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Introduction A surgical site infection is defi ned by the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network as an infection of the surgical site following a surgical procedure. The surgical proce- dure must involve an incision through skin or mucous membrane. Surgical site infections following surgical pro- cedures are classifi ed as superfi cial incisional, deep inci- sional, or organ/space, depending upon the tissue or body part involved (Association for Professionals in Infection Control and Epidemiology [APIC], 2010, p. 17 ) (Level II).

Surgical site infection is recognized as one of the most prevalent healthcare-associated infections (Mangrum et al., Horan, T., Pearson, M., Silver, L., & Jarvis, W., 1999) (Level I). Up to 355,500 surgical pa- tients develop SSI after orthopaedic surgery each year ( Eislet, 2009 ) (Level I). Surgical site infections play a major role in increasing morbidity and mortality rates, prolonging hospitalizations, and increasing hospital re- admissions, in addition to contributing to rising health- care costs ( Bachoura et al., 2011 ) (Level II).

To reduce the risk of SSIs, a systematic but realistic approach must be applied with the awareness that this risk is infl uenced by the presence of modifi able and non- modifi able factors ( Reyes & Chang, 2011 ) (Level I). Modifi able risk factors include surgical technique and the measures of infection prevention that are utilized. Nonmodifi able risk factors are the presence of patient comorbidities, the type of procedure performed (emer- gent vs nonemergent), and the presence of wound con- tamination prior to surgery ( Mu, Edwards, Horan, Berrios-Torres, & Fridkin, 2011 ) (Level IV). Other non- modifi able risk factors that highly infl uence the develop- ment of SSI following skeletal trauma include the site of injury, the number of operations required to effectively address the injury, the utilization of a drain, and the pa- tient being a methicillin-resistant Staphylococcus au- reus (MRSA) carrier ( Bachoura et al., 2011 ) (Level II).

Purpose The purpose for the Surgical Site Infection Prevention Clinical Practice Guideline is to educate staff in promot- ing a multifaceted approach to prevent all orthopaedic surgery-related infections. A consistent implementation of practices related to preoperative surgical site prepa- ration, intraoperative as well as postoperative care would serve to improve outcomes.

Clinical Practice Guideline Surgical Site Infection Prevention

Mary Atkinson Smith ▼ Nancy R. Dahlen

Rationale for Guideline Because of increasing prevalence, extent of injury, rising healthcare costs pertaining to SSIs, and the increasing incidence of MRSA-related SSIs, prophylaxis pertaining to SSIs has become a national priority ( Evans, 2009 ) (Level I). The incidence of SSIs may be decreased and the extent of injury minimized by utilizing evidence- based SSI prophylaxis measures ( Hall, 2007 ) (Level I).

The Surgical Care Improvement Project (SCIP) is a national partnership that was developed in 2003 by the Centers for Medicare and Medicaid Services, the CDC, and various organizations committed to improving the safety of surgical care through the reduction of postop- erative complications by utilizing evidence-based core measures. The SCIP was developed as a result of core measures pertaining to the prevention of surgical infec- tions in the hospital setting that were introduced by The Joint Commission in 2003. SCIP Infection (INF) mile- stones for infection prevention include the following:

• SCIP INF 1a : Prophylactic antibiotic received within 1-hour prior to surgical incision ( Evans, 2009 ) (Level I);

Mary Atkinson Smith, DNP, FNP-BC, ONP-C, Nurse Practitioner, Starkville Orthopedic Clinic, Starkville, MS; Adjunct Faculty, University of Alabama Capstone College of Nursing, Tuscaloosa, AL.

Nancy R. Dahlen, RN, BSN, ONC, Nursing Supervisor, Orthopaedic Trauma Clinic, Mayo Clinic, Rochester, MN .

Reviewers

Ann Bruemmer, RN, BSN, MSN, CNOR

Stephanie Davis, RN, MSHA, CNOR

Crystal Heishman, BSN, RN, CIC, ONC

The authors have disclosed that they have no fi nancial interests to any commercial company related to this educational activity.

