Surgical Site Infection Prevention Guidelines Widely Known, Practice Lagging
Survey of perioperative registered nurses demonstrates need for practical application and education.
Cary, IL, October 20, 2009 — Preoperative antiseptic skin preparation to reduce infection-causing microorganisms is recommended for the 27 million patients in the United States undergoing surgery each year. According to a survey of registered nurses, there is a significant gap between the Association of periOperative Registered Nurses (AORN) antiseptic skin preparation guidelines and actual practice that is putting patients at risk for surgical site infections (SSIs).
In a poll conducted at the 2009 AORN annual conference in Chicago, more than 30 percent of the 302 perioperative registered nurses interviewed noted that their hospitals do not follow the 2008 AORN guidelines requiring antiseptic skin preparation the night before/morning of surgery. Approximately 88 percent of those surveyed also said that their hospitals are aware of the AORN guidelines.
“The preoperative shower/cleansing process is an important front-end component for reducing the risk of postoperative surgical site infections. All patients undergoing an elective surgical procedure should be afforded the opportunity to cleanse their skin surfaces prior to hospital admission with an effective antiseptic cleansing agent,” said Dr. Charles E. Edmiston, Jr., PhD, CIC, Professor of Surgery and Hospital Epidemiologist at the Medical College of Wisconsin/Froedtert Hospital in Milwaukee.
Each year, SSIs impact between 500,000 to 750,000 individuals in the United States leading to significantly more required medical care at a cost of $10 billion and 20,000 deaths. If an SSI occurs, the average hospitalization increases by a median of two weeks with 60 percent of patients likely to spend time in the ICU.
The AORN guidelines for preoperative skin preparation suggest patients should be bathed with chlorhexidine gluconate (CHG) before surgery in order to reduce the number of microorganisms on the skin and subsequently reduce potential contamination to the surgical wound. Fifty-five percent of respondents suggested that CHG is the method most often used for bathing.
In a recent study conducted by Dr. Edmiston at Froedtert Hospital and published last year in the Journal of the American College of Surgeons, high levels of CHG were achieved on the surface of the skin using a thoughtful, standardized shower/cleansing strategy with either 4% CHG-soap or a 2% CHG-coated polyester cloth. The study noted that the highest skin surface levels of CHG (approaching 2,000 ug/ml) were achieved when the skin surface was cleansed twice using the 2% CHG polyester cloth.
“While it may be impossible to thoroughly eliminate all bacteria from the surface of the skin, high residuals levels of CHG have been noted by previous investigators to be an important factor in reducing the risk of selective healthcare-associate infections, such as catheter-related bloodstream and surgical site infections,” said Edmiston.
Research on surgical site infections suggests a wide number of potential causes. According to the RNs surveyed, endogenous flora on the patient’s skin ranked the highest among the most common causes, followed by poor surgical technique, co-morbidity, lack of antibiotic prophylaxsis and contaminated equipment, respectively.
Recent healthcare quality reform warrants additional emphasis on SSI prevention. In October 2008, the Centers for Medicare and Medicaid Services (CMS) added SSIs to their list of never events, errors on the hospital’s behalf that should have never occurred. As a result, CMS will not provide reimbursement for SSIs.
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Edmiston CE, Krepel CJ, Seabrook, GR, Lewis, BD, Brown KR, Towne, JB. The preoperative shower revisited: Can high topical antiseptic levels be achieved on the skin surface prior to surgical admission? J Am College Surgeons 2008;207:233-239.