AORN Journal
Volume 86, Issue 5 , Pages 801-814, November 2007

Surgical Site Infection: The Host Factor

  • Donald E. Fry, MD

      Affiliations

    • Donald E. Fry, MD, is the executive vice president of Michael Pine and Associates consulting firm, Chicago, IL. Dr Fry has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Rosemary V. Fry, RN, BSN, CNOR

      Affiliations

    • Rosemary V. Fry, RN, BSN, CNOR, is a retired OR nurse from Chicago, IL. Ms Fry has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

Article Outline

ABSTRACT 

MORE THAN 30 MILLION surgical procedures are performed annually in the United States, and surgical site infections (SSIs) remain a major postoperative complication.

ALTHOUGH BACTERIA contaminate all surgical wounds, not all wounds become infected. In most cases, the host response eradicates the microbes. The patient's (ie, host's) responsiveness, therefore, is an important variable in the equation of factors that influence the rate of infection.

OPTIMIZING THE PATIENT'S PHYSIOLOGICAL condition can help prevent SSIs. Initiatives that show promise in reducing SSI rates include use of supplemental oxygen, maintenance of core body temperature, and rigorous management of blood sugar. Perioperative nurses play an important role as the patient's infection control advocate. AORN J 86 (November 2007) 801–810.

 

It is estimated that in 2006 more than 30 million surgical procedures were performed in the United States.1 According to the most recent National Nosocomial Infections Surveillance (NNIS) data, infection will have occurred at the surgical site in 2.6% of those surgical procedures.2 It is likely that these statistics are underestimated, however, because surgical site infection (SSI) surveillance techniques are not capable of capturing all infections that occur, particularly because the majority of SSIs are not identified until after the patient has been discharged.

An SSI is an unexpected event that complicates a patient's postoperative course and adversely affects patient outcomes. An SSI causes the patient pain, misery, and possible deformity. Furthermore, an SSI may require the patient to undergo additional surgical procedures or could result in the patient's death.

Surgical site infections are recognized by the public and lay media as a major medical problem because articles and television exposés about medication errors, multidrug-resistant Staphylococcus aureus (S aureus) infections in hospitalized patients, wrong site surgery, and SSIs frequently are present in the public media. Public and government agencies, such as the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services have made decreasing the rate of SSIs a goal for improvement.3, 4 Pay-for-performance initiatives for surgeons use SSI rates as a performance measure,5 and public reports of surgical outcomes in hospitals place rates of SSIs at the top of the list of areas for improvement.6

The National Surgical Infection Prevention (SIP) Project established reduction of potential SSIs by 40% to 60% as its objective,7 primarily focusing on preventive antibiotic use in surgical patients.8 The SIP now has transitioned into the Surgical Care Improvement Project (SCIP), which has a goal of reducing the incidence of surgical complications 25% nationally by the year 2010; SSIs still are a major focus of interest.9 Table 1 lists the infection measures that the SCIP has identified.

Table 1. Surgical Care Improvement Project (SCIP) Infection Control Measures1
SCIP Inf #1—Prophylactic antibiotics should be received within one hour before the surgical incision.

SCIP Inf #2—Prophylactic antibiotic selection should be appropriate and specific for surgical patients.

SCIP Inf #3—Prophylactic antibiotics should be discontinued within 24 hours after surgery end time (48 hours for cardiac patients).

SCIP Inf #4—Cardiac surgery patients should have a controlled 6 AM postoperative serum glucose (ie, less than or equal to 200 mg/dL).

SCIP Inf #5—Postoperative wound infection should be diagnosed during the index hospitalization.

SCIP Inf #6—Surgery patients should undergo appropriate hair removal, when necessary.

SCIP Inf #7—Colorectal surgery patients should have immediate postoperative normothermia.

1 Surgical Care Improvement Project: infections. MedQic. http://www.medqic.org/dcs/ContentServer?cid=1089815967030&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents. Accessed September 10, 2007.

