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Causes, prevention and management of surgical site infection NS653 Gould D (2012) Causes, prevention and management of surgical site infection. Nursing Standard. 26, 47, 47-56. Date of acceptance: February 29 2012.

Abstract Superficial surgical site infection (SSI) usually resolves quickly causing only short-term discomfort. However, SSI involving deeper tissues is a leading cause of morbidity and mortality and increases the overall cost of care. Although SSI commonly originates in the operating theatre, signs and symptoms of infection often do not appear until patients have been discharged from hospital. Nurses in a range of clinical settings are involved in the care of patients who either develop or are at risk of developing SSI and therefore need to know how to advise and manage these patients.

Author Dinah Gould Professor in applied health, School of Health Sciences, City University, London. Correspondence to: [email protected]

Keywords Bacteria, healthcare-associated infection, infection prevention and control, surgical site infection, wound infection

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

Aims and intended learning outcomes This article aims to provide advice for healthcare professionals on the causes and management of surgical site infection (SSI). After reading this article and completing the time out activities you should be able to: �4Describe the effect of superficial and more serious SSI on patients. �4Name the bacteria responsible for causing SSI. �4List the factors that increase a patient’s risk of developing SSI. �4Explain why infection control teams audit SSI. �4Discuss how SSI is identified.

Introduction SSI is infection of a wound following invasive surgical procedures (Murphy 2006). Infection develops when the number and activity of bacteria in the wound overwhelm the patient’s immune system, resulting in tissue breakdown and delayed healing (Murphy 2006). SSI is a common cause of healthcare-associated infection (HCAI) (Plowman et al 2001) and is a leading cause of morbidity and mortality. SSI often originates in the operating theatre when tissues are exposed during surgery, although secondary infection occurring on the ward or after the patient has been discharged from hospital is also possible. The UK government has prioritised the prevention of bloodstream infections caused by meticillin-resistant Staphylococcus aureus and Clostridium difficile. It could be argued that SSI merits the same rigorous approach to reduce the rate of HCAI in the NHS.

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Prevalence of surgical site infection Prevalence is the number of existing cases of a condition in a population at a single point in time. Prevalence studies give little explanation of risk factors so they are not helpful as a means of suggesting control measures. However, prevalence studies can reveal problems that merit more detailed investigation.

The most comprehensive information on SSI in the UK has been generated by the national prevalence surveys of infection in hospital conducted in 1993/94 (Emmerson et al 1996) and in 2006 (Hospital Infection Society and Infection Control Nurses Association 2007). In the 1993/94 survey, SSI accounted for 10.7% of all HCAI (Emmerson et al 1996). The 2006 survey established that SSI was responsible for 13.8% of HCAI in acute hospitals (Hospital Infection Society and Infection Control Nurses Association 2007). The National Institute for Health and Clinical Excellence (NICE) (2008) estimated that 5% of all surgical procedures in the UK result in SSI, accounting for one in every seven cases of HCAI. However, this figure is likely to be underestimated as most SSI presents after patients have been discharged from hospital (Tanner et al 2008).

Knowing how epidemiological data such as rates of SSI were collected is essential to enable interpretation of information and comparison of results from different studies. The high rates of SSI reported in the UK support patients’ fears about contracting a HCAI (Gould et al 2009).

Microorganisms associated with surgical site infection The bacteria responsible for causing SSI are Staphylococcus aureus; Staphylococcus epidermidis; Gram negative bacilli; Streptococcus spp; Enterococci; and Clostridium perfringens (gas gangrene). More than 50% of SSI is caused by S. aureus because it is highly virulent (Health Protection Agency (HPA) 2009). Staphylococcus epidermidis is less virulent and usually causes SSI only in patients who are already immunocompromised. Complete time out activity 1

Sources of infection in surgical wounds Bacteria causing SSI originate from two possible sources: �4Endogenous (self) infection, which occurs

when bacteria are transferred from another site on the patient into the wound. �4Exogenous (cross) infection, which occurs when bacteria from the environment or another person enter the wound.

