Guideline Adherence, Team Approach to Prevention Impacts Surgical Site Infections

By Kelly M. Pyrek

A hospital's surgical services department represents one of the most sizable challenges to infection prevention and control. Surgery also presents a significant risk to patients, and together, the operating room should be on the infection preventionist's radar for healthcare-associated infection (HAI) mitigation and elimination.

Research indicates that SSIs are the most common type of hospital-acquired infection. SSIs account for 20 percent of all infections that occur in the hospital setting. Although most patients recover from an SSI without any long-term consequences, they are at a two- to 11-fold increased risk of mortality. Furthermore, SSIs are the most costly of all hospital-acquired infections. With an annual estimated overall cost of $3 to $5 billion in the U.S., SSIs are associated with a nearly 10-day increased length of stay and an increase of $20,000 in the cost of hospitalization per admission. As many as 60 percent of SSIs are considered to be preventable. Now that the Centers for Medicare and Medicaid Services no longer pays additional amounts for the cost of treating conditions acquired in a hospital, SSIs have been targeted not only to improve clinical quality, but also to protect hospital reimbursement.

As the time of writing, the Centers for Disease Control and Prevention (CDC)'s HICPAC has not released its long-awaited update of its 1999 surgical site infection (SSI) prevention guidelines. In the meantime, newly released guidelines for the prevention, detection and management of SSIs issued by the American College of Surgeons (ACS) and the Surgical Infection Society (SIS) provide a comprehensive set of recommendations clinicians can use to optimize surgical care and educate patients about ways to contribute to their own well-being. The guidelines, titled "American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update," are based on a review of the best available research and clinical practice experience and update previous sets of recommendations on detecting and preventing SSIs from professional clinical and hospital societies.

The new guidelines were developed by investigators from the ACS and SIS, who reviewed evidence from the clinical literature as well as consulted outside content experts to reach consensus across the full course of treatment of surgical patients, including prehospital preparation, hospital interventions, and post-discharge care.

"The guidelines give clinicians step-by-step ways to address SSIs, because there is no single specific fix to the problem and there are many factors in the processes of care," says principal author Therese M. Duane, MD, MBA FACS, FCCM, vice-chair of quality and safety of the department of surgery and medical director of acute-care surgical research, Texas Health Care, at John Peter Smith Health Network, Fort Worth.

There are numerous challenges to ensuring compliance with any guidelines, and Duane offers some advice for boosting implementation of best practices for SSI prevention: "Focus on the team approach," she says. "This means having surgeons active and invested in infection prevention and control. Find the champion in your institution who is passionate about it so that he/she may be your liaison to the surgeons."

No guidelines are perfect, and there exist SSI prevention-related challenges in the real world of the operating suite that reflect both knowledge gaps and implementation gaps. "There is a little of both," Duane acknowledges. "We are finding that operationalizing guidelines that require coordination between surgeons and anesthesiology to be very difficult. It is two-fold -- making sure everyone understands the science behind the guideline and then secondly- folks taking ownership for the steps even when that means there will be overlap. An example, if the surgeons fail to get the antibiotic ordered – we need our anesthesiology colleagues to dose it anyway with a standardized protocol. There is some resistance to do this but it is necessary to have checks and balances in place."

It remains to be seen if HICPAC’s long-awaited update to its 1999 SSI prevention guideline could conflict with those from the ACS/SIS, especially in terms of unresolved issues. "There will always be conflict as evidence changes and it is often up to the mind of the interpreter," Duane says. "Ultimately if we are all just trying to do the next right thing for the patient then we should see improvement overall."

Let's take a look at the various recommendations of the updated ACS/SIS guidelines.

Hair removal
Hair in the surgical site should be removed only if it would interfere with surgery. Shaving causes microscopic cuts and abrasions, resulting in disruption of the skin's barrier defense against microorganisms. Clippers generally should be used instead of razors to remove hair.

Antibiotic sutures
Historically, guidelines have not recommended using antibiotic sutures to decrease SSIs, but there now is considerable evidence to support their use.

Surgical gloves
Surgical gloves can contain or develop defects. Double gloving decreases the risk of holes to the inner glove, so routine double gloving is recommended to protect the surgeon.

Showering
No studies have shown a difference in SSIs between patients who shower as early as 12 hours after surgery and patients who delay showering for more than 48 hours. Early showering does not increase the risk of SSIs and can be encouraged at the surgeon's discretion.

Topical and local antibiotics
Studies of individual procedures have shown promising results when using topical and local antibiotics to reduce infections, but large, randomized clinical trials of a wider range of procedures would be needed before supporting more widespread use or formal recommendations.

