The purpose of this video is to provide general information and education about the care of
a critically ill child.
It is in no way a substitute for the independent decision-making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis, or to overrule
the advice of a qualified health care provider, nor should it be used to provide advice for
emergency medical treatment.
Prevention of Surgical Site infections, by Deb Morrow Hi, I'm Deb Morrow, a Staff Nurse
III and the Infection Prevention Coordinator for the Cardiovascular Intensive Care Unit
at Children's Hospital Boston.
Today I'd like to share with you some strategies that we have implemented a Children's Hospital
for preventing surgical site infections.
Epidemiology.
The prevalence of surgical site infections varies by country and type of surgery.
In the United States, surgical site infections account for about 31% of all healthcare associated
infections.
Surgical site infections lead to an average increase in length of hospital stay of four
to seven days.
Infected patients are twice as likely to die, twice as likely to spend time in an intensive
care unit, and five times more likely to be readmitted after discharge.
Health care costs increase substantially for patients with surgical site infections.
Surgical site infections are preventable.
Pathogenesis.
During the surgical procedure, microbial contamination can lead to surgical site infections.
Sources of microbial contamination include the patient's own flora from skin, mucous
membranes, or hollow viscera.
Seeding from a distant focus of infection, especially when an implanted foreign body
is present.
And other external sources, such as hands of surgical personnel, the operating room
environment, and contaminated instruments and equipment.
The patient's own bacterial flora is the most common source of pathogens that cause surgical
site infection.
Most surgical wounds are contaminated with bacteria, but only a few will progress to
infection.
Three important factors that determine whether microbial contamination of incision will lead
to surgical site infection are the dose of bacterial contamination, the ability of the
bacteria to invade tissue and cause infection, and the ability of the patient to fight infection.
There are three classifications of surgical site infection as defined by the United States
Centers for Disease Control and Prevention.
Superficial incisional involves only the skin or subcutaneous tissues of incision, and occurs
within 30 days of the procedure.
Deep incisional involves the fascia and/or muscle layers.
And organ space infection involves any part of the anatomy, other than the incision, that
was opened or manipulated during the operation.
For example, the mediastinum.
Deep incisional and organ space infections are considered hospital-acquired if they occur
within 90 days of the procedure.
Risk Factors.
A recently published study from Children's Hospital Boston identified the risk factors
for surgical site infection in pediatric cardiac patients.
These are: a patient less than one year of age and cardiopulmonary bypass time greater
than 105 minutes.
In addition to these risk factors, risk factors for an organ space infection also include
a greater than three post-operative blood transfusions, pre-operative hospitalization,
and an aortic cross clamp time greater than 85 minutes.
Surgical Site Infection Prevention Bundle.
The four components of our surgical site infection prevention bundle for pediatric cardiac patients
include: hand hygiene-- which is the cornerstone of any infection prevention initiative-- appropriate
hair removal, appropriate use of prophylactic antibiotics, and post-operative wound management.
Other practices that are recommended by the World Health Organization address pre-operative
showering and intra-operative skin disinfection.
Before a patient's skin is prepared for a surgical procedure, dirt, soil, or any other
debris should be removed.
Pre-operative showering may decrease the bacterial counts and assure that the skin is clean.
At Children's Hospital Boston, patients receive a chlorhexidine bath the night before and
the morning of cardiac surgery.
Pre-operative hair removal should not occur unless the presence of hair at the operative
site will interfere with the operation.
If hair removal is necessary, remove by clipping immediately prior to surgery, outside of the
operating room.
Do not use razors.
Microscopic cuts caused by razors may serve as a location for bacterial growth.
Several antiseptic agents are available for intra-operative skin preparation, and any
of these is considered an appropriate choice if used correctly.
These are alcohols, iodophors such as povidone-iodine, and chlorhexidine gluconate.
There are limited high-quality controlled studies to compare the impact of different
agents on surgical site infection risk, for a given operation.
Alcohol is inexpensive, rapid, and results in the greatest reduction in skin flora.