Disclaimer: This clinical guideline was developed by the NAON Evidence- Based Practice and Research Committee and is provided as an educa- tional tool on the basis of an assessment of current scientifi c and clinical research information. The tool is not intended to replace a clinician’s inde- pendent judgment and critical thinking, but to enhance the clinician’s knowledge base regarding the prevention of surgical site infections.

Levels of Evidence: The evidence within this clinical practice guideline is rated to differentiate evidence of varying strengths and quality. “The underlying assumption is that recommendations from strong evidence of high quality would be more likely to represent best practices than evi- dence of lower strength and less quality” ( Newhouse, Dearholt, Poe, Puch, & White, 2007 , p. 90). Refer to the Appendix for an explanation of the levels of evidence contained within this guideline.

DOI: 10.1097/NOR.0b013e3182a39c6b

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• failure to obliterate dead space; • tissue trauma; and • postoperative wound care ( Mangram, Horan,

Pearson, Silver, & Jarvis, 1999 ) (Level I).

A variety of patient or host and procedure-associated factors also appear to be related to an increased risk of infection following orthopaedic surgery. Host-specifi c SSI risk factors include the following:

1. obesity; 2. current smoking; 3. hematocrit < 36; 4. elevated preoperative or postoperative serum

glucose; 5. diabetes; 6. chronic steroid use 7. advanced age 8. renal failure 9. low serum albumin level 10. patient being a carrier of MRSA; 11. male gender; 12. rheumatoid arthritis; 13. The American Society of Anesthesiologists (ASA)

Score of 3 or greater; 14. disseminated cancer; and 15. admission from a healthcare facility.

Procedure specifi c SSI risk factors include the following:

• estimated blood loss of greater than 1 L; • longer procedure time; • suboptimal timing of prophylactic antibiotic; • two or more residents participating in the

procedure; • prolonged wound drainage; • spinal procedure via the posterior or the anterior/

posterior approach; • previous infection at the site; and • low volume of procedures performed by the sur-

geon or low volume performed at the hospital ( APIC, 2010, p. 12 ) (Level II).

Defi nition of the Problem Surgical site infections can lead to compromised wound healing and failure of components and hardware, in ad- dition to increased medical costs, morbidity, and mor- tality ( Evans, 2009 ) (Level I).

Pathophysiology • Methicillin-sensitive Staphylococcus aureus

(MSSA) and drug-resistant organisms including MRSA and vancomycin-resistant enterococci colo- nize on the skin and are spread by contact ( Evans, 2009 ) (Level I).

• MSSA and MRSA bacteria can live with other bac- teria on a person’s skin, such as on the hands or in a person’s nose. Whenever a person touches peo- ple or things, he or she can pass on the bacteria ( Evans, 2009 ) (Level I).

• Every surgical wound is able to tolerate some de- gree of host damage locally and a certain amount of

• SCIP INF 2a : Prophylactic antibiotic selection for surgical patients ( Evans, 2009 ) (Level I);

• SCIP INF 3a : Prophylactic antibiotics discontin- ued within 24 hours after surgical end time ( Evans, 2009 ) (Level I);

• SCIP INF 6 : Surgery patients with appropriate hair removal ( Evans, 2009 ) (Level I); and

• SCIP INF 10 : Surgery patients with perioperative temperature management ( Bergstrom, 2010 ) (Level I).

Goal of Clinical Practice Guideline Identifi cation of evidence-based prevention measures pertaining to SSIs will provide orthopaedic nurses with the knowledge base needed to effectively deliver high- quality, continuity of care among patients undergoing surgery of the musculoskeletal system.

Assessment of Scientifi c Evidence The CDC guidelines for reducing the transmission of SSIs include utilizing contact precautions for patients with known or suspected infections, employing appro- priate hand hygiene measures, performing effective en- vironmental cleaning, and following the SCIP measures ( Hall, 2007 ) (Level I). Studies have also been conducted regarding the utilization of patient-centered modalities to decrease the incidence of SSIs. These modalities in- clude, but are not limited to nasal swabbing, preopera- tive skin cleansing, preoperative hair removal, periop- erative antibiotic timing, and specifi c postoperative care measures ( Standiford & Aziz, 2005 ) (Level I).

