Prevention Of Surgical Site Infection 353t73

D

Prepare for revalidation: read this D article and write a reflective http://revalidation.zone

CONTINUING PROFESSIONAL DEVELOPMENT

 Page 60

Surgical site infection multiple choice questionnaire

 Page 61

Read Clio Badenhorst’s reflective on ethical practice

 Page 62

Guidelines on how to write a reflective

Prevention of surgical site infection

NS754 Harrington P (2014) Prevention of surgical site infection. Nursing Standard. 28, 48, 50-58. Date of submission: March 7 2014; date of acceptance: April 28 2014.

Abstract

Aims and intended learning outcomes

Keywords

This article is aimed at nurses who care for patients during the pre, peri and post-operative periods. It is intended to provide information on the risk of developing surgical site infection (SSI) and on how it can be prevented and managed. After reading this article and completing the time out activities you should be able to: Recognise the signs and symptoms of SSI. Understand the importance of SSI audit and surveillance. Describe measures that can be taken to reduce the incidence of SSI. Explain management strategies for patients with SSI. Discuss the role of the nurse in treating patients with SSI.

Healthcare-associated infection, infection prevention and control, surgical site infection, wound care

Introduction

Surgical site infection (SSI) is a common healthcare-associated infection that can cause patients extreme pain and discomfort, resulting in prolonged hospitalisation and additional costs to the NHS. Multidisciplinary team working, combined with audit and surveillance, early recognition of signs and symptoms of infection, and implementation of evidence-based guidance are essential for reducing the incidence of SSI. Nurses caring for patients in the pre, peri and post-operative period have an important role in advising individuals about the risks associated with SSI and how infection should be managed.

Author Pauline Harrington Surgical site infection surveillance manager, Public Health England, London. Correspondence to: [email protected]

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

Online For related articles visit the archive and search using the keywords above. To write a D article: please email [email protected] Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines

SSI s for an estimated 16% of all healthcare-associated infections (HCAIs) and can lead to increased antibiotic consumption and healthcare costs, prolonged recovery for patients, increased pain, anxiety, further risk of complications and, in some cases, death (National Audit Office (NAO) 2000, Health Protection Agency (HPA) 2012). Patients who develop SSI after discharge from hospital are at increased risk of reission, resulting in additional costs to the NHS. Estimates suggest that it costs the NHS £700 million per year to treat patients with SSI (Adams-Howell et al 2011). SSI can be prevented with appropriate intervention, and healthcare professionals have an important role in this area. Guidance is available to assist healthcare professionals in the prevention, recognition and treatment of SSI, and should be integrated into local

policies so that every patient undergoing surgery receives the best possible care. SSI rates are often reported using the cumulative incidence measure, which is calculated as the number of new infections divided by the population at risk over a defined period of time, expressed as a percentage. The infections included in this measure are those detected during inpatient stay or on reission. The incidence of SSI varies widely between hospitals and between surgical categories in NHS hospitals in England (Public Health England (PHE) 2013a). This may be because of differences in case ascertainment, clinical practices and case mix. Categories with the highest degree of wound contamination have a higher incidence of infection. For example, large bowel surgery has an incidence rate for SSI of 10.6%, while categories generally considered as associated with clean wounds, such as knee and hip surgery are lower – with an SSI incidence of less than 1%. Figure 1 shows the incidence of SSI for the 17 categories of surgery available at PHE. Complete time out activity 1

Definition of surgical site infection An SSI is a wound infection that occurs following surgery. Most surgical wounds heal rapidly without complications; however, some become infected. Such infection occurs when microorganisms are introduced through the surgical incision as a result of bacteria or fungi migrating from the patient’s skin or gastrointestinal tract (microflora; endogenous infection), direct transfer from surgical instruments, equipment or hands of healthcare workers, or via the airborne route (exogenous infection) (Table 1). When the microorganism gains entry to the wound, it can multiply. The development of an SSI is influenced by the virulence of the organism and the host’s ability to resist infection. In some cases, bacteria can enter the body and travel in the blood, then deposit on prosthetic implants and multiply, causing infection. This is called haematogenous seeding (NAO 2000, Collier 2004, PHE 2013c). An SSI usually develops within 30 days of surgery – although, in some patients with a prosthetic implant, SSI can occur up to one year after surgery (PHE 2013c). Studies in

1 Make a list of the endogenous and exogenous risk factors for developing SSI. Could any of these be prevented and, if so, how? Speaking to of the infection prevention and control team may help your decisions.