Endogenous surgical site infection Most SSI is endogenous and the source of bacteria is the patient’s own flora. The skin is heavily populated with microorganisms – on average each square centimetre of skin carries up to three million bacteria (Fredricks 2001). However, density of bacteria varies with anatomical location (Reichel et al 2011). Numbers are lowest on the arms and legs and higher on the forehead, between the webs of the toes and in areas that tend to be moist such as the axillae, groin and perineum (Fredricks 2001). Skin is a major source of endogenous SSI. Other sources include mucous membranes and hollow viscera (organs) if they are opened during surgery (Beldi et al 2009).

Exogenous surgical site infection Bacteria comprising transient flora carried superficially on the surface of the skin are acquired readily during contact with the environment, including other people. Bacteria become dislodged easily and are readily transferred from one location to another, resulting in exogenous infection. In environments where health care is delivered, transient skin flora is likely to include potential pathogens and antibiotic-resistant bacterial strains (Fredricks 2001).

Exogenous SSI is possible via the airborne route from bacteria on the skin of people present in the operating theatre or by direct contact via hands or equipment. A single skin scale from a staphylococcus carrier can transport up to 100 individual bacteria. Skin scales become airborne and settle on the hands of staff or on drapes and then are carried into the wound. Seminal work established that microbial contamination of the operating theatre was a risk factor for SSI, especially during clean procedures (Beldi et al 2009).

Movement of people increases the number of airborne particles which can then settle in the wound. Movement also increases the number of airborne bacteria because of friction of the skin against clothing (Ayliffe 1991). Special ventilation systems are used to filter airborne bacteria and prevent such bacteria in the corridors and theatre suite entering the operating room. The quality of the air supply

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in the operating theatre is monitored strictly, either by estimating the number of bacteria contained in a known volume of air or the number of airborne particles that it contains (Landrin et al 2005). Precautions to reduce exogenous infection in the operating theatre include (NICE 2008): �4Restricting the number of people present in theatre during an operation and reducing the levels of activity of those who are present. Spectators should use a viewing gallery. �4Regularly maintaining the operating environment. Dust should not be allowed to settle on any surface and filters in the ventilation system should be checked.

More recently, the use of incise drapes impregnated with antiseptic has been recommended to reduce the risk of exogenous SSI (NICE 2008).

Effects of surgical site infection The effect of SSI on the patient depends on whether infection is superficial or involves deeper tissues (deep incisional SSI) or an organ space (NICE 2008). Superficial SSI usually resolves after a course of oral antibiotics and causes short-term discomfort, although it can be a source of anxiety and distress to the patient and family members (Box 1). SSI involving the deeper tissues and organ spaces is a leading cause of morbidity and mortality. Affected patients typically stay in hospital an additional seven days (Plowman et al 2001, Coello et al 2005), are more likely to spend time in the intensive care unit and be re-admitted to hospital, and are twice as likely to die (Tanner et al 2008).

Other poor clinical outcomes include unsightly scarring, persistent pain, itching and restriction of movement, especially if the wound is situated over a joint (Ward et al 2008). SSI reduces quality of life, delays return to work, restricts domestic and social activities and is a drain on NHS resources (Plowman et al 2001). Numerous methods have been used to establish the cost of SSI. Overall, patients who develop SSI cost the NHS twice as much as those who are not infected (Broex et al 2009). Complete time out activity 2

Early research by Cruse and Foord (1973) identified two key factors that influence the development of SSI, including patient resistance to infection and number of bacteria present with potential to contribute to infection.

Patient resistance to infection Patient-related factors that influence susceptibility to SSI are: general health; age; gender; nutritional status; metabolic disorders; corticosteroids; and cigarette smoking. The most obvious determinant is the patient’s general health at the time of surgery and any previous debilitating illness. Rates of SSI are higher for patients who have cancer, especially if they have received pre-operative radiotherapy or chemotherapy (Hall and Hall 2000). Age is also important. People between 20 and 40 years have lower rates of SSI, probably because the immune system functions optimally in people of this age (Ayliffe et al 1977). Gender is also influential. Men are at higher risk, especially of staphylococcal infection (Ayliffe et al 1977), possibly because they are more likely to carry staphylococci on the skin than women (Reichel et al 2011).