NURSING DIAGNOSIS Defi cient knowledge Risk for infection Risk for impaired skin/tissue integrity Risk for imbalanced nutrition Risk for ineffective tissue perfusion Risk for hypothermia Risk for injury Potential for ineffective thermoregulation Risk for fl uid imbalance Risk of impaired self-image

DESCRIPTION Identifying characteristics that may infl uence risk of SSI development are as follows:

• patient being an MRSA carrier; • preoperative skin prep; • duration of surgical scrub; • preoperative shaving; • duration of surgery; • antimicrobial prophylaxis; • inadequate operating room ventilation; • inadequate sterilization of instruments; • foreign material in the surgical site; • surgical drains; • surgical technique with poor hemostasis; • presence of fl uid imbalance;

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bacterial fl ora; however, the condition of the wound and the bacterial fl ora are interrelated. If either of these exceeds a tolerable threshold, infection may develop. The threshold may be determined by host factors such as the presence of comorbid condi- tions (diabetes, autoimmune disorders), age, and nutritional status ( Evans, 2009 ) (Level I).

Utilization of Clinical Quality Indicators

• Clinical quality indicators allow for the identifi ca- tion of areas that need improvement and serve as evidence-based guides that assist with the meas- urement of the quality and safety of patient care ( Smith, Jacobs, Rodier, Taylor, & White, 2011 ) (Level II).

• Clinical quality indicators specifi c to infection prophylaxis include intravenous antibiotic admin- istration, adherence to perioperative skin prepara- tion, systematic assessment of postsurgical inci- sion, proper technique with postsurgical dressing changes, and compliance with facility-specifi c perioperative and postoperative protocols ( Smith et al., 2011 ) (Level II).

Nursing Interventions and Expected Outcomes The spread of infectious disease can be prevented by maintaining contact precautions for patients with an infection that is present or suspected. This includes, but is not limited to, good hand-washing practices, utilizing private patient rooms along with contact precautions, using personal protective equipment, and maintaining sterility when performing all sterile and aseptic proce- dures. Soap and water are the most effective means of removing infectious organisms from hands/fi ngers. Hand antiseptics should be used as directed ( Standiford & Aziz, 2005 ) (Level I).

Before entering the operating room, traditional or dry scrubbing of hands must take place to help prevent the development of SSI. There is no increased risk for SSI with the use of dry scrubbing versus traditional scrubbing ( Parienti, Thibon, & Heller, 2002 ) (Level I).

NURSING ASSESSMENT PERTAINING TO PATIENT CARE • Inspect wounds for redness, tenderness, warmth,

drainage, drainage that has an odor, or if patient is febrile ( Horan, Gaynes, Martone, Jarvis, & Emori, 1992 ) (Level III).

• Determine wound classifi cation to predict the risk for SSI development ( Association of periOperative Registered Nurses [AORN], 2011 ) (Level II).

• Determine the presence of comorbid conditions that may increase incidence of SSI (Bosco, Slover, & Haas, 2010) (Level I).

• Determine the presence of modifi able and non- modifi able risk factors ( Bachoura et al., 2011 ) (Level II).

• Review with patients their previous history of in- fections ( Bachoura et al., 2011 ) (Level II).

• Ask the patient to describe his or her living envi- ronment ( Bachoura et al., 2011 ) (Level II).

• Observe very closely those patients with nonmodi- fi able risk factors that may be at increased risk for SSI postoperatively ( Prokuski, 2008 ) (Level I).

Patient Care Management

DETERMINE WOUND CLASSIFICATION The CDC recommends assessing surgical wounds and determining the probability of SSI by utilizing a classi- fi cation that consists of four types of surgical wounds ( AORN, 2011 ).

Clean wounds (Class I) : Uninfected operative wounds where no infl ammation is present and no signs of infection. These wounds are primarily closed and are able to be drained with a closed wound drainage system. An example of a clean wound is a total joint replacement.

Clean contaminated wounds (Class II) : Operative wounds that involve entering the respiratory, ali- mentary, or genitourinary tracts. There are no signs of infection present. Examples are hysterec- tomy, nonperforated appendectomy, or lobectomy.