Some of the new guidelines call for a change in hospital management to reduce the risk of SSIs. While the presence of diabetes and use of diabetic medications are considered to be risk factors for SSIs, studies show that control of high blood sugar is more important immediately before an operation than over the long term. Research indicates that high blood sugar levels during an operation increase the risk of an SSI; excessively low blood sugar levels increase the risk of adverse outcomes and the frequency of hypoglycemic episodes, but they do not reduce the risk of an SSI. The consensus guidelines therefore set target blood glucose levels at 110-150 mg/dL for all patients regardless of their diabetic status in the immediate preoperative period.

A change in lifestyle habits can help patients reduce their risk of SSI. Recent research corroborates that smokers have the highest risk of SSIs and former smokers are at greater risk of infection than nonsmokers. A consensus guideline therefore encourages surgeons to advise their patients to stop smoking four to six weeks before an operation.

"An important message coming out of these guidelines is that patients have a major role in their own outcomes. That message cannot be underscored enough. Smoking cessation, blood glucose control for diabetic patients, and weight loss are some of the things patients can do to prevent an SSI," Duane says.

Some aspects of surgical management still do not have enough robust, high-quality data to warrant clear recommendations, such as optimal wound care after discharge. "These days, you can do all the right things preoperatively and in the hospital, but if clinicians do not give patients sufficient guidance about wound care and follow-up once they leave the hospital, patients can set themselves up for infections down the line," Duane says. "Trying to make sure patients and their families optimize wound care after they go home is integral to the success of their treatment."

The recommendations on reducing SSIs serve as starting points. These points provide benchmarks against which clinicians can track and trend their outcomes, and they identify for researchers the areas of surgical care that require more study.

"The guidelines show how we in the surgical community can make an impact from a practice and research standpoint," Duane says.

The study's first author, Kristen A. Ban, MD, a resident in the department of surgery of Loyola University Medical Center. "Guidelines serve as a starting point for the delivery of evidence-based care, but they are only useful if they are implemented successfully. Hospitals must engage individuals at all levels, from front-line providers to leadership."

These are the main areas in which there is new evidence to support new or different guidelines:
- Blood glucose control is now recommended for all patients, regardless of diabetic status.
- Adherence must be high to all components of SSI reduction bundles for there to be a benefit.
- With some exceptions, prophylactic antibiotics should be stopped at the time of incision closure.

There still are areas of controversy, including surgical attire, in which there are not enough high-quality data to support guidelines.

In August 2016, ACS issued a statement on professional attire for surgeons in and out of the OR. The ACS said this guideline for appropriate attire was based on professionalism, common sense, decorum, and the available evidence, and it includes the following tenets:
- Soiled scrubs and/or hats should be changed as soon as feasible and certainly before speaking with family members after an operation.
 - Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.
 - Masks should not be worn dangling at any time.
 - OR scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up.
 - OR scrubs should not be worn at any time outside of the hospital perimeter. 
- OR scrubs should be changed at least daily.
- During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination.  Large sideburns and ponytails should be covered or contained.  There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections.
 - Earrings and jewelry worn on the head or neck where they might fall into or contaminate the sterile field should all be removed or appropriately covered during procedures.

The ACS encourages surgeons to wear clean, appropriate professional attire (not scrubs) during all patient encounters outside of the OR. In addition, the statement provides details on wearing the skullcap in a way that ensures patient safety, and puts forth respective cleaning or disposal recommendations for cloth and paper caps. To facilitate enforcement of the guideline on wearing scrubs only within the perimeter of the hospital, the ACS also suggests the adoption of distinctive, colored scrub suits for OR personnel.

 “This statement reflects our strong commitment to surgical patient safety," said ACS executive director David B. Hoyt, MD, FACS. "It’s important to provide an optimal surgical care environment for our patients. These recommendations for a comprehensive dress policy for surgeons will help us to achieve that goal." 
The statement was approved by the ACS board of regents in July 2016, and was published in the October 2016 Bulletin of the American College of Surgeons.  (To view the entire statement online, visit: www.facs.org/about-acs/statements/87-surgical-attire/).

The Association of periOperative Registered Nurses (AORN) reviewed the ACS statement in detail to compare all available evidence to the statement and provide perioperative team members with the information necessary to achieve high quality safe patient care. All current evidence for safe surgical attire is presented with recommended evidence-based practices in AORN’s Guideline for Surgical Attire. The AORN guideline development process meets the rigorous requirements of, and are accepted by, the AHRQ National Guidelines Clearinghouse.