Cruse and Foord (1973) detected a significant association between SSI and obesity – for clean wounds, overweight people had an infection rate of 13% compared with 1.8% for those of normal body weight. Subcutaneous adipose tissue is poorly supplied with blood vessels and it may be difficult to reduce bleeding when the wound is closed if the patient is overweight. Rates of SSI after caesarean section are higher

BOX 1 Case study

Jane underwent a laparoscopic procedure as a day surgery patient. The small incision, located in the umbilical region, was secured with an absorbable suture. She was told that the suture would come away when the wound had healed. Jane was given a leaflet that included basic self-care information, including what to do if the wound became particularly painful or itchy or if discharge was present. Although she had been advised that it would take several days to recover, Jane was surprised at how tired and lethargic she was feeling. Three days after the operation, as she dried herself after taking a bath, she noticed that the wound site had begun to look moist and felt sore. Jane dried the surrounding skin with a towel, but avoided touching the wound.

The next day the wound felt tender, even when it was not being touched, and the surrounding area was painful and looked a dull red colour. Jane was anxious. She did not want to return to the day surgery unit because she had been told that the suture would not need to be removed, so the next day, although she was still not feeling fully recovered after the operation, she made an appointment at her local health centre. By this time the wound was weeping and she was embarrassed when the practice nurse examined it, as she was aware that it had developed an unpleasant odour. The nurse removed the suture, took a swab and cleaned and dressed the wound. She told Jane to keep it dry and take a shower if possible instead of bathing.

Microscopy and culture revealed that the wound had become infected with Pseudomonas spp. The infection was superficial and resolved after the wound had been cleaned thoroughly and kept dry. Until it healed Jane felt ‘dirty’ and worried about its odour. She did not return to work for a week, although the patient information leaflet suggested that if her recovery progressed according to plan, she need be away no longer than three days.

1 Use a standard textbook such as Gould and Brooker (2008) or Wilson (2006), or go online to check your understanding of the terms: infection and colonisation; endogenous and exogenous infection; Gram-negative and Gram-positive bacteria; transient and resident flora; virulence; and pyogenic.

2 What factors do you think might contribute to a patient’s susceptibility to SSI?

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for women who are obese than those who are not (Johnson et al 2006, Ward et al 2008).

The risk of SSI is also higher for people significantly below their ideal body weight (Beldi et al 2009), probably because the inflammatory and immunological responses and tissue repair depend on adequate supplies of protein. Negative nitrogen balance as a result of loss of amino acids through the stress response to trauma impedes healing and increases the risk of SSI. Metabolic disorders alter the ability of tissues to withstand pathogenic invasion, but the mechanism is obscure and the underlying reason may be related to the specific medical condition.

Cruse and Foord (1973) established a relationship between diabetes mellitus and SSI. The physiological mechanism is still unknown, although findings have since been confirmed for particular groups of patients, for example those undergoing cardiac surgery (Swenne et al 2004). An association between depressed inflammatory response and corticosteroid

therapy has been well established (Zerr et al 1997). Physical and psychological stress increase the release of corticosteroid hormones from the adrenal cortex, suppress healing, increase the risk of SSI and delay recovery (Boore 1978).

Different factors interact and contribute to the risk of SSI. Bowel surgery is a good example. Surgery to the bowel (a ‘dirty’ procedure) places patients at risk of SSI – this risk increases further if patients are older, especially if they are debilitated (Platell and Hall 2001).

For elective patients it is possible to enhance resistance to infection through careful nursing, and medical assessment and intervention (Box 2). However, there are limitations to what can be achieved in emergency situations. A well-established relationship exists between emergency procedures and the incidence of SSI (Ward et al 2008).

Number of bacteria present with potential to contribute to infection The number of bacteria present with the ability to contribute to SSI is influenced by: �4Presence of contamination in the wound (wound category). �4Pre-operative interventions. �4Events in the peri-operative period. �4Post-operative conditions and events.

Wound category Incidence of SSI is influenced by the type of surgical procedure undertaken and whether the wound is clean or contaminated (Coello et al 2005). The National Research Council (1964) developed a system to enable direct comparison between SSI rates for wounds likely to share similar degrees of contamination (Box 3).