Contaminated wounds (Class III) : Open, fresh, ac- cidental wounds. This is any type of penetrating trauma or open fractures.

Dirty-Infected wounds (Class IV) : Wounds that in- volve an existing clinical infection. Examples are incision and drainage of an infected wound or de- layed primary closure of a contaminated wound.

PREOPERATIVE CARE

Nasal Swabbing • Preoperative nasal swabbing may be utilized to

screen for patients who are carriers of MRSA or MSSA. Initiating treatment for those patients who test positive preoperatively may decrease the SSI rate as much as 82% among patients undergoing total joint arthroplasty ( Sporer, 2011 ) (Level II).

• If preoperative nasal swab screening is done, it should be done at least 14 days prior to the surgi- cal procedure. If a culture is positive, decoloniza- tion with 2% mupirocin intranasally twice a day is recommended until day of surgery ( Sporer, 2011 ) (Level II).

Preoperative Patient Skin Cleansing • Chlorhexidine gluconate-containing products re-

quire several applications to attain maximum anti- microbial benefi t; so repeated antiseptic showers are usually indicated preoperatively (preferably the evening before surgery and the morning of sur- gery). If advanced notice prior to surgery, cleans- ing can be recommended each day up to approxi- mately 5 days before surgery ( Mangram et al., 1999 ) (Level I).

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that may lead to seeding of bacteria and a deep joint infection ( Kaar, Bogoch, & Devlin, 2000 ) (Level II).

• Determine the use of chronic medications such as steroids and immunosuppressives. These medica- tions have been shown to increase SSI rates and negatively affect wound healing ( McPhee, Williams, & Swanson, 1998 ) (Level II).

• Patients with a history of renal failure should have their renal function evaluated and optimized (Bosco et al., 2010) (Level 1).

• Assess patients for evidence of malnourishment. Patients who are malnourished and have low al- bumin levels are more likely to develop SSIs ( Cierny & Rao, 2009 ) (Level I).

• Keep preoperative hospital stay as short as possible while allowing for adequate preoperative prepara- tion of the patient ( Mangram et al., 1999 ) (Level I).

INTRAOPERATIVE CARE

Surgical Hand Antisepsis Surgical hand antisepsis is a crucial factor in preventing SSIs. It is performed before donning sterile gloves. The purpose of a surgical hand antisepsis is to reduce tran- sient and resident microorganisms on the hands and maintain the bacterial level below baseline, as this may reduce hospital-acquired infections ( APIC, 2010 ) (Level II). In the United States, a standardized surgical hand scrub or rub should be performed, using either an anti- microbial surgical agent or an alcohol-based antiseptic surgical hand rub with documented persistent and cu- mulative activity that has met the U.S. Food and Drug Administration regulatory requirements for surgical hand antisepsis.

Skin Antisepsis The selection of the preoperative skin antiseptic agent should be based on patient assessment for any allergy or sensitivity to skin preparation agents. Qualities the pre- operative antiseptic agent should possess are (APIC, 2011) (Level II) as follows:

• signifi cantly reduce microorganisms on intact skin;

• contain a nonirritating antimicrobial preparation; • be broad spectrum and fast acting; and • have a persistent effect.

After a patient has been placed on the operating room table, the surgical site should be prepared by painting it with a povidone-iodine, iodine with alcohol base, or chlorhexidine solution. Chlorhexidine has been proven to be more effective in preventing SSIs when compared to iodine-based solutions ( Digison, 2007 ) (Level II).

Antibiotic Prophylaxis • Many facilities include antibiotic prophylaxis as a

routine part of the surgical time-out. An important consideration in total knee replacements is the in- fusion of the antibiotic prior to infl ation of the tourniquet (APIC, 2011) (Level II).

Preoperative Hair Removal • If hair removal is required in the perioperative set-

ting, it should be removed just prior to the surgi- cal procedure. It is recommended that hair re- moval take place with electric clippers ( Hall, 2007 ) (Level I).