The federal government also has become involved in the issue of SSIs.10 The Deficit Reduction Act of 2005 requires that specific national hospital inpatient performance measures be reported for Medicare patients, and hospitals face economic penalties for noncompliance.10 For surgery, the use of antibiotics for the prevention of SSIs is a top priority. The Deficit Reduction Act also instructs the Secretary of Health and Human Services to begin phasing out payment increases associated with complications of care. Economic sanctions are expected to improve clinical outcomes of care and reduce the frequency of SSIs.10

Discussion of SSIs has focused on the failure of physicians, nurses, and hospitals to perform in a fashion that should yield ideal results. The reality is that SSIs are the consequence of a multitude of variables. This article discusses the causative factors of SSIs and identifies the clinical variables of the patient (ie, host factor) that affect SSI rates. Although specific elements of host responsiveness will not be discussed in detail, host responsiveness in the context of this discussion will refer to the general presence of inflammation, phagocytic responses, and the specific immunologic responses (eg, antibody production) that enable humans to avoid infection from the environment. New directions in SSI prevention are presented and methods describing how perioperative nurses must be active participants in these processes are discussed.

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Predictors of SSIs 

Intact skin is the patient's first line of defense against bacterial invasion. A surgical incision is an intentional breech of this defense mechanism, after which the surgical wound can be contaminated by bacteria from multiple sources. Contamination may come from normal colonization of the patient's skin or may enter the wound via “fall out” from dispersed bacteria in the air of the OR,11 which is the rationale for using specialized air handling and laminar flow systems to reduce potential contamination.

Surgical entry into areas with heavy colonization (eg, the colon, the female genital tract) may result in wound contamination from endogenous microorganisms that reside within the patient. Infection virtually never occurs at the surgical site from bloodborne bacteria from remote sources.12 Typically, bacteria responsible for SSIs are introduced into the wound at the time of the surgical procedure; however, infection may not be evident for many days or even weeks after the surgical procedure.

The multitude of different sources of bacteria that contaminate the wound can lead to a few fundamental conclusions. First, all surgical wounds are contaminated by bacteria, but only a small minority of surgical wounds actually become infected.13 A cultured biopsy of the surgical wound at the end of the procedure will document that bacteria are present. Second, different surgical procedures have different numbers of bacteria that may contaminate the wound; increased numbers of bacteria within the wound will result in increased infection rates. Third, the same surgical procedure performed by the same surgeon with the same degree of contamination in different patient populations can result in different rates of infection. The patient's (ie, host's) responsiveness, therefore, is an important variable in the equation of factors that influence the rate of infection. The three major variables associated with SSIs are illustrated in Figure 1.

  • View full-size image.
  • Figure 1. 

    Surgical site infections occur because of multiple factors: bacterial inoculum, which may come from a variety of sources; virulence of the bacteria that may contaminate the wound, which varies from patient to patient; and the conditions of the microenvironment of the wound, which is affected by hemostasis, electrosurgery, silk sutures, and dead space in the wound. All of these factors may result in infection in a patient, but the absence of these variables may lead to an uneventful recovery.

The inoculum 

The bacterial inoculum (ie, the quantity of bacteria that contaminate the wound during the surgical procedure) is the variable most used and of greatest concern in the prediction of SSIs. Clean surgical procedures (eg, thyroidectomy, inguinal herniorrhaphy) have low SSI rates because the patient's skin is the likely source of contamination. Staphylococcus from the skin is the major pathogen, but with appropriate antiseptic preparation of the surgical site, infection in these clean procedures should be low (ie, 1%).14 During clean-contaminated surgical procedures, a normally colonized visceral structure is surgically entered under controlled circumstances. Colonic resection and hysterectomy are examples in which the human colon or the female genital tract, respectively, are entered, and significant contamination of the surgical site may occur as a result. The microbiology of these clean-contaminated procedures reflects the aerobic and anaerobic colonists of the anatomic structure.

The virulence factors 

A second important variable is the virulence of the bacterial contaminant. Different bacteria have a varied propensities to cause infection. Staphylococcus aureus has more virulent factors (eg, coagulase) than does Staphylococcus epidermidis (S epidermidis). So although S epidermidis may be a more common contaminant of the surgical wound, it is infrequently the pathogen of infection. Resistance to antibiotics, another virulence factor, is becoming more problematic in SSIs. Methicillin-resistant S aureus (MRSA) has become a more common pathogen in SSIs because of its resistance to common antibiotics used for prophylaxis. The newly recognized community-associated MRSA has both antibiotic resistance and an equally potent exotoxin (ie, Panton-Valentine leukocidin) that gives it a particularly important role as an emerging pathogen of the surgical site.15

The microenvironment of the wound 

A third variable that permits infection is the microenvironment of the surgical wound itself. Hemoglobin from red cells and hematoma (ie, clot) within the wound is a rich source of iron, which promotes rapid bacterial replication and results in enhanced virulence. Devitalized tissue from surgical trauma and necrotic tissue from electrosurgery become havens for bacterial proliferation. Foreign bodies such as silk sutures increase the probability that a given contaminant will cause infection. Plasma and body fluids accumulate in dead space within the wound, and the bacterial contaminants within this accumulated fluid increase the likelihood of infection.