The first major research study to examine SSI was performed by Cruse and Foord (1973) in Canada. Incidence of SSI was determined prospectively in an 850-bed hospital over five years. A ten-year prospective study was later published (Cruse and Foord 1980). All wounds were examined daily until the 28th post-operative day. Initially, 23 649 wounds were inspected. The overall SSI rate was 4.8%, but there was considerable variation depending on the wound category.

Other studies indicate differences in SSI rates depending on the nature of the operation. Amputation of a limb presents the highest risk of SSI, followed by bowel surgery. Vascular and gastric surgery and cholecystectomy are also associated with high rates of SSI (HPA

BOX 2 Interventions to improve surgical outcomes

�4Optimal fluid and electrolyte balance. �4Optimal nutritional status, with correction of negative nitrogen balance. �4Correction of a low haemoglobin level. �4Control of any underlying metabolic disorder, for example diabetes mellitus. �4Opportunity to learn and practise deep breathing and leg exercises. �4Opportunity to discuss the operation, anticipate what will happen in hospital and during recovery at home, and plan for any resulting change, for example stoma formation or mastectomy.

BOX 3 Wound classification

Clean wounds �4No inflammation, no lapse in aseptic technique during surgery and no surgical entry into the respiratory and gastrointestinal tracts. Cholecystectomy, hysterectomy and appendicectomy without evidence of inflammation are clean wounds.

Clean contaminated wounds �4Those generated by surgical procedures that involve entry into the respiratory or gastrointestinal tract, but where no significant spillage of the contents of viscera has occurred.

Contaminated wounds �4Evidence of acute inflammation without the formation of pus, or where gross spillage has occurred from a hollow internal organ. An otherwise clean operation in which there has been a major breach of aseptic technique and recent traumatic wounds are considered to be contaminated.

Dirty wounds �4Pus or presence of a perforated internal organ, traumatic wounds not of recent origin.

(Adapted from the National Research Council 1964)

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2006). There are reports of a 2-20% SSI rate in leg and sternal wounds for patients undergoing coronary artery bypass surgery, possibly because normal physiological function is disrupted severely during the operation as a result of haemodilution associated with the use of hypothermia and cardiopulmonary bypass procedures (Swenne et al 2004). Although arthroplasty is a clean procedure, risks of SSI are considerable because infection can result from contamination with only a few bacteria. SSI can be devastating for patients, who may be left with reduced levels of mobility and quality of life, and with the prospect of repeated surgery, delayed recovery and extensive rehabilitation (Nascrimento et al 2005).

The risk of SSI is higher for procedures that are undertaken at anatomical locations where there is a high risk of subsequent contamination (HPA 2006). Cruse and Foord (1980) found that dirty wounds were more than 20 times more likely to become infected. The site of the wound is also important. Tissue repairs faster in areas that have a good blood supply.

Pre-operative influences on surgical site infection Length of hospital stay Cruse and Foord (1973) demonstrated that increased length of pre and post-operative stay was associated with higher rates of SSI. The move towards day surgery and shorter post-operative stay has helped to reduce these risks. Cigarette smoking Cigarette smoking interferes with wound healing, possibly by constricting peripheral blood vessels, thus reducing blood supply and oxygenation of the tissues (Beldi et al 2009). In one study, abstinence from smoking for at least four weeks before surgery reduced the risk of acquiring SSI (Beldi et al 2009). Antibiotic prophylaxis Systemic antibiotics reduce the incidence of SSI significantly (Beldi et al 2009). However, no single antibiotic is a ‘wonder drug’ that will reduce all risks for all patients. Antibiotics should be prescribed only to protect a particular patient from bacteria known to represent a specific threat according to the type of procedure undertaken, and not as part of a blanket policy (Beldi et al 2009). Metronidazole is an appropriate prophylactic measure for patients undergoing abdominal or gynaecological surgery because of the risk of infection caused by anaerobes present in the gut or vagina. Prophylactic metronidazole is not appropriate for patients with superficial incisions because anaerobes will not survive in the presence of oxygen. Appropriate antibiotics