FIGURE 1 Cumulative incidence of surgical site infection by surgical category in NHS hospitals in England from April 2008 to March 2013 10.6

Large bowel 6.5

Bile duct, liver and pancreatic surgery

6.4

Small bowel 4.4

Coronary artery by graft (CABG)

4.2

Cholecystectomy 3.3

Limb amputation 2.8

Vascular

2.7

Gastric 1.6

Cranial

1.5

Repair of neck of femur

1.5

Abdominal hysterectomy

1.3

Cardiac (non-CABG) Reduction in long bone fracture

1.2 1.1

Spinal Breast

1.0 0.7

Hip prosthesis Knee prosthesis

0.6 0

2

4

6

8

10

Percentage of operations resulting in surgical site infection (Public Health England 2013b)

12

D infection control the United States have shown that there is a long-term risk of developing SSI following primary hip and knee replacements, with one quarter of infections diagnosed between two and ten years following surgery (Ong et al 2009, Kurtz et al 2010). Clinicians should bear the possibility of infection in mind when treating patients who have unresolved problems with their prosthesis. Complete time out activity 2

Clinical signs of surgical site infection, effects and classification Following surgery, patients usually experience pain, swelling and redness around the wound as part of the normal wound healing process (PHE 2013c). However, SSI may intensify these symptoms (National Institute for Health and Care Excellence (NICE) 2008). SSIs are associated with redness, heat, pain,

swelling, temperature greater than 38 degrees centigrade, purulent discharge, abscess and cellulitis directly related to the surgical wound, and dehiscence (Cutting and White 2004). A study conducted by Cahill et al (2008) investigated the long-term effect of SSI on several quality-of-life measures in patients undergoing knee and hip surgery. The results showed that SSI significantly affected patients’ mobility, independent living and psychological health. Another study conducted by Andersson et al (2010) showed that patients with deep SSI experienced physical, social, emotional and economic problems. Therefore, it is important that healthcare professionals understand the seriousness of SSI and the importance of prevention. Complete time out activity 3 Some infections may be difficult to diagnose, as there may not be obvious clinical signs

TABLE 1 Mode of infection spread

2 What information and advice might you give to a surgical patient following discharge regarding observing for signs and symptoms of SSI and how to care for the wound?

Direct physical (body surface to body surface) between infected or colonised individual and susceptible host. Examples of transmission: shaking hands, kissing, coitus. Examples of infections: common cold, sexually transmitted diseases. Precautions: hand hygiene, masks, condoms.

Indirect

Infectious agent deposited onto an object or surface (fomite) surviving long enough to transfer to another person who subsequently touches the object. Examples of transmission: not washing hands between patients, contaminated instruments. Examples of infections: respiratory syncytial virus, Norwalk, rhinovirus. Precautions: sterilising instruments, disinfecting surfaces in school.

Droplet

, but transmission is through the air. Droplets are relatively large (>5µm) and projected up to about one metre. Examples of transmission: sneezing, coughing, during suctioning. Examples of infections: meningococcus, pertussis, respiratory viruses.

Airborne

Transmission via aerosols (airborne particles <5µm) that contain organisms in droplet nuclei or in dust. Examples of transmission: via ventilation system in a hospital. Examples of infections: tuberculosis, varicella, measles, chickenpox, smallpox. Precautions: masks, negative pressure rooms in hospitals.