Blood Transfusions • Autologous and allogeneic blood transfusions in-

traoperatively and postoperatively may slightly in- crease the risk for SSI. The risk is greater with allogeneic than autologous ( Kendall, Weir, Aspinall, Henderson, & Rosson, 2000 ) (Level III).

IV Antibiotic Timing ( Hall, 2007 ) (Level I) • Initiate up to 60 minutes before incision: cefazo-

lin, cefuroxime, clindamycin. • Initiate up to 120 minutes before incision:

vancomycin. • Infusion completed a minimum of 10 minutes

prior to tourniquet infl ation.

Duration of Antimicrobial Use • Single preoperative dose ( Hall, 2007 ) (Level I). • Redose antimicrobial intraoperatively when pro-

cedure exceeds one to two times the antibiotic’s half-life or when there is signifi cant blood loss ( Prokuski, 2008 ) (Level I).

• When using postoperative doses, discontinue within 24 hours after closure of the incision ( Hall, 2007 ) (Level I).

• Patients with a higher than normal body mass index may require higher dosages of antimicrobial therapy.

Preoperative Issues • Whenever possible, identify and treat all infections

remote to the surgical site before elective surgery and postpone elective surgery on patients with re- mote site infections until infection has resolved ( Mangram et al., 1999 ) (Level I).

• Consider checking hemoglobin A1C levels in pa- tients with diabetes. Adequately control serum blood glucose levels in patients with diabetes and particularly avoid hyperglycemia during periop- erative phase ( Mangram et al., 1999 ) (Level I).

• Adequately control serum blood glucose levels of less than 180 mg/dl in all diabetic patients and particularly avoid hyperglycemia perioperatively. Hyperglycemia reduces the body’s natural resist- ance to infection. “Diabetes has been associated with an increased risk of surgical site infections in several orthopaedic disciplines. While this so- called diabetic disadvantage may be due, in part, to the impact of the disease on a patient’s biology and physiology, it is more likely that the acute ef- fects of perioperative hyperglycemia are even more detrimental” ( Evans, 2009 , p. 4) (Level I).

• Preoperative dental screenings to evaluate for the presence of tooth decay, infl ammatory gum disease- gingivitis, periodontitis, or dental abscesses

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Postoperative Care of Negative Pressure Wound Therapy

• Postoperative care should be carried out per nega- tive pressure wound therapy manufacturer’s rec- ommendations or per the physician’s orders.

• Strict hand washing before and after negative pres- sure wound therapy care should always take place.

• Sterile technique should always take place when conducting dressing change.

Disinfection of Noncritical Items • Noncritical items include items that come in con-

tact with intact skin. Examples of these items would include continuous passive motion machines, ice therapy packs, blood pressure cuffs, and so forth (AORN, 2010) (Level II).

• These noncritical items should be cleaned at the point of use with an immediate-level or low-level disinfectant such as alcohols, sodium, hypochlo- rite, phenolic solutions, or ammonium solutions (AORN, 2010) (Level II).

Nursing Responsibilities With Prophylaxis Antibacterial Therapy

• Assess the patient’s allergy history before begin- ning IV antibacterial therapy or applying topical antiseptic agents ( AORN, 2011 ) (Level II).

• Practice strict hand washing and contamination precautions before handling each patient’s IV site (Bosco et al., 2010) (Level I).

• Monitor infusion/injection site for signs of extravasation—pain, edema, and drainage ( AORN, 2011 ) (Level II).

• Ensure that IV antibiotics are given on time as ordered if the patient is receiving postoperative inpatient antibiotic IV therapy ( AORN, 2011 ) (Level II).

• Monitor closely for hypersensitivity reaction dur- ing and after each dose ( AORN, 2011 ) (Level II).

• Monitor for and instruct the patient to report se- vere diarrhea ( Standiford & Aziz, 2005 ) (Level I).

• Monitor for and instruct the patient to report signs of renal impairment—blood urea nitrogen and creatinine intake and output and urine color ( Horan et al., 1992 ) (Level III).

• Monitor and instruct the patient to report any side effects specifi c to particular antibacterial agent ( Horan et al., 1992 ) (Level III).

• Ensure that IV antibiotics are discontinued within 24 hours after surgical end time ( Evans, 2009 ) (Level I).