should be administered within 60 minutes of the incision being made and repeated only in the case of excessive blood loss, if the operation is prolonged or if it involves prosthetic surgery – factors associated with increased risk of SSI (Beldi et al 2009). Bowel preparation The incidence of SSI after surgery to the small or large bowel is approximately 10% (Coello et al 2005). Bowel preparation is essential to reduce the risk of endogenous infection with Gram-negative bacteria. The bowel must be emptied before the operation and the patient should receive antibiotic prophylaxis (Beldi et al 2009). Hair removal Several randomised controlled trials have been conducted to evaluate the relationship between hair removal and SSI (Beldi et al 2009). Evidence that removing hair can reduce SSI is mixed. However, shaving increases the risk of SSI compared to removing hair with clippers, possibly because it causes micro-abrasions in the skin, increasing the surface area that can be contaminated by bacteria (Alexander et al 1983). It is recommended that if hair is growing over the site of the planned incision, it should be removed with clippers fitted with a disposable head as close to the time of surgery as possible (Guenaga et al 2009). Showering Early research suggested that applying antiseptics to the skin pre-operatively could reduce the risk of SSI (Cruse and Foord 1973). However, these findings have not been supported by later large-scale, epidemiological studies (Byrne et al 1990, Lynch et al 1992). NICE (2008) guidelines recommend that patients shower using ordinary soap and water the night before surgery. However, in some other European countries, patients are asked to shower using an antiseptic, usually chlorhexidine, to reduce bacterial counts on the skin, thereby reducing the risk of SSI (Tanner and Khan 2008). Surgical hand antisepsis Surgical teams have disinfected their hands to remove transient and resident flora immediately before surgery for the past 150 years (Tanner et al 2008). The aim of surgical hand antisepsis is to remove transient microorganisms and resident flora deep in the stratum corneum because the effects may have to last for several hours (Tavolacci et al 2006). The number of bacteria able to contribute to SSI increases as they are leached out of the deeper layers of the stratum corneum and subungual spaces (beneath the finger nails) when hands sweat beneath surgical gloves, especially if the operation is protracted.

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Gloves frequently become perforated, allowing microorganisms to escape into open tissues (Beldi et al 2009). The Centers for Disease Control (CDC) in the United States recommend that hands and forearms are washed before the first case on the operating list and then scrubbed for two to five minutes with aqueous antiseptic solution before each new surgical case (Mangram et al 1999).

Since the publication of the CDC guidelines (Mangram et al 1999), alcohol products have been introduced for pre-operative hand antisepsis (Tanner et al 2007). They have a wide spectrum of antimicrobial activity, are rapidly effective and do not damage the skin as much as surgical scrubbing – abrasions increase bacterial counts and thus the numbers available to contribute to infection (Widmer et al 2010). In the UK, 20% of practitioners report using alcohol rubs for several cases in succession, but chlorhexidine remains the product used most frequently for pre-operative hand antisepsis (Tanner et al 2007). A Cochrane review established that pre-operative hand antisepsis using alcohol is as effective as scrubbing with traditional aqueous antiseptics to prevent SSI, but there is no evidence that one particular alcohol product is more effective than any other (Tanner et al 2008).

Peri-operative influences on surgical site infection Skin disinfection Traditionally, antiseptics have been applied to the skin in the operating theatre immediately before the first surgical incision is made to reduce the number of bacteria on the skin able to gain access to the wound (Tanner and Khan 2008). Despite a large number of trials, evidence for the effectiveness of skin preparation is mixed (Tanner and Khan 2008). A Cochrane review failed to identify any evidence that pre-operative skin preparation could reduce the risk of SSI (Edwards et al 2004). However, a recent trial demonstrated a reduction in SSI when the skin was cleaned pre-operatively with 2% chlorhexidine in 70% isopropyl alcohol, compared with povidone-iodine (Darouiche et al 2010). This finding has resulted in changes to recommendations for pre-operative skin preparation issued by the Department of Health (2011). Single-use sachets of antiseptic are recommended to reduce the risks of contamination associated with large, multiple-use containers (Pratt et al 2007). Temperature Maintaining the patient’s normal body temperature in the operating