Thus, were it not for an effective host defense system, the interactive and collective effects of the

•inoculum,

•virulence factors, and

•microenvironment of the wound

would result in virtually all surgical sites being infected. As the host response is negatively affected by systemic factors, these pro-infection variables will have an increased effect on infection rates.

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The Host 

The innate host response is an important factor in the equation that produces an SSI. Within limits, the host responsiveness can eradicate bacterial contaminants in the surgical wound and maintain infection rates at very low levels. When host responsiveness is compromised, SSIs occur more frequently. Host responsiveness is affected by both genetic and acquired factors. Genetic variability dictates a baseline of efficiency and effectiveness in response to potential pathogens from the environment. This genetic variation means that some people are genetically less prone to infection than others. Measurement of genetically programmed host responses has been elusive, and it remains unclear what quantitative effect this actually has on SSIs and other infection rates in surgical patients.

Acquired impairment of host responsiveness appears to be a more commonly studied issue in regard to SSIs. Figure 2 details many of the variables that adversely affect the host. Some of the variables are naturally occurring events (eg, aging), others are a result of acute physiologic events (eg, hypoglycemia), while still others actually relate to treatments administered to patients (eg, transfusion, corticosteroid treatments).

  • View full-size image.
  • Figure 2. 

    The host defense system is a complex combination of innate and adaptive responses that prevent infection from occurring with every surgical procedure that the host experiences. Many acute physiologic changes can be managed during the preoperative, intraoperative, and postoperative periods so that infection can be prevented. Chronic medical conditions also affect the host's defenses and increase the likelihood that the patient will incur a surgical infection.

Recent studies have focused on the role of these clinical variables on SSI rates. Dunne et al16 studied nearly 500 patients undergoing abdominal wall hernia repair. The researchers found that SSIs occurred in 4.3% of patients. Risk factors associated with increased infection rates were

•surgical time longer than four hours,

•chronic pulmonary disease, and

•decreased preoperative serum albumin concentration.

It is interesting to note that the researchers found that increasing age was not an associated factor.

Imperatori et al17 studied nearly 1,000 patients undergoing open lung resection. Infection at the surgical site, of the lung itself, or both occurred in 14% of patients. The researches identified the following risk factors:

•surgical procedures lasting more than three hours;

•patient age greater than 70 years;

•serum albumin less than 3.5 g/dL; and

•existence of medical comorbidities (eg, diabetes, chronic obstructive pulmonary disease).

Schwartz et al18 studied more than 2,000 patients undergoing laryngectomy. Researchers observed an overall SSI rate of 10%. Identified risk factors included

•prolonged surgical time (ie, greater than 10 hours);

•prior radiation of the surgical site;

•diabetes;

•hypoalbuminemia;

•anemia; and

•thrombocytosis.

Cardiac surgical procedures have been of particular interest in regard to the host factor in SSIs. Harrington et al19 studied more than 4,000 patients undergoing coronary artery bypass grafting and found an overall SSI rate of 7.8%. Increasing age, diabetes, and obesity were significant variables associated with infection.

Banbury et al20 studied more than 15,000 cardiovascular surgery patients at the Cleveland Clinic, Ohio. They reported infection rates by severity criteria:

•superficial infection occurred in 2.3% of patients,

•deep infection in 1.4%, and

•septic/bacteremic infection in 2.2%.

They identified blood transfusions, obesity, chronic obstructive pulmonary disease (COPD), and diabetes as risk factors.

De Oliverra et al21 studied more than 600 patients undergoing surgical procedures of the digestive tract. The researchers found that 22% of the patients acquired an infection. Using logistic regression analysis, the researchers determined that obesity and long procedures had the greatest odds ratios for predicting infection.

Kaye et al22 evaluated more than 500 surgical procedures in patients older than 65 years. The researchers determined that obesity and COPD were significant variables. Undergoing a clean-contaminated or contaminated procedure also was significant. The researchers noted that the socioeconomic variable of not having private insurance also was associated with SSIs.