Vehicle

A single contaminated source spreads the infection (or poison) to multiple hosts. This can be a common source or a point source. Examples of transmission – point source: food-borne outbreak from infected batch of food, cases typically cluster around the site (such as a restaurant), intravenous (IV) fluid, medical equipment.

Vectorborne

Transmission by insect or animal vectors. Example of transmission: mosquitoes. Example of infection: malaria. Precautions: window screens, bed nets, insect sprays.

One-to-one

3 Carol is aged 80 years, has diabetes and osteoarthritis and has undergone a total hip replacement. Five days after surgery, she experiences difficulty in walking, her hip is swollen, and the area surrounding the wound is red and dehisced. Using the SSI criteria in Table 2, decide whether Carol has a wound infection? Does she have any risk factors for developing SSI? Explain the rationale for your answer.

Direct

Non-

(Adapted from University of Ottawa 2013)

such as heat and swelling, and may require multidisciplinary discussions between surgeons, microbiologists, infection control nurses and radiologists. However, it is important that SSI is diagnosed correctly and consistently, using the three standard classifications of SSI: superficial, deep, and organ or space infections (Table 2). Figures 2, 3 and 4 show respectively a superficial wound infection, a deep incisional wound infection with dehiscence, and a deep incisional wound infection with purulent drainage.

Risk factors Several factors increase the risk of developing SSI. These may be patient-related (endogenous) or environmental (exogenous) (Barnard 2003, Johns Hopkins Medicine 2010), as shown in Table 3. Some risk factors are modifiable, for example obesity, malnutrition and tobacco use. While not all risk factors are modifiable, understanding the role each plays in the development of SSI will assist in implementing appropriate prevention strategies.

Prevention of surgical site infection To prevent SSI occurring, a full clinical assessment is required to identify risk factors, followed by measures to modify these risks where possible. These measures should be based on Department of Health (DH) (2007) and NICE (2013) guidance, which recommend that: Patients should be encouraged to stop smoking at least four weeks before surgery to promote primary wound healing (when the margins of the wound are brought together with suturing, glue or clips). Smoking causes blood vessels to constrict and thus reduces the delivery of oxygen and nutrients to promote wound healing. Pre-operative showering to reduce bacterial load on the skin. Antibiotic prophylaxis, when recommended, should be given within 60 minutes before the incision and at the correct dose and duration to protect against organisms likely to cause infection. If hair removal is required, it must be performed as close to the incision as possible

TABLE 2 Criteria for defining surgical site infection (SSI) Superficial incisional infection SSI that occurs within 30 days of surgery, involves only the skin or subcutaneous tissue of the incision and meets at least one of the following criteria: 1. Purulent drainage from superficial incision. 2. Culture of organisms and pus cells present in:  Fluid and/or tissue from superficial incision, or  Wound swab from superficial incision. 3. At least two symptoms of inflammation:  Pain, tenderness, localised swelling, redness, heat.  And either: i) Incision deliberately opened to manage infection, or ii) Clinician’s diagnosis of superficial SSI. Note: stitch abscesses (minimal inflammation or discharge at suture point) do not classify as SSI.

Deep incisional infection SSI involving the deep tissues (fascia and muscle layers), within 30 days of surgery (or one year if a prosthetic implant is in place), where the infection appears to be related to the surgical procedure and meets at least one of the following criteria: 1. Purulent drainage from deep incision (not organ space). 2. Organisms from culture and pus cells present in:  Fluid and/or tissue from deep incision, or  Wound swab from deep incision. 3. Deep incision dehisced or deliberately opened and patient has at least one symptom of:  Fever, localised pain, tenderness. 4. Abscess or other evidence of infection involving the deep incision seen during re-operation or by histopathological or radiological examination. 5. Clinician’s diagnosis of deep incisional SSI.