theatre decreases the risk of SSI and promotes healing (Kurz et al 1996). Reductions in body temperature, especially during major surgery, promotes SSI, particularly in older people and those with pre-existing disease. Recommendations are that temperature should be maintained at 36 C̊ throughout the peri-operative period (NICE 2008). Theatre attire Sterile gloves are worn to prevent the transfer of microorganisms from theatre staff to patients during surgery. If gloves become perforated, the risk of infection to patients is increased as is the risk of bloodborne infection to staff (Beldi et al 2009). In one study, SSI rates were significantly higher if gloves were perforated and patients had not received prophylactic antibiotics (Misteli et al 2009). Double gloving is recommended to protect patients and staff (Tanner and Parkinson 2006).

The need for surgical face masks during routine surgery has been explored and the results are mixed (Beldi et al 2009). However, their use continues because they help protect staff from exposure to splashes and associated risks of bloodborne infection. The effectiveness of traditional theatre clothing (scrubs), head gear and overshoes on rates of SSI has not been evaluated. However, scrubs are probably the most practical and comfortable form of clothing for work in the operating theatre. Length of operation and surgical technique Duration of the operation reflects the amount of time tissues are exposed to potential sources of contamination – longer operations tend to be associated with higher rates of SSI (Leong et al 2006). Duration reflects the complexity of the procedure and the surgical expertise required to undertake it. The introduction of minimally invasive techniques has helped reduce these risks, provided that they are undertaken by skilled practitioners.

Foreign bodies such as sutures, wound drains and swabs left in by accident after the wound is closed, increase risks of SSI. The normal immunological defence mechanisms are usually able to cope with small numbers of bacteria, but are likely to be overwhelmed in the presence of foreign material. One silk suture reduces the risk of infection dramatically; sutures, especially multi-braided types, trap bacteria (Beldi et al 2009). Risks of SSI are increased for patients undergoing cardiac or orthopaedic surgery in which prostheses are inserted (Coello et al 2005).

Accumulation of body fluids (blood, serous exudates, bile) within the tissues increases the risks of infection and promotes abscess formation, while the presence of a haematoma

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increases the risk of SSI, hence the use of wound drainage systems (Hall and Hall 2000). The rate of SSI is higher if the drain is inserted via the incision instead of adjacent tissues, so a separate incision for the drain is preferable (Beldi et al 2009). Surgical expertise The incidence of SSI varies widely between hospitals and surgeons, suggesting that surgical techniques and practices have an important role (HPA 2006, Ward et al 2008). Feedback of SSI rates to surgeons helps reduce infection rates, demonstrating that many SSIs are avoidable (HPA 2009). Numerous guidelines for the prevention of SSI have been developed in the UK and other countries (Mangram et al 1999, NICE 2008), but adherence is often poor (Humphreys and Taylor 2002). Complete time out activity 3

Post-operative factors affecting surgical site infection Post-operative management of the wound influences healing and the risk of secondary infection. Patients should be given information on how to look after the incision and surrounding tissues, how to reapply dressings, where to obtain new supplies of dressing materials and where to seek advice if they are concerned. Patients also need to know that a newly created wound will probably appear moist, but should not leak. Excessive weeping and the appearance of pus or blood are associated with infection for which medical or nursing advice should be sought.

A certain amount of pain is to be expected because the skin and underlying tissues have been cut and manipulated, but sudden increase in pain or throbbing pain could indicate infection. It should be possible to control anticipated levels of pain with a simple analgesic such as paracetamol. Feeling generally unwell and symptoms of high temperature are also an indication of SSI and patients should seek medical or nursing advice. Patients discharged while still taking antibiotics need to be told about the importance of finishing the course of antibiotics even if they feel well and to avoid alcohol if they are taking metronidazole (it can react with alcohol, causing unpleasant side effects).

Dressing materials should be stored in a secure, dry place and hands should be washed before and after dressing changes. Small dressings can be wrapped and disposed of with normal household waste, but special arrangements will need to be made for larger,

soiled items. It is better to avoid bathing until the incision appears healed, unless it is covered with an occlusive dressing that is intact, to avoid risks of contamination and secondary infection. The site should be dried carefully after showering or bathing and a new dressing applied as necessary.