PATIENT EDUCATION

Preoperative • Encourage tobacco cessation. At a minimum, in-

struct patients to abstain from smoking cigarettes, cigars, pipes, or any other form of tobacco con- sumption for at least 30 days before an elective

Air Quality • The quality of air entering the operating room

should be carefully controlled by keeping operat- ing room doors closed except as needed for pas- sage of equipment, personnel, and the patient (AORN, 2011) (Level II).

Traffi c Patterns • Limit the number of personnel entering operating

room to necessary personnel only (AORN, 2010) (Level II).

Maintain Normothermia to Avoid Hypothermia

• Hypothermia is defi ned as a core temperature less than 96.8 ° F ( AORN, 2011 ) (Level II).

Sterilization of Surgical Instruments • Sterilize all surgical instruments according to in-

stitutional guidelines. • Perform fl ash sterilization only in emergent situa-

tions when instruments will be used immediately. Do not use fl ash sterilization for reasons of con- venience, as an alternative to purchasing addi- tional instrument sets, or to save time (AORN, 2010) (Level II).

POSTOPERATIVE CARE

Postoperative Incisional Care • Protect an incision that has been closed primarily

with a sterile dressing for 24–48 hours postopera- tively ( Mangram et al., 1999 ) (Level I).

• Perform hand hygiene before and after dressing changes and any contact with the surgical site ( Mangram et al., 1999 ) (Level I).

• When an incision dressing must be changed, use sterile technique ( Mangram et al., 1999 ) (Level I).

• Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms (Mangram et al., 1999) (Level I).

Postoperative Skeletal Pin Care • Be aware that pins located in soft tissue area are at

greater risk for infection ( Holmes & Brown, 2005 ) (Level II).

• After the fi rst 48–72 hours following skeletal pin placement, pin site care should be done daily or weekly ( Holmes & Brown, 2005 ) (Level II).

• Chlorhexidine 2 mg/mL solution is considered to be the most effective cleansing solution for skele- tal pin site care ( Holmes & Brown, 2005 ) (Level II). Saline should be used if chlorhexidine solution is contraindicated according to the Royal College of Nursing (2011). (Level V).

• Strict hand washing before and after skeletal pin site care should always take place. Note : Follow your facility’s specifi c policy and pro- cedure pertaining to skeletal pin care.

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Association for Professionals in Infection Control and Epidemiology . ( 2010 ). Guide to the elimination of or- thopedic surgical site infections . Washington, DC : Author . Retrieved from http://www.apic.org/ Resource_/EliminationGuideForm/34e03612d1e6421 4a76be532c6fc3898/File/APIC-Ortho-Guide.pdf

Bachoura , A. , Guitton , T. , Smith , M. , Vrahas , M. , Zurakowski , D. , & Ring , D. ( 2011 ). Infi rmity and in- jury complexity are risk factors for surgical-site infec- tion and operative fracture care . Clinical Orthopaedics and Related Research , 469 ( 9 ), 2621 – 2630 .

Bergstrom , T . ( 2010 ). New CMS normothermia measure brings warmth to surgical patients: SCIP-Inf-10 inpa- tient measure applies to “all surgical patients, regardless of age.” Retrieved from http://healthvie.com/new-cms- normothermia-measure-brings-warmth-to-surgical- patients/

Bosco , J. A., III , Slover , J. D. , & Haas , J . ( 2010 ). Perioperative strategies for decreasing infection: A comprehensive evidence-based approach . Journal of Bone and Joint Surgery , 92 ( 1 ), 232 – 239 .

Cierny , G. , & Rao , N . ( 2009 ). Procedure-related reduction of the risk of infection: Musculoskeletal infections . In Orthopaedic Knowledge Update (pp. 43–49). Rosemont, IL: American Academy of Orthopaedic Surgeons .

Digison , M. ( 2007 ). A review of anti-septic agents for pre- operative skin preparation . Plastic Surgery Nursing , 27 ( 4 ), 185 – 189 .