Note: an infection involving both superficial and deep incisional = deep incisional

Organ or space infection SSI involving the organ or space (other than the incision) opened or manipulated during the surgical procedure, that occurs within 30 days of surgery (or one year if a prosthetic implant is in place), where the infection appears to be related to the surgical procedure and meets at least one of the following criteria: 1. Purulent drainage from drain (through stab wound) into organ or space. 2. Organisms from culture and pus cells present in:  Fluid and/or tissue from organ or space, or  Swab from organ or space. 3. Abscess or other evidence of infection in organ or space seen during re-operation or by histopathological or radiological examination. 4. Clinician’s diagnosis of organ or space infection.

D infection control using clippers to prevent any break in the skin and the potential for microorganisms to gain access to the wound. Blood glucose control should be maintained below 11mmol/L in patients with diabetes. Body temperature should be maintained

FIGURE 2 Superficial wound infection

above 36°C before, during and after surgery to prevent vasoconstriction. Skin preparation should be carried out in theatre using a recommended antiseptic to remove soil and transient organisms. The hands of those present in the operating theatre should be decontaminated. A sterile theatre environment should be maintained by limiting the number of people in the theatre during surgery and ensuring that staff who are present wear appropriate theatre clothing. SSI surveillance should be conducted along with of results to staff involved in patient care.

Role of surveillance

FIGURE 3 Deep incisional wound infection with dehiscence

FIGURE 4 Deep incisional wound infection with purulent drainage

Haley et al (1985) showed that establishing an infection control programme which includes on SSI rates to surgeons can lower the overall rate of SSI by as much as 35%. Two European studies have also shown similar findings (Gastmeier et al 2006, Astagneau et al 2009). The national SSI surveillance programmes in the UK provide effective frameworks for hospitals to reduce SSI by monitoring patients following surgery. Such monitoring helps hospitals identify any problems with their rates of SSI. The aim of SSI surveillance is to enhance the quality of patient care by encouraging hospitals to use the data to compare their rates of SSI over time and against a benchmark. However, if the surveillance of SSI is to provide comparable and valid data, it is crucial the methods used are standardised. Data derived from surveillance can then be used by hospitals to review and guide clinical practice. There are several benefits to conducting SSI surveillance. It enables proactive early intervention, reduces preventable harm to patients, reduces the additional length of hospital stay, and promotes compliance with care bundles. A national SSI surveillance programme in England was launched in 1997 by the Public Health Laboratory Service now hosted by PHE. Scotland (Health Protection Scotland), Wales (Public Health Wales) and Northern Ireland (Public Health Agency) have similar surveillance programmes. PHE identifies 17 categories of surgery in which hospitals can undertake surveillance, four of these are orthopaedic categories mandated by the DH. NHS trusts are asked to undertake surveillance in one of the four orthopaedic categories in each financial year (PHE 2013b). Hospitals may choose to conduct surveillance in as many categories as they wish

TABLE 3 Risk factors for surgical site infection Endogenous risk factors  Extremes of age: older adults and neonates.  Immunosuppression.  Alcoholism.  Pre-existing infection at another site.  Diabetes mellitus.  Hypothermia.  Poor nutrition or physical status.  Obesity.  Shock.  Length of pre-operative stay.  Previous radiotherapy or chemotherapy.  Skin disease in the area of the wound, for example psoriasis.  Smoking and use of tobacco products.

Exogenous risk factors  Contaminated or dirty surgical procedure, or poor surgical instrument processing.  Operations that last longer than predicted.  Surgical scrub that is not applied for the recommended time.  Excessive movement of staff in theatre.  Foreign material in the surgical site.  Staff with skin infections.  Type of surgery – some operations carry high risk of infection, for example colorectal surgery – and complexity of the procedure.  Surgical drains.  Surgical technique – laparoscopic procedures carry a lower risk of infection than open techniques.  Transplant or implant operations.