Patients should be informed about arrangements for removing sutures or that removal will not be necessary in the case of absorbable sutures. Selection of appropriate dressing materials is important. Patients should be advised that particles from gauze or cotton dressings may leave contaminants in the wound and should be avoided. Capillary loops can grow into the weave, leading to trauma when they are removed (Wood 1976). Wounds in moist areas present a challenge, especially if dressings are difficult to apply and retain in position, for example over incisions in the inguinal, perianal and vulval areas. Patients may need support to cope with these practical issues and problems of delayed healing, which may affect return to usual activities, for example as a result of reduced mobility. Complete time out activity 4

Nursing implications Although most SSI originates in the operating theatre, and signs and symptoms of infection usually do not appear until patients have been discharged from hospital, nurses in a range of clinical settings are involved in the care of those who either develop or are at risk of developing SSI. Nurses who work in pre-surgical admission clinics are likely to encounter patients concerned about HCAI and should be able to provide realistic reassurance and practical advice. Patients need to know what to expect after their operation, how to manage their wound, where to obtain additional supplies of dressings if necessary, how to recognise signs and symptoms of infection and where to seek help. This information should be reiterated at discharge and they should be informed about the importance of finishing a course of antibiotics that has been prescribed even if they feel well.

Nurses who work in the operating department have a pivotal role in the prevention of SSI. They should be aware of extrinsic factors that can be manipulated to reduce the risks of SSI and ensure that patients are managed optimally to allow for the effects of intrinsic factors that cannot be changed. Extrinsic factors relate to the patient’s management and care. They include antibiotic prophylaxis, peri-operative skin preparation

3 What information about wound care should be given to a patient being discharged from hospital following surgery?

4 Risk factors for SSI fall into two broad categories: 4Intrinsic factors that can be modified by practitioners to improve patient outcomes. 4Extrinsic factors that cannot be modified. List the factors discussed in the text that you think can be modified.

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and post-operative wound management. Intrinsic factors are patient-related variables such as age and general health that cannot be changed. However, they can be identified, allowing strategies for optimal management to be put in place.

In their role as patient advocate, nurses should be prepared to ensure that good standards of practice are adhered to by all theatre personnel and that poor practice is documented and reported. Nurses who work in recovery areas, surgical wards and those who are employed in general practice and in the domiciliary nursing services should be able to identify and manage SSI. Specialist nurses have a unique role auditing SSI as part of surveillance schemes.

Auditing surgical site infection Surveillance of SSI is an important way of monitoring and maintaining quality of care and clinical outcomes (Astagneau et al 2009). Early recognition of the importance of monitoring SSI began with the work of Cruse and Foord (1973). They reported a 1.5% incidence of SSI after clean surgery. Higher rates suggest that there have been breaches in standards that must be identified and prevented in future (Hall and Hall 2000).

The study of the efficacy of nosocomial infection control in the US by the CDC resulted in the development of a risk index for SSI (Haley et al 1985) (Box 4). This was later modified (Box 5) and now forms the basis of the National Nosocomial Infections Surveillance System used throughout the US and other countries (Clements et al 2007). The Surgical Site Infection Surveillance Service operated by the HPA in England is based on this system and was established in 1997 to enable NHS trusts to undertake routine surveillance and compare their results with aggregated data drawn from a larger pool. Irrespective of the auditing system used to document SSI, accuracy and effectiveness depend on the same key elements (Sherlaw-Johnson et al 2007): �4Adopting standard definitions of infection agreed and implemented by everyone using the system. �4Collecting accurate and complete information. �4Stratification of rates of SSI according to known risk factors associated with the different categories of wound.