Eislet , D. ( 2009 ). Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of sur- gical site infection in orthopedic surgical patients . Orthopaedic Nursing , 28 ( 3 ), 141 – 145 .

Evans , R., & American Academy of Orthopaedic Surgeons Patient Safety Committee . ( 2009 ). Surgical site infec- tion prevention and control: an emerging paradigm . Journal of Bone and Joint Surgery , 91 ( 6 ), 2 – 9 .

Hall , M . ( 2007 ). Surgical care improvement project (SCIP) module 1: Infection prevention update . Retrieved from www.medscape.com/viewprogram/7214

Holmes , S ., & Brown , S . ( 2005 ). Skeletal pin site care: National Association of Orthopaedic Nurses guide- lines for orthopaedic nursing . Orthopaedic Nursing , 24 ( 2 ), 99 – 107 .

Horan , T. , Gaynes , R. , Martone , W. , Jarvis , W. , & Emori , G . ( 1992 ). CDC defi nitions of nosocomial surgical site in- fections: a modifi cation of CDC defi nitions of surgical wound . Infection Control Hospital Epidemiology , 13 ( 10 ), 606 – 608 .

Kaar , T. , Bogoch, E. , & Devlin , H . ( 2000 ). Acute metastatic infection of a revision total hip arthroplasty with oral bacteria after noninvasive dental treatment . Journal of Arthroplasty , 15 ( 5 ), 675 – 678 .

Kendall , S. , Weir , J. , Aspinall , R. , Henderson , D. , & Rosson , J. ( 2000 ). Erythrocyte transfusion causes immunosup- pression after total hip replacement . Clinical Orthopaedics , 381 , 145 – 155.

Lindstrom , D. , Sadr , A. , Wladis , A. , Tonnesen , H. , Linder , S. , Nasell , H., … Adami , J . ( 2008 ). Effects of a periop- erative smoking cessation intervention on post-opera- tive complications: A randomized trial . Annals of Surgery , 248 ( 5 ), 739 – 745 .

Mangram , A. , Horan , T. , Pearson , M. , Silver , L. , & Jarvis , W . ( 1999 ). Guidelines for prevention of surgical site infec- tion . Infection Control and Hospital Epidemiology , 20 ( 4 ), 247 – 278 .

McPhee , I. , Williams , R. , & Swanson , C . ( 1998 ). Factors infl uencing wound healing after surgery for meta- static disease of the spine . Spine Journal , 23 ( 6 ), 726 – 732 .

operation. The nicotine in tobacco products results in microvascular vasoconstriction, in addition to tissue hypoxia that can contribute to the develop- ment of SSI ( Lindstrom et al., 2008 ) (Level II).

• Review preoperative bathing and skin preparation instructions. Give the patient written instructions if possible ( Eislet, 2009 ) (Level I).

Postoperative patient and/or family education pertaining to

• Signs and symptoms of infection (Mangram et al., 1999) (Level I).

• Hand washing ( Bosco et al., 2010 ) (Level I). • Appropriate wound care ( Bosco et al., 2010 ) (Level I). • Antibiotics (if prescribed after hospital discharge):

emphasizing the importance of taking all medica- tion until fi nished and the potential side effects ( Evans, 2009 ) (Level I).

Discharge Destination The discharge destination for the patient is based on the level of care required and the support system available to the patient. The goal would be to return to prehospi- tal environment, but special consideration is required on the basis of the need for oral or intravenous antibiot- ics and/or wound care. Assistance with placement for follow-up care may be needed.

Trends and Controversies No recommendation to taper or discontinue systemic steroid use (when medically permissible) before elective surgery. No recommendation to enhance nutritional support for surgical patients solely as a means to prevent SSI. No recommendation to provide measures that enhance wound space oxygenation to prevent SSI. No recommendations to use a dressing to cover an inci- sion closed primarily beyond 48 hours, or an appropri- ate time to shower or bathe with an uncovered incision. No recommendation on the use of novel 2% chlorhex- idine gluconate cloths. Controversy exists on skeletal pin care.

