of hospital stay of four to seven days. Infected patients are twice as likely to die,
twice as likely to spend time in an intensive care unit, and five times more likely to be
readmitted after discharge. Health care costs increase substantially for
patients with surgical site infections. Surgical site infections are preventable. Pathogenesis. During the surgical procedure, microbial contamination
can lead to surgical site infections. Sources of microbial contamination include
the patient’s own flora from skin, mucous membranes, or hollow viscera. Seeding from a distant focus of infection,
especially when an implanted foreign body is present. And other external sources, such as hands
of surgical personnel, the operating room environment, and contaminated instruments
and equipment. The patient’s own bacterial flora is the most
common source of pathogens that cause surgical site infection. Most surgical wounds are contaminated with
bacteria, but only a few will progress to infection. Three important factors that determine whether
microbial contamination of incision will lead to surgical site infection are the dose of
bacterial contamination, the ability of the bacteria to invade tissue and cause infection,
and the ability of the patient to fight infection. There are three classifications of surgical
site infection as defined by the United States Centers for Disease Control and Prevention. Superficial incisional involves only the skin
or subcutaneous tissues of incision, and occurs within 30 days of the procedure. Deep incisional involves the fascia and/or
muscle layers. And organ space infection involves any part
of the anatomy, other than the incision, that was opened or manipulated during the operation. For example, the mediastinum. Deep incisional and organ space infections
are considered hospital-acquired if they occur within 90 days of the procedure. Risk Factors. A recently published study from Children’s
Hospital Boston identified the risk factors for surgical site infection in pediatric cardiac
patients. These are: a patient less than one year of
age and cardiopulmonary bypass time greater than 105 minutes. In addition to these risk factors, risk factors
for an organ space infection also include a greater than three post-operative blood
transfusions, pre-operative hospitalization, and an aortic cross clamp time greater than
85 minutes. Surgical Site Infection Prevention Bundle. The four components of our surgical site infection
prevention bundle for pediatric cardiac patients include: hand hygiene– which is the cornerstone
of any infection prevention initiative– appropriate hair removal, appropriate use of prophylactic
antibiotics, and post-operative wound management. Other practices that are recommended by the
World Health Organization address pre-operative showering and intra-operative skin disinfection. Before a patient’s skin is prepared for a
surgical procedure, dirt, soil, or any other debris should be removed. Pre-operative showering may decrease the bacterial
counts and assure that the skin is clean. At Children’s Hospital Boston, patients receive
a chlorhexidine bath the night before and the morning of cardiac surgery. Pre-operative hair removal should not occur
unless the presence of hair at the operative site will interfere with the operation. If hair removal is necessary, remove by clipping
immediately prior to surgery, outside of the operating room. Do not use razors. Microscopic cuts caused by razors may serve
as a location for bacterial growth. Several antiseptic agents are available for
intra-operative skin preparation, and any of these is considered an appropriate choice
if used correctly. These are alcohols, iodophors such as povidone-iodine,
and chlorhexidine gluconate. There are limited high-quality controlled
studies to compare the impact of different agents on surgical site infection risk, for
a given operation. Alcohol is inexpensive, rapid, and results
in the greatest reduction in skin flora. However, it is highly flammable. Iodophors exert an effect while they are present
on skin. But there must be a two-minute contact time
to allow for the release of free iodine. Iodophors have no effect when they are wiped
off the skin, and they are inactivated by blood or serum proteins. Chlorhexidine achieves greater reductions
in skin flora than povidone-iodine, and has residual activity on the skin, which can last
for 48 hours. It is not inactivated by serum proteins. And most formulations of chlorhexidine skin
prep contain 70% alcohol, which also poses a flammability risk. There are important points to remember for
any agent that you use. The application technique must be correct. There must be sufficient contact time for
the disinfecting agent. High-colonization areas– for example, the
umbilicus, axilla, perineal area– need extra attention. And the agent should be allowed to dry, prior
to draping. At Children’s Hospital Boston, the skin prep
in the operating room is done by the operating room nurse. Our hospital is a large teaching institution,
so this assures that the scrub will be done the correct way, every time. The use of intra-operative antibiotics will
not sterilize tissues. But the antibiotic will reduce bacterial contamination
to a level that cannot overwhelm the body’s defenses. The use of intra-operative antibiotic prophylaxis
pertains to elective operations, in which the skin is closed in the operating room. It does not pertain to preventing surgical
site infections caused by post-operative contamination, such as delayed sternal closures in cardiac
patients. In 2005, the National Surgical Infection Prevention
Project recommended that the infusion of the first antimicrobial dose be 60 minutes before
the time of incision. Infusion of fluoroquinolones or vancomycin
should be 120 minutes before the time of incision. Additionally, for pediatric cardiac surgery
at Children’s Hospital Boston, a dose of cefazolin is administered at the start of bypass and
at the conclusion of bypass. Maintenance cefazolin is started eight hours
after this last dose. In our primary closure patients, postoperative
antibiotic prohylaxis is discontinued at 48 hours from the first intraoperative dose or
when chest tubes discontinued, whichever happens first. Many programs are considering discontinuing
post operative prophylaxis at 24 hours Post-operative wound management is an important component
of the bundle. We use a permeable dressing that allows for
gas exchange, but does not allow microorganisms to contaminate the wound. Gauze and tape dressings are also acceptable. We keep the initial dressing in place for
48 hours after surgery to promote healing. Nurses and doctors should perform hand hygiene,
and then wear sterile or clean gloves to lift the dressing for wound examination. We use occlusive dressings on all chest tubes,
pacing wires, and intracardiac lines. We continue to protect the surgical incision
from endotracheal secretions, ventilator condensate, sputum, and emesis in the post-operative period,
by the use of a dry, sterile dressing after the initial dressing is changed at 48 hours. At Children’s Hospital Boston, we perform
a sterile echo on patients in the post-operative period within five days of surgery, or if
there is still any indwelling catheters in place on the chest. The echo probe is covered with a sterile sleeve,
and we use a sterile gel– such as a sterile ultrasound gel– to perform the echocardiogram. Delayed sternal closure is used in cases where
there may be edema, or when the patient is unstable coming off of bypass. The chest opening is covered with a sterile
occlusive dressing. The nurse should maintain patency of the chest
tubes and monitor the patient for tamponade by assessing the level of the patch over the
sternal opening. Patients are kept normothermic, or slightly
cooler. The patient should be monitored for infection,
and antibiotics broadened if symptoms of infection occur. The chest is closed when the patient is stable,
or body wall edema has decreased. Conclusion. Evidence-based practices can reduce surgical
site infection rates. These practices include– appropriate antibiotic
use, appropriate skin antisepsis, no hair removal or hair removal with clippers, and
appropriate wound management. Hospitals should establish policies for the
management of surgical sites. They should educate doctors and nurses on
surgical site infection prevention and initiate communication training, which will help staff
to speak up when policy is not followed. That concludes our video on prevention of
surgical site infections. Thank you. Please help us improve the content by providing
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