Complete time out activity 5

A number of different approaches can be taken to SSI surveillance. These include

observing wounds directly to identify signs and symptoms of SSI, monitoring laboratory reports, and reviewing nursing notes, temperature charts and prescriptions of antimicrobial agents, or a combination of these approaches. In one study, patients’ recall of antibiotic prescription corroborated better with diagnosis of SSI confirmed by an experienced nurse than any other measure (Whitby et al 2002). Although direct inspection provides first-hand information for the practitioner, signs and symptoms of inflammation associated with normal healing can be difficult to distinguish from SSI (Cutting and Harding 1994).

Inferences about the appearance of the wound should be interpreted in conjunction with other indications of infection, such as pyrexia. If SSI is suspected, a swab or sample of pus aspirated from the wound should be sent to the laboratory for microscopy and culture. These approaches are not possible once patients have left hospital, although this is when most SSI manifests. Post-discharge surveillance is undertaken by telephoning patients, postal questionnaires, community visits by practitioners or by reviewing antibiotic prescriptions issued by GPs. Complete time out activity 6

Identifying surgical site infection Differentiating between SSI and inflammation is not always straightforward. Pyrexia might indicate SSI, but might also occur as a systemic

BOX 4 Risk factors for surgical site infection

Operations that: �4Involve the abdomen. �4Last longer than two hours. �4Were classified as contaminated or dirty. �4Were carried out on patients who had three or more co-morbidities when they left hospital.

(Haley et al 1985)

BOX 5 The National Nosocomial Infections Surveillance (NNIS) system

The NNIS system calculates risk according to three factors: �4State of health at the time of surgery. �4Wound classification as contaminated or dirty. �4Length of operation.

(Clements et al 2007)

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reaction to tissue damage, especially early in the post-operative period. The nurse might suspect that a wound has become infected because of the appearance of discharge or because inflammation appears pronounced (cellulitis). Newly created wounds usually produce colourless exudate and are moist rather than wet. Exudate containing pus or blood are indicative of infection (Cutting and Harding 1994).

Cellulitis is diffuse inflammation of the connective tissue, usually caused by haemolytic streptococci. Its presence is indicated by the classic hallmarks of inflammation, including erythema and local heat with accompanying pain and oedema. In rare cases, vesicles develop leading to ulceration and necrosis. Odour may be detectable in healthy wounds, but should not be pervasive or unpleasant. Odour resulting from SSI is caused by putrefaction of

the tissues from the activity of Gram-negative and anaerobic bacteria – streptococcal and staphylococcal infections do not usually produce noticeable odour. Other factors that might lead healthcare professionals to suspect the presence of SSI include discolouration, delayed healing or an abnormally painful wound (Cutting and Harding 1994). Throbbing is an indication of severe inflammation. It arises because the resulting oedema exerts pressure on adjacent tissues.

Chemicals released as part of the inflammatory response further contribute to pain. Severe pain accompanied by a feeling of malaise could indicate the presence of an abscess. Abscesses are localised collections of purulent material (necrotic tissue, bacteria and phagocytes) surrounded by a fibrin network. They may exert considerable pressure, forcing bacteria into the surrounding tissues or the

5 With colleagues, discuss the different methods that might be used to collect information during SSI surveillance. What are the advantages and disadvantages of each?

6 Explain to a colleague how you would identify SSI.

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Learning zone infection control

blood and lymphatic vessels, resulting in septicaemia. Wherever possible, an abscess should be incised and drained. Antibiotics cannot penetrate a mass of purulent tissue and will be ineffective. Staphylococci are the pyogenic bacteria most likely to cause abscesses (Beldi et al 2009).

Conclusion Many factors contribute to the high level of SSI reported in the UK. Surveillance indicates that rates of SSI reported for the same type of operation vary considerably, suggesting that at least some could be prevented (HPA 2006, Ward et al 2008). Early research focused on

identifying and controlling environmental factors in the operating theatre, such as ventilation systems, to help prevent SSI. Today research is addressing factors related to practitioners’ behaviour during surgery, particularly adherence to evidence-based infection prevention and control precautions.

Members of the public in the UK are more concerned about the risks of HCAI than any other aspect of hospitalisation (Gould et al 2009). Nurses employed in a range of different clinical settings will encounter patients before, during and after surgery and can do much to advise them of the risks of SSI, how to recognise it and how it should be managed NS Complete time out activity 7

7 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 60.

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