(Barnard 2003, Johns Hopkins Medicine 2010)

and can also conduct in-house surveillance in categories not identified by PHE. PHE provides training on SSI surveillance methodology for hospital surveillance staff, to equip them to conduct surveillance effectively while ensuring comparability of data. A protocol outlining SSI definitions and methodology is provided to all hospitals participating in surveillance to use as a guide or point of reference (PHE 2013c). At the end of each surveillance period, hospitals are able to generate their reports and identify their rates of SSI. Some surgical teams are able to reduce the hospital’s SSI rates by planning relatively simple and inexpensive interventions such as auditing the patient’s journey to identify any breaches in infection control or failure to comply with SSI guidelines (Adams-Howell et al 2011). A report including data from the 17 categories of surveillance identified by PHE is published each year. Named trust-level data for the four orthopaedic mandatory categories are reported publicly as an annex in the main report (PHE 2013b). Multidisciplinary teamwork is essential in preventing and managing SSI and in ensuring effective surveillance. The multidisciplinary team should include surgeons, anaesthetists, theatre managers, microbiologists, infection control nurses, audit and surveillance staff, istrative staff and ward staff. The roles in the team are different, ranging from co-ordination of the surveillance, data collection, clinical care, infection prevention advice, microbiological testing, reporting of results and advice on treatment. A cohesive

multidisciplinary team will analyse the reports and communicate results to all team , reviewing local policies and procedures to ensure patient safety is not compromised. Strong leadership, knowledge of SSI, effective communication and multidisciplinary working are essential for a successful surveillance programme and reduction of SSI. A champion who is well known, driven and respected is required to engage the main surgical staff (surgeons, anaesthetists, theatre managers and ward staff) to create and maintain a culture that makes SSI surveillance a priority and places patient safety first (Adams-Howell et al 2011). Complete time out activity 4

Treatment Most SSIs can be treated with antibiotic therapy; however, treatment should be discussed with the surgeon and microbiologist so that patients are prescribed an antibiotic that provides protection against the likely causative organisms. Local resistance patterns and the results of microbiological tests must also be considered when choosing an antibiotic to treat the infection. Patients with infections involving the deeper tissues may need to undergo further surgery to manage the infection. For example, surgical debridement or replacement of an infected prosthetic implant may be necessary (Smith et al 2013). Tissue viability specialist nurses can advise on types of dressings to be used to treat infected wounds and how frequently dressings should be changed. It is important to consider

4 Investigate whether the healthcare setting where you work collects information on SSI incidence. What, if any, methods of surveillance are used? Discuss with colleagues the importance of SSI audit and surveillance in the prevention and reduction of SSI.

D infection control factors that could promote wound healing, for instance the role of diet and exercise in recovery from surgery. Exercise helps to increase tissue perfusion, and oxygen plays a crucial role in the formation of collagen, the growth of new capillaries, and the control of infection (Whitney 1990).

Wound care

5 Suppose you are a nurse working on a gynaecology ward and have expressed concern to your manager about a number of women who have developed infections in their wounds following abdominal hysterectomies. Your manager suggests you set up a surveillance programme to monitor the situation. What considerations are important when planning a surveillance programme for SSI? Describe how you intend to use the results of the surveillance.

The evidence for optimal choice of dressing is based on chronic wounds and not surgical wounds. However, an interactive dressing is recommended for protecting surgical wounds (DH 2007). Interactive dressings create a moist wound environment and interact with the wound to enhance wound healing by reducing colonisation count and level of exudate, improving wound bed moisture retention, wound collagen matrix, and removing cellular products or providing protection for the new cells (Swezey 2010). NICE (2008) guidelines on the prevention and treatment of surgical site infection and the DH (2007) High Impact Intervention care bundle recommend dressings applied in theatre should remain in situ for at least 48 hours before removal, to prevent the entry of microorganisms and promote healing. Dressings should be removed before this time only if there is excessive leakage from the dressing. Nurses should ensure that any signs and symptoms of infection in patients are discussed with surgeons responsible for the care of these patients to ensure timely and appropriate treatment. Patients who are at high risk of developing SSI after surgery or those who develop serious infections should be referred to the tissue viability specialist for wound management.