Different surgical procedures studied by various investigators among varied populations of patients resulted in different host variables being implicated in SSI. The uncertainty of variables may result from the fact that no standard type of variable has been examined in each of the studies. The results of these studies indicate that acquired host variables affect host responsiveness, but no consensus exists about which variables have the greatest influence.

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Augmentation of the Host 

Prevention of SSIs has largely focused on methods to reduce variable bacteria in the wound at the completion of the procedure. Antiseptic preparation of the surgical site and use of preventive systemic antibiotics are examples of strategies commonly employed for this purpose. The question remains whether other strategies (eg, nutritional management to avoid hypoalbuminemia, avoiding hypothermia, maintaining blood glucose levels within normal limits) can be applied to improve host responsiveness in the surgical patient.

Hypoalbuminemia 

Hypoalbuminemia is a surrogate marker for protein malnutrition and can indicate that nutritional management should be implemented before the surgical procedure, if practical.23 Reduced use of transfusions and greater use of autologous blood donation before selected procedures would seem to have some utility.24 Even immune modulation has been explored with medication administration to enhance the host's immune system, especially in emergency surgical situations,25, 26 but none of these treatment options have been accepted as routine clinical practice.

Tissue oxygenation 

In recent years, renewed attention has focused on optimizing the patient's physiology to enhance the host's resistance to SSIs. Tissue oxygen availability has experimentally been shown to enhance the host's resistance to SSIs and may do so by improving the bacteriocidal function of human phagocytic cells.27 Several studies have investigated providing supplemental oxygen to increase intraoperative and early postoperative inspired oxygen concentration in an effort to improve SSI rates. Greif et al28 and Belda et al29 demonstrated reduced SSIs in elective colorectal surgery by using a fraction of inspired oxygen (ie, FiO2) of 0.8 compared to 0.3. Pryor et al,30 however, studied major intra-abdominal surgery with an FiO2 of 0.8 compared to 0.35 and demonstrated an increased infection rate with oxygen supplementation. Although a strong intellectual case can be made for use of supplemental oxygenation, evidence indicating that it decreases SSIs is not conclusive at this point, and additional studies are needed to validate the use of supplemental oxygen to achieve a reduction in SSIs.

Hypothermia 

Passive hypothermia is a known problem for patients undergoing surgical procedures of the major body cavities. Core body temperature plays a role in the vigor of phagocytic cell function. Kurz et al31 studied whether maintenance of core body temperature at or above 36.5° C (97.7° F) would improve SSI rates in patients undergoing elective colon surgery compared with patients whose core temperatures were allowed to drop as low as 34.5° C (94.1° F). Maintaining higher temperatures reduced the incidence of SSIs from 19% to 6%.

Hyperglycemia and hypoglycemia 

Elevated blood sugar concentration impaired the function of phagocytic cells in experimental studies.32 Furnary et al33 demonstrated significant reduction in sternal SSI rates in diabetic patients undergoing open heart surgery by maintaining intraoperative blood sugar at less than 200 mg/dL. Zerr et al34 showed that infection rates in cardiac surgery proportionally declined as blood sugar concentrations were reduced from 300 mg/dL to 100 mg/dL. Van den Berghe et al35 identified reduction in septic deaths among postoperative patients when blood sugar was maintained between 80 mg/dL and 110 mg/dL. Hypoglycemia also is thought to impair phagocytic cell function. Intraoperative and postoperative blood sugar control remains a logistical problem. Furthermore, the ideal blood sugar level remains undefined. It generally is agreed that maintaining euglycemia (ie, normal blood glucose concentration) for the patient is desirable.32, 33, 34, 35 Future developments in real-time, on-line measurement of blood glucose will allow this conundrum to be resolved.

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The Ever-Changing Role of Perioperative Nurses 

Perioperative nursing activities in caring for surgical patients can increase the host's resistance to SSIs. Nurses in the preoperative holding area, OR, and postanesthesia care unit must deal with important infection control responsibilities. In addition to traditional roles, perioperative nurses often play the role of infection control officer.

In preoperative holding, nurses are responsible for coordinating preoperative antibiotic administration. Antibiotics should be administered between 30 minutes and one hour before incision depending on the type of prophylactic medication used.36 This may occur in the preoperative holding area, or the medications may be transported with the patient and administered enroute to the OR in an effort to avoid the problem of the antibiotics being initiated in preoperative holding only to have an unanticipated delay in the procedure result in the administration having been premature.

