Surgical Site Infection and the Operating Room Checklist - Safer ...

PREVENTION OF SURGICAL 

SITE INFECTION 

Refueling Your Quality Engine 

Winnipeg 

March 3 & 4, 2011

Risk Factors for SSI 

Patient Operation Post-op care 

Age Antimicrobial prophylaxis p Wound care 

Nutritional status 

Blood Glucose 

Discharge 

Diabetes 

Smoking 

Obesity 

Steroid use 

Normothermia 

Hair Removal 

Antiseptic technique 

Surgical technique 

Prolonged pre-op LOS Wound classification 

Length of surgery 

Blood transfusion 

OR Ventilation 

Traffic Control

Prophylactic Antibiotics

Appropriate Use Of Antibiotics 

• The right drug 

• The right dose 

• At the right time* 

• For the right duration 

Performance e measure (target): 

• % surgical patients given pre-op ABx within 60 min* 

(Goal ≥ 95% ) 

• % surgical patients having ABx , discontinued within 

24 hrs ( Goal ≥ 95% )

Duration Concerns 

• There is a lack of evidence that antibiotics given 

after the end of the operation prevent SSIs. 

• There is evidence that unnecessary or prolonged 

use of antibiotics promotes antibiotic resistance 1 

1. Bratzler & Houck. Clinical infectious Diseases 2004; 38: 1706-15

SHN! Recommendation 1 

• Based on the evidence, the Safer Healthcare Now! faculty 

recommend that prophylactic antibiotics be completely 

absorbed within 60 minutes of first incision, and should 

be repeated for surgeries lasting longer than the half-life life 

of the antibiotic (4 hours for cephalosporins). 

• Antibiotics administered for cardiac, thoracic, 

orthopaedic and vascular patients should be discontinued 

within 24 hours of the end of surgery, whereas noncomplex 

and uncomplicated surgeries require no further 

administration of antibiotics following surgery. 

1. Safer Healthcare Now! Getting Started Kit: Surgical Site Infection Prevention, March 2010

Prophylaxis Dosing 

• Consider the upper range of doses for large 

patients 

- Gastroplasty: SSI rates 16.5% vs 5.6% 1 

• Repeat doses for long operations (> 4 hours) 

- Cardiac surgery: SSI rates 16% vs 7% 2 

1 

Forse, R; Karam, B; Maclean, D; Cristou, N. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery, 1989, 106: 750-7 

2 

Zanetti et al., Emerg Infect Dis, 2001

Weight Based Dosing in Canada: 

Evidence into Practice 

Healthcare Facility Cefazolin Vancomycin 

Fraser Health Authority, Vancouver, 

British Columbia 

Edmonton and Area Acute Care 

Facilities, Alberta Health Services, 

Alberta 

Grace Hospital, Winnipeg Regional 

Health Authority, Winnipeg, 

Manitoba 

University Health Network, Toronto, 

Ontario 

North York General Hospital, 

Toronto, Ontario 

Sunnybrook Health Sciences, 

Toronto, Ontario 

1g IV if ≤80kg 

2g IV if >80kg 


2g IV >100kg 

1g IV if 80kg 


2g IV >100kg 

Not Available 

Not Available

SHN! Recommendation 

• Based on the evidence, SHN Faculty recommends that 

prophylactic antibiotic administration be started and 

completed within 60 min. of first incision for 

c-sections instead of after cord-clamping. clamping 

• Faculty recommend that prophylactic antibiotic 

• Faculty recommend that prophylactic antibiotic 

infusion be started and completed within 60 min. (120 

min. for Vancomycin) prior to application of 

tourniquet to maximize antibiotic efficacy.

Change Ideas 

Use pre-printed printed or computerized standing orders specifying choice of antibiotic, 

dose, timing, and discontinuation. 

Change operating room drug stocks to include only standard doses and 

standard drugs, reflecting locally agreed upon guidelines. 

Incoporate pre-mixed antibiotics for use by OR staff. 

Reassign antibiotic administration responsibilities to anesthesia or holding area 

nurse to improve timeliness. 

I t th f th i l f t h kli t th t “A tibi ti b b d” 

Incorporate the use of the surgical safety checklist so that “Antibiotic absorbed” 

is addressed in the time out.

Hair Removal


• Based on the evidence, the Safer Healthcare Now! SSI 

faculty recommend that patients be educated d not to 

shave in the vicinity of the incision for one week 

preoperatively. 

• No hair removal prior to surgery is optimal. 

• If hair removal is necessary, clippers should be used 

outside of the OR and within 2 hours of surgery. 

• Do not use razors in the vicinity of the surgical area. 