Infection control measures

Hand decontamination is essential in reducing the risk of SSI both during surgery and when carrying out wound care. Dressings should be changed by nurses who have been trained and are competent in carrying out aseptic non-touch technique (ANTT). ANTT is a clinical practice framework for ensuring high standards of aseptic technique and has helped in reducing HCAIs (Rowley and Clare 2009). NICE (2008) recommends an aqueous antiseptic solution (povidone-iodine) for use by the surgical team for hand decontamination before surgery, while the Centers for Disease Control and Prevention (2002) recommend the use of an antimicrobial soap such as chlorhexidine or povidone-iodine,

which should be used for between two and six minutes. The World Health Organization (WHO) (2009a) recommends a suitable antimicrobial soap or alcohol-based hand rub be used before sterile gloves are worn. NICE (2008) suggests that patients’ skin should be prepared for surgery using an antiseptic that is an aqueous or alcohol-based preparation such as povidone-iodine or chlorhexidine. However, the DH (2007) High Impact Intervention care bundle recommends 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, and one study has shown that 2% chlorhexidine gluconate and 70% isopropyl alcohol solution is more effective in reducing microbial load (Hibbard 2005). If the patient has sensitivity to this solution, then povidone-iodine application should be used. Complete time out activity 5

Role of the nurse in preventing surgical site infection Nurses need to be knowledgeable about the cause, effect and management of SSI to ensure optimum patient outcomes following surgery. This can be obtained by reading literature on the topic, and working closely with the infection control and audit and surveillance teams. There is a range of guidance available to assist nurses in preventing SSI, including the High Impact Intervention care bundle (DH 2007), SSI quality standards (NICE 2013) and the WHO (2009b) Surgical Safety Checklist. NICE (2008) guidance for the prevention and management of SSI outlines three phases: preoperative, intra-operative and post-operative care (Box 1). The WHO (2009b) Surgical Safety Checklist is intended to be used as a tool by clinicians to improve safety during surgical operations, and reduce unnecessary deaths and complications. It has introduced organisational guidelines to reduce patient harm and decreased complications resulting from surgery. WHO (2009b) states that at least half-a-million deaths per year worldwide would be prevented with effective implementation of the checklist. The checklist covers tasks that should be carried out before induction of anaesthesia, before skin incision and before the patient leaves the operating theatre. It is important to ensure the checklist is not used as a tick-box exercise and that the actions are implemented. This can be achieved through educating staff

BOX 1 Preventing surgical site infections Pre-operative phase  Do not use hair removal routinely to reduce the risk of surgical site infection.  If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection.  Give antibiotic prophylaxis to patients before: – Clean surgery involving the placement of a prosthesis or implant. – Clean-contaminated surgery. – Contaminated surgery.  Do not use antibiotic prophylaxis routinely for clean, non-prosthetic, uncomplicated surgery.  Use the local antibiotic formulary and consider potential adverse effects when choosing specific antibiotics for prophylaxis.  Consider giving a single dose of antibiotic prophylaxis intravenously when commencing anaesthesia. Provide prophylaxis earlier for operations that involve a tourniquet. Intra-operative phase  Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation: povidone-iodine or chlorhexidine are most suitable.  Cover surgical incisions with an appropriate interactive dressing at the end of the operation. Post-operative phase  Refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings for the management of surgical wounds that are healing by secondary intention. (NICE 2008)

who are responsible for the care of patients undergoing surgery and by conducting audits to assess compliance. The DH (2007) High Impact Intervention for SSI aims to ensure appropriate and high-quality patient care is provided. It is designed to cycles of review and continuous improvement in surgical care settings. The care bundle is based on NICE (2008) guidelines for the prevention and treatment of SSIs, expert advice, and other international and national infection control best practice; it also s the implementation of the WHO (2009b) checklist.