In the preoperative holding area and the OR, appropriate methods for hair removal and preparation of the surgical site commonly are the nurses' responsibility.37 Hair should be left at the surgical site whenever possible. If it is determined that hair should be removed, only personnel skilled in hair removal techniques should perform the removal. The hair should be removed as close to the time of surgery as possible, except when a depilatory is used, and should be performed in a manner that preserves skin integrity. The hair removal process should be performed in an area outside of the room where the procedure will be performed. If possible, an electric or battery-powered clipper with a disposable or reusable head that can be disinfected between uses should be used. Razors can disrupt skin integrity so hair removal with a razor is not recommended.

When indicated, the surgical site and surrounding area should be prepared with an antiseptic solution.37 Performing the surgical skin preparation can become a casual routine, but it must be performed with thoroughness to reduce potential pathogens that colonize the patient's skin. The circulating nurse should uniformly apply the prep solution using sterile supplies in a contiguous fashion circumferentially from the incision site to the periphery. The sponge/applicator should be discarded after the periphery has been reached. Table 2 provides additional skin preparation techniques that should be employed to prepare the surgical site in a manner that preserves skin integrity and prevents injury to the patient's skin.

Table 2. Factors to Consider When Preparing the Patient's Skin for a Surgical Procedure
When preparing the patient's skin for a surgical procedure, special considerations should include

•preparing areas of high microbial counts within the prepared areas last (eg, umbilicus, pubis, open wounds);1, 2, 3, 4

•isolating colostomy site(s) from the prepared area, covering the site(s) with an antiseptic-soaked sponge, and preparing the colostomy site(s) last;2, 3

•using normal saline to prepare burned, denuded, or traumatized skin;2

•avoiding using chlorhexidine gluconate and/or alcohol or alcohol-based products on mucous membranes;5, 6

•using gentle preparation techniques when preparing skin of patients with certain medical conditions (eg, diabetes, skin ulcerations);6(p79)

•allowing sufficient contact time of antiseptic agents with the skin before applying sterile drapes to achieve maximum effectiveness of the agent;7, 8, 9

•allowing sufficient time for complete evaporation of any flammable antiseptic agent (eg, alcohol, alcohol-based preparations) to reduce the possibility of fire;6, 9 and

•preventing the antiseptic agent from pooling beneath patients, pneumatic tourniquet cuffs, electrodes, or electrosurgical unit dispersive pads to reduce the risk of chemical burns.

Adapted with permission from Recommended practices for skin preparation of patients. In: Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:654-655.

1 Earl A. Operating room. In: APIC Infection Control and Applied Epidemiology: Principles and Practice. St Louis, MO: Mosby; 1996:95-101.

2 Fortunato NH. Berry & Kohn's Operating Room Technique. 9th ed. St Louis, MO: Mosby; 2000:507.

3 Fairchild SS. Patient care management. In: Fairchild SS, ed. Perioperative Nursing: Principles and Practice. 2nd ed. Boston, MA: Little, Brown and Co; 1996:333.

4 Fogg D. Infection control. In: Meeker MH, Rothrock JC, eds. Alexander's Care of the Patient in Surgery. 11th ed. St Louis, MO: Mosby; 1999:145.

5 Briggs M. Principles of closed surgical wound care: a review of the factors before, during and after surgical procedures that may predispose patients to post-operative wound infection. J Wound Care. 1997;6(6):290.

6 Mews PA. Establishing and maintaining a sterile field. In: Phippen ML, Wells MP, eds. Patient Care During Operative and Invasive Procedures. Philadelphia, PA: WB Saunders Co; 2000:79-80.

7 Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Contr. 1988;16(6):259.

8 Rutala W. APIC guidelines for infection control practice: APIC guideline for selection and use of disinfectants. Am J Infect Contr. 1996;24(4):330, 334.

9 Mangram A J, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Infect Cont Hosp Epidemiol. 1999;20(4):250-278.

The surgical “time out” has become a valuable method to verify the patient's identity; correct surgical site and laterality, if applicable; and availability of needed supplies, equipment, and implants. Some facilities also are using the time out to verify that preoperative antibiotics were administered at the appropriate time. Those facilities may require in their time-out policy that the perioperative nurse initiate an additional time out during long procedures when redosing of antibiotics is required.