• Patients should shower after clipping due to increased risk 

of bacterial contamination of the surgical site. 


Change Ideas 

• Develop a letter for surgeon’s offices to provide to 

their patients that includes a reminder about not 

shaving for one week prior to surgery 

I di t th t th li i f h i ill b d i 

• Indicate that the clipping of any hair will be done in 

the hospital on the day of surgery

Perioperative Normothermia

Consequences of Mild Hypothermia 

• Increases duration of hospitalization 

• Increases intra-operative blood loss 

• Increases adverse cardiac event 

• Increases patient shivering in PACU 

• Promotes metabolic acidosis 

• Increases SSI rates 1 

1. Melling et al. 2001 Lancet, 358: 876-80


• Based on the evidence, the Safer 

Healthcare Now! SSI faculty recommend 

that measures are taken to ensure that 

surgical patient core temperature 

remain between 36.0⁰C and 38⁰C 

preoperatively, intraoperatively, and in 

PACU. 


Change Ideas 

• Pre operative warming utilizing forced warm air blankets 

for 30+ min pre-op 

• Continue active warming in the OR (include warmed IV 

fluid and lavage for abd. cases) 

• Increase the ambient temperature in the operating room 

to 20⁰C 

• Hats and booties on patients during surgery 

• PACU warming to discharge as needed 

• Do this routinely on all procedures slated 60 min. +

Blood Glucose Control

Recent Research 

• Strict t vs. conventional blood glucose control 

• 2009 consensus statement on glycemic control from 

• 2009 consensus statement on glycemic control from 

American Association of Clinical Endocrinologists and 

American Diabetes Association report BG should be 

maintained between 7.8 and 10 mmol/L for most 

critically ill patients


• Basedontheevidence evidence, TheSafer 

Healthcare Now! SSI faculty recommend 

that preoperative blood glucose levels be 

checked on all surgical patients. Teams 

are encouraged to apply glucose control 

to surgical populations as directed by 

your local organization. 


Change Ideas 

• Pre-op blood sugar analysis to pick up on undiagnosed 

diabetics 

• Referral to endocrinology or initiate treatment prior to 

slated date

Skin Prep 

Prevention Strategies and Skin Antisepsis

The Ideal Skin Antimicrobial 

• The “ideal” antimicrobial agent for skin should 

have the following properties: 

- Broad spectrum 

- Rapid bactericidal activity 

- Persistence or residual properties on the skin 

- Effective in the presence of organic matter 

- Non-irritating or have low allergic and/or toxic responses 

- None or minimal systemic absorption

Current Approaches: Prevention of SSIs 

Multiple studies have shown that CHG and CHG/alcohol 

solutions display these important properties: 

•CHG plus 70% isopropyl alcohol (IPA) has demonstrated 

efficacy against a wide range of bacteria, including P. 

aeruginosa, S. aureus, and antibiotic-resistant bacteria. 

•CHG/IPA exhibits a rapid onset of action, persists for up to 

24 hours, and has increased efficacy with repeated 

applications. 

•Chlorhexidine is not inactivated in the presence of blood, 

which neutralizes the effects of iodine and PCMX and dilutes 

the effects of alcohol. 

Florman et al. Current Approaches for the Prevention of SSIs. Am J Infect Dis. 3(1):51-61, 2007.

Safety 

• CHG 2%/70% IPA solution is flammable 

• CHG-alcohol skin prep solution should not be used 

around eyes, ears, and mouth, or come in direct 

contact with neural tissue


• Based on the evidence, the Safer Healthcare Now! SSI faculty 

recommends that the skin should be cleansed before surgery 

with a chorhexidine–based solution, preferably with no rinse 

disposable chlorhexidine gluconate impregnated wash cloths. 

• The antiseptic of choice for skin prep should be alcohol based 

chlorhexidine antiseptic solutions instead of povidone-iodine. 

• Following application of chlorhexidine-alcohol skin prep 

solution, surgical teams should complete the time out of the 

surgical checklist to allow time for the skin prep to dry. 



• To maximize its efficacy, CHG-alcohol skin prep should not be 

washed off for at least 6 hours following surgery. 

• In order to prevent a fire hazard, It is imperative that CHG- 

alcohol lskin prep be allowed to air dry for at least 3 minutes, or 

longer if there is excessive hair insitu. 

• Povidone-iodine should be used as a skin preparation in 

emergent cases where there is not enough time to allow CHG- 

alcohol solution to completely dry before incision. 

• Chlorhexidine-based solutions must not be used for procedures 

involving the ear, eye, mouth or neural tissue. 


• http://www.youtube.com/watch?v=4IG8ItaTTzY

Surgical Site Infection and the Operating Room Checklist - Safer ...

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