Web Sites PROFESSIONALS www.cdc.gov/ncidod/dhqp/ www.gao.gov/new.items/d08808.pdf www.cdc.gov/drugresistance www.ahrq.gov/qual/ssi

PATIENT AND FAMILY http://www.cdc.gov/getsmart/ http://www.cdc.gov/GetSmart/antibiotic-use/know-and- do.html

REFERENCES Association of periOperative Registered Nurses . ( 2011 ).

Perioperative standards and recommended practices . Denver, CO : Author .

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Royal College of Nursing . ( 2011 ). Guidance on pin site care: Report and recommendations from the 2010 con- sensus project on pin site care. London, England : Author .

Reyes , G. , & Chang , P . ( 2011 ). Prevention of surgical site infections: Being a winner . Operative Techniques in Sports Medicine , 19 ( 3 ), 238 – 244 .

Smith , M. , Jacobs , L. , Rodier , L. , Taylor , A. , & White , C. ( 2011 ). Clinical quality indicators: infection prophy- laxis for total knee arthroplasty . Orthopaedic Nursing , 30 ( 5 ), 301 – 304 .

Sporer , S . ( 2011 ). Preop screening reduces SSI rate after TJA . AAOS Now. Retrieved from http://www.aaos.org/ news/acadnews/2011/AAOS10_2_19.asp

Standiford , D. , & Aziz , H . ( 2005 ). Emerging pathogens and revisited prevention strategies for the clinical environ- ment . Orthopaedic Nursing , 24 ( 6 ), 406 – 413 .

Mu , Y. , Edwards , J. , Horan , T. , Berrios-Torres , S. , & Fridkin , S . ( 2011 ). Improving risk-adjusted measures of surgical site infection for the National Healthcare Safety Network . Infection Control and Hospital Epidemiology , 32 ( 10 ), 970 – 998 .

Newhouse , R. , Dearholt , S. , Poe , S. , Puch , L. , & White , K. ( 2007 ). Johns Hopkins nursing evidence-based practice model and guidelines. Indianapolis, IN : Sigma Theta Tau International .

Parienti , J. , Thibon , P. , & Heller , R. ( 2002 ). Hand-rubbing with an aqueous alcoholic solution vs. traditional sur- gical hand-scrubbing and 30-day surgical site infec- tion rates: A randomized equivalence study . Journal of the American Medical Association , 288 ( 6 ), 722 – 727 .

Prokuski , L. ( 2008 ). Prophylactic antibiotics in orthopae- dic surgery . Journal of the American Academy of Orthopaedic Surgeons , 16 ( 5 ), 283 – 293 .

Appendix

System for Rating the Strength of Evidence Level I High-quality, randomized, controlled trial with a large sample and statistically signifi cant difference or no statistically signifi cant

difference but narrow confi dence intervals. Evidence from a systematic review, a meta-analysis, or an evidence-based clinical practice guideline where only results from randomized controlled clinical trials were used

Level II Evidence from at least one well-designed, randomized, prospective comparative clinical trial. Systematic review of primarily Level II studies

Level III Evidence from well-designed case-controlled trials without randomization, comparative studies and evidence from a systematic review, a meta-analysis, or an evidence-based clinical practice guideline where results from randomized clinical trials and con- trolled clinical trials were used. Systematic review of primarily Level III studies

Level IV Evidence from case series and cohort studies. Evidence from well-designed descriptive, qualitative, or psychometric studies. Evidence from a systematic review, a meta-analysis, or meta-synthesis of descriptive or qualitative studies

Level V Evidence from the opinion of authorities or experts

Level VI Common practice, as documented in clinical articles or nursing textbooks

Note. Modifi ed from the “Rating System for the Hierarchy of Evidence” by B. M. Melnyk & E. Fineout-Overholt, in Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (p. 10), 2005, Philadelphia, PA: Lippincott Williams & Wilkins. Modifi ed by E. C. Devine (2007) for the Knowledge-Based Nursing Initiative. Knowledge-Based Nursing Initiative Protocol (2007). Unpub- lished manuscript. Modifi ed from Centre for Evidence-Based Medicine, Oxford, UK. See www.cebm.net .

For 74 additional continuing nursing education articles on orthopaedic nursing topics, go to nursingcenter.com/ce.

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