The AORN evidence review of the ACS statement concludes:
- ACS: Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure.
- AORN: The Occupational Safety and Health Administration (OSHA) requires attire that has been penetrated by blood, body fluids or other infectious materials be removed immediately or as soon as possible and be replaced with clean attire.

- ACS: Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.
- AORN: Evidence shows that perioperative team members who are following standard precautions, using personal protective equipment (PPE) and conducting hand hygiene should not need to change scrubs and hats between cases. Doing so could give a false sense of security that PPE and hand hygiene are not needed. This statement may cause confusion by introducing a different standard for surgeons than for other perioperative team members. All should be following the same, evidence-based standards.

- ACS: Masks should not be worn dangling at any time.
- AORN: Evidence-supported.

- A-CS: OR scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up over them.
- AORN: Evidence shows that lab coats can be contaminated with large numbers of pathogenic organisms. Evidence also shows that lab coats are not always discarded daily after use or laundered on a frequent basis and therefore, should not be recommended wear over scrubs. If one chooses to wear a lab coat it should be laundered in a healthcare accredited laundry facility after each daily use and sooner when contaminated, or should be single use.

- ACS: OR scrubs should not be worn at any time outside of the hospital perimeter.
- AORN: Evidence-supported.

- ACS: OR scrubs should be changed at least daily.
- AORN: Evidence-supported.

- ACS: During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections.
- AORN: As with most other aspects of surgical practice, there are no randomized, controlled trials demonstrating the effect of different types of surgical head covering on surgical site infection rates. However, there is a body of evidence that supports covering the hair and ears due to the fact that hair and skin can harbor bacteria that can be dispersed into the operating room environment. As patient safety is the primary consideration for all perioperative personnel, reducing the risk of patient exposure to microorganisms that are shed from the skin and hair to help reduce the risk for surgical site infection should be high priority for all perioperative personnel. The ACS statement says “limited amount of hair and modest sideburn can be uncovered.” Until an evidence-based definition for “limited” and “modest” can be determine, there is no way for facilities to enforce such a recommendation.

- ACS: Earrings and jewelry worn on the head or neck where they might fall into or contaminate the sterile field should all be removed or appropriately covered during procedures.
- AORN: Evidence-supported.

- ACS: The ACS encourages clean appropriate professional attire (not scrubs) to be worn during all patient encounters outside of the OR.
- AORN: No opinion.

- ACS: The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case. Religious beliefs regarding headwear should be respected without compromising patient safety.
- AORN: See the above statements regarding the enforcement confusion introduced by words such as “limited” and “modest.” Wearing a particular head covering based on its symbolism is not evidence-based, and should not be a basis for a nationwide practice recommendation. Several types of evidence exist that support recommendations that perioperative personnel cover their head and ears in the OR. This evidence includes the fact that human skin and hair is naturally colonized with many bacteria, and perioperative personnel shed microorganisms into the air around them.  We know airborne bacteria in the OR can fall into the operative field, contribute to the overall air contamination of the OR, and place patients at risk of surgical site infections. Completely covering the hair can reduce the number of bacteria introduced into OR air by perioperative personnel.
The National Guidelines Clearinghouse requires guideline developers to examine the risk and benefit of a recommendation to patients and personnel. There is no risk to perioperative personnel to cover their skin and hair, while the benefit of doing so to patients is that it reduces the patient’s exposure to potentially pathogenic organisms and helps to protect them from harm.  Head coverings based on symbolism and a personal attachment to historical norms have no place in the patient benefits analysis expected of guidelines developers by the National Guidelines Clearinghouse.

- ACS: Many different healthcare providers (surgeons, anesthesiologists, CRNAs, laboratory technicians, aids, etc.) wear scrubs in the OR setting. The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any healthcare provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel. 
- AORN:  AORN supports this statement, however, nurses and scrub techs should be included in any list of healthcare providers who wear scrubs in the OR.

Duane says that infection preventionists can partner with the surgical team to ensure compliance with the ACS guidelines and that the process "starts with everyone being at the table to identify what the barriers to compliance are at their particular institution," she says. "If surgeons feel that IP and admin are dictating from a far compliance will always be problematic. They have to feel like everyone has skin in the game."

References:

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons. DOI: http://dx.?doi.?org/?10.?1016/?j.?jamcollsurg.?2016.?10.?029.

Anderson DJ, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology 2014; 35(06):605-627.

Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy 2013; 70(3)195-283.

Mangram AJ, et al. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology 1999; 20(4):247-278.

Magill SS, et al. Multistate point-prevalence survey of health-care associated infections. NEJM 2014;370(13):1198-1208.