However, it is highly flammable.
Iodophors exert an effect while they are present on skin.
But there must be a two-minute contact time to allow for the release of free iodine.
Iodophors have no effect when they are wiped off the skin, and they are inactivated by
blood or serum proteins.
Chlorhexidine achieves greater reductions in skin flora than povidone-iodine, and has
residual activity on the skin, which can last for 48 hours.
It is not inactivated by serum proteins.
And most formulations of chlorhexidine skin prep contain 70% alcohol, which also poses
a flammability risk.
There are important points to remember for any agent that you use.
The application technique must be correct.
There must be sufficient contact time for the disinfecting agent.
High-colonization areas-- for example, the umbilicus, axilla, perineal area-- need extra
attention.
And the agent should be allowed to dry, prior to draping.
At Children's Hospital Boston, the skin prep in the operating room is done by the operating
room nurse.
Our hospital is a large teaching institution, so this assures that the scrub will be done
the correct way, every time.
The use of intra-operative antibiotics will not sterilize tissues.
But the antibiotic will reduce bacterial contamination to a level that cannot overwhelm the body's
defenses.
The use of intra-operative antibiotic prophylaxis pertains to elective operations, in which
the skin is closed in the operating room.
It does not pertain to preventing surgical site infections caused by post-operative contamination,
such as delayed sternal closures in cardiac patients.
In 2005, the National Surgical Infection Prevention Project recommended that the infusion of the
first antimicrobial dose be 60 minutes before the time of incision.
Infusion of fluoroquinolones or vancomycin should be 120 minutes before the time of incision.
Additionally, for pediatric cardiac surgery at Children's Hospital Boston, a dose of cefazolin
is administered at the start of bypass and at the conclusion of bypass.
Maintenance cefazolin is started eight hours after this last dose.
In our primary closure patients, postoperative antibiotic prohylaxis is discontinued at 48
hours from the first intraoperative dose or when chest tubes discontinued, whichever happens
first.
Many programs are considering discontinuing post operative prophylaxis at 24 hours Post-operative
wound management is an important component of the bundle.
We use a permeable dressing that allows for gas exchange, but does not allow microorganisms
to contaminate the wound.
Gauze and tape dressings are also acceptable.
We keep the initial dressing in place for 48 hours after surgery to promote healing.
Nurses and doctors should perform hand hygiene, and then wear sterile or clean gloves to lift
the dressing for wound examination.
We use occlusive dressings on all chest tubes, pacing wires, and intracardiac lines.
We continue to protect the surgical incision from endotracheal secretions, ventilator condensate,
sputum, and emesis in the post-operative period, by the use of a dry, sterile dressing after
the initial dressing is changed at 48 hours.
At Children's Hospital Boston, we perform a sterile echo on patients in the post-operative
period within five days of surgery, or if there is still any indwelling catheters in
place on the chest.
The echo probe is covered with a sterile sleeve, and we use a sterile gel-- such as a sterile
ultrasound gel-- to perform the echocardiogram.
Delayed sternal closure is used in cases where there may be edema, or when the patient is
unstable coming off of bypass.
The chest opening is covered with a sterile occlusive dressing.
The nurse should maintain patency of the chest tubes and monitor the patient for tamponade
by assessing the level of the patch over the sternal opening.
Patients are kept normothermic, or slightly cooler.
The patient should be monitored for infection, and antibiotics broadened if symptoms of infection
occur.
The chest is closed when the patient is stable, or body wall edema has decreased.
Conclusion.
Evidence-based practices can reduce surgical site infection rates.
These practices include-- appropriate antibiotic use, appropriate skin antisepsis, no hair
removal or hair removal with clippers, and appropriate wound management.
Hospitals should establish policies for the management of surgical sites.
They should educate doctors and nurses on surgical site infection prevention and initiate
communication training, which will help staff to speak up when policy is not followed.
That concludes our video on prevention of surgical site infections.
Thank you.
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