Implementing quality standards

NICE (2013) has developed evidence-based quality statements for SSI. These statements contain seven main interventions, which hospitals should implement to reduce the

risk of SSI. Some of these statements can be nurse-led, for example statement 1, Personal preparation for surgery; statement 4, Minimisation of transfer of microorganisms by staff; statement 5, Patients’ and carers’ information and advice on wound care; and statement 7, Surveillance and of results. Statements 1 and 5 are based on providing patients and carers with information about what they could do to prepare for surgery and how to recognise problems with their wounds. Nurses should ensure patients and carers understand their role in prevention and early recognition of problems with their wounds and know what actions to take. Patients should be made aware pre-operative shaving should not be carried out; showering before surgery is important and that keeping warm before surgery will help to reduce the risk of developing SSI. Nurses have a responsibility to ensure all the standards are met. This can be achieved by conducting audits and providing to all involved in the care of patients undergoing surgery. There are other considerations that should be taken into to assist in reducing SSI, for example nutrition to encourage wound healing (Gherini et al 1993, Thompson and Fuhrman 2005). Nutrition has a crucial role in how fast the wound heals, how strong the wound tissue becomes, the duration of the recovery period and how well the body fights infection. Protein helps repair the damaged tissue and increase the wound tensile strength. Vitamins A, C and E and selenium act as scavengers to remove necrotic tissue and inactivate bacteria that occur in the inflammatory stage of wound healing. Vitamin C increases the strength of the wound as it heals, and it helps with the creation of collagen in the skin. Collagen is important in the creation of new blood vessels, and helps with iron absorption. Zinc helps the body synthesise proteins and develop collagen (Johnston 2007). It is important that surgical wounds are kept clean and special attention is paid to prevent wounds becoming contaminated with faecal matter or urine in patients who have difficulty maintaining continence. There is the potential for tissue damage and for the wound to become infected if there is contamination with urine or faeces (Gray 2007). Patients and carers should be provided with written information on wound care, how to recognise problems with the wound and who to if there are concerns regarding the wound following discharge from hospital (NICE 2013).

D infection control Conclusion

6 Now that you have completed the article, you might like to write a reflective . Guidelines to help you are on page 62.

The risk of developing an SSI depends on patient-related and environmental factors. Measures can be taken to minimise the risk of these infections occurring. However, some patients may still develop SSI, and for those patients, early detection through surveillance, of data to surgeons and appropriate treatment are crucial. Nurses have a pivotal role in preventing SSI and ensuring optimum patient outcomes by implementing evidence-based guidance, followed by audits to ensure compliance.

The implementation of the Surgical Safety Checklist, High Impact Intervention care bundle, NICE guidance on the prevention and treatment of SSI and NICE quality standards can help to prevent SSI, reduce length of recovery following surgery and save lives, if implemented correctly and consistently NS Complete time out activity 6 Acknowledgements The author wishes to thank colleagues Theresa Lamagni, Catherine Wloch and Suzanne Elgohari for their contributions to this article.

References

Adams-Howell P, Bhabra M, Enright M et al (2011) Under the Knife; Taking a Zero Tolerance Approach to Preventable Surgical Site Infections in UK Hospitals. inyurl.com/oavvyuj (Last accessed: July 14 2014.)

Andersson AE, Bergh I, Karlsson J, Nilsson K (2010) Patients’ experiences of acquiring a deep surgical site infection: an interview study. American Journal of Infection Control. 38, 9, 711-717.

Astagneau P, L’Hériteau F, Daniel F et al (2009) Reducing surgical site nfection incidence through a network: results from the French SO-RAISIN surveillance system. Journal of Hospital Infection. 72, 2, 127-134.

Barnard B (2003) Prevention of surgical site infections. Infection Control Today. 7, 4, 57-60.

Cahill JL, Shadbolt B, Scarvell JM, Smith PN (2008) Quality of life after infection in total t eplacement. Journal of Orthopaedic Surgery. 16, 1, 58-65.

Centers for Disease Control and Prevention (2002) Guideline for Hand Hygiene in Health-Care Settings. www.cdc.gov/mmwr/pdf/ r/rr5116.pdf (Last accessed: July 14 2014.)