As technology that affects a patient's susceptibility to SSIs evolves, such as that used to maintain the patient's core body temperature, perioperative nurses will continue to be involved in the maintenance and operation of that equipment. Continuous glucose monitoring technology also is likely to change dramatically in coming years, and perioperative nurses will need to remain informed regarding the use of new equipment. Furthermore, postanesthesia care unit nurses will continue to be responsible for early postoperative administration of oxygen, control of core body temperature, and glycemic management.

It is likely that newer and more intense efforts to improve outcomes from SSIs will continue. The SCIP will develop both process and outcome measures that will expand the total spectrum of preventive methodologies, the responsibility for which may fall to perioperative nurses.38 It also is likely that these continued efforts will have preoperative, intraoperative, and postoperative nursing activities as the primary focus of attention, because preparation of the patient and management of intraoperative contamination has the greatest likelihood of reducing SSI rates. Understanding the evidence on which these practices are based will remain important for perioperative nurses of the future so that these newer techniques can be applied in efficient and effective ways.

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Examination 

Surgical Site Infection: The Host Factor 

Purpose/Goal 

To educate perioperative nurses about the host factor's effect on surgical site infections (SSIs).

Behavioral Objectives 

After reading and studying the article on SSIs and the host factor, nurses will be able to

1.discuss causes of SSIs,

2.identify clinical variables of the patient that affect SSI rates, and

3.describe care that optimizes the patient's condition to help prevent SSIs.

Questions 

1.A surgical wound may be contaminated by bacteria from
1.normal colonization of the patient's skin.

2.the air in the OR.

3.surgical entry into areas with heavy colonization of endogenous microorganisms.
a.1 and 2

b.2 and 3

c.1, 2, and 3



2.The major variables associated with SSIs are
1.inoculum of bacteria.

2.microenvironment of the surgical site.

3.virulence of bacteria.
a.1 and 3

b.2 and 3

c.1, 2, and 3



3.Staphylococcus epidermidis is the most common surgical wound contaminant and is therefore most often the pathogen of infection.
a.true

b.false


4.The microenvironment of the surgical wound permits infection because
1.devitalized and necrotic tissue become havens for bacterial proliferation.

2.foreign bodies such as silk sutures increase the probability that a contaminant will cause infection.

3.hemoglobin and hematoma in the wound are a rich source of iron that promote bacterial growth.
a.1 and 3

b.2 and 3

c.1, 2, and 3



5.Although some people are genetically less prone to infection than others, there is no clear measurement of genetically programmed host responses.
a.true

b.false


6.Acute physiologic events or changes that increase the risk of SSIs include
1.being obese.

2.having chronic lung disease.

3.experiencing hypovolemia.

4.suffering from shock.

5.undergoing a blood transfusion.
a.2 and 3

b.3, 4, and 5

c.2, 3, 4, and 5

d.1, 2, 3, 4, and 5



7.Strategies that can be employed to improve host responsiveness in the surgical patient include
1.avoiding hypoalbuminemia with proper nutritional management.

2.ensuring antiseptic preparation of the surgical site.

3.maintaining blood glucose levels within normal limits.

4.preventing hypothermia.
a.1 and 2

b.3 and 4

c.2, 3, and 4

d.1, 2, 3, and 4



8.Preoperative antibiotics should be administered between _____________ minutes before the incision is made, depending on the type of prophylactic medication used.
a.20 and 40

b.30 and 60

c.40 and 80

d.60 and 100


9.Hair should be left at the surgical site whenever possible, but if it is determined that hair removal is necessary, it should be performed
1.with a disposable razor rather than a depilatory or electric razor.

2.in the room where the procedure will be performed.

3.as close to the time of surgery as possible, except when a depilatory is used.

4.only by personnel skilled in hair removal techniques.
a.1 and 2

b.3 and 4

c.1, 2, and 4

d.1, 2, 3, and 4



10.Some factors to consider when preparing the patient's skin for a surgical procedure include
1.allowing sufficient time for complete evaporation of any flammable antiseptic agent.

2.allowing sufficient contact time of antiseptic agents with the patient's skin before applying sterile drapes.

3.avoiding use of chlorhexidine gluconate and alcohol or alcohol-based products on mucous membranes.

4.preparing areas of high microbial counts within the prepared areas last.

5.preventing antiseptic