Collier M (2004) Recognition and Management of Wound Infections. inyurl.com/fq698 (Last accessed: July 14 2014.)

Cutting KF, White RJ (2004) Defined and refined: criteria or identifying wound infection evisited. British Journal of Community Nursing. 9, 3, S6-S15.

Department of Health (2007) High Impact Intervention. Care Bundle to Prevent Surgical Site Infection. tinyurl.com/q27puny (Last accessed: July 14 2014.) Gastmeier P, Geffers C, Brandt C et al (2006) Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. The Journal of Hospital Infection. 64, 1, 16-22. Gherini S, Vaughn BK, Lombardi AV, Mallory TH (1993) Delayed wound healing and nutritional deficiencies after total hip arthroplasty. Clinical Orthopaedics and Related Research. 293, 188-195. Gray M (2007) Incontinence-related skin damage: essential knowledge. Ostomy Wound Management. 53, 12, 28-32. Haley RW, Culver DH, White JW et al (1985) The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. American Journal of Epidemiology. 121, 2, 182-205. Health Protection Agency (2012) HCAI and Antimicrobial Point Prevalence Survey – England. tinyurl.com/lvl4g7e (Last accessed: July 14 2014.) Hibbard J (2005) Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. Journal of Infusion Nursing. 28, 3, 194-207. Johns Hopkins Medicine (2010) Surgical Site Infection Prevention. tinyurl.com/qaauco2 (Last accessed: July 14 2014.)

Johnston E (2007) The Role of Nutrition in Tissue Viability. tinyurl. com/khpstxr (Last accessed: July 14 2014.) Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J (2010) Prosthetic t infection risk after TKA in the Medicare population. Clinical Orthopaedics and Related Research. 468, 1, 52-56. National Audit Office (2000) The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. Report by the Comptroller and Auditor General. The Stationery Office. London. National Institute for Health and Care Excellence (2008) Surgical Site Infection: Prevention and Treatment of Surgical Site Infection. Clinical guideline No. 74. NICE, London. National Institute for Health and Care Excellence (2013) QS49 Surgical Site Infection. List of Quality Statements. tinyurl.com/qhem69k (Last accessed: July 14 2014.) Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J (2009) Prosthetic t infection risk after total hip arthroplasty in the Medicare population. Journal of Arthroplasty. 24, 6 Suppl, 105-109. Public Health England (2013a) Protocol for the Surveillance of Surgical Site Infection. PHE, London. Public Health England (2013b) Surveillance of Surgical Site Infections in NHS Hospitals in England 2012/13. PHE, London. Public Health England (2013c) Monitoring Surgical Wounds for

Infection: Information for Patients. PHE, London. Rowley S, Clare S (2009) Improving standards of aseptic practice through an ANTT trust-wide implementation process: a matter of prioritisation and care. Journal of Infection Prevention. 10, 1 Suppl, S18-S23. Smith F, Dryburgh N, Donaldson J, Mitchell M (2013) Debridement for surgical wounds. Cochrane Database of Systematic Reviews. Issue 9, CD006214. Swezey L (2010) Interactive Wound Dressings. tinyurl.com/q4d4puc (Last accessed: July 14 2014.) Thompson C, Fuhrman MP (2005) Nutrients and wound healing: still searching for the magic bullet. Nutrition in Clinical Practice. 20, 3, 331-347. University of Ottawa (2013) Routes for Spread of Infectious Diseases. tinyurl.com/7zqujxe (Last accessed: July 14 2014.) Whitney JD (1990) The influence for tissue oxygen and perfusion on wound healing. AACN Clinical Issues in Critical Care Nursing. 1, 3, 578-584. World Health Organization (2009a) WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge. Clean Care Is Safer Care. tinyurl.com/ybwu8b5 (Last accessed: July 14 2014.) World Health Organization (2009b) WHO Surgical Safety Checklist and Implementation Manual. tinyurl. com/7swy88x (Last accessed: July 14 2014.)

Copyright of Nursing Standard is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, s may print, , or email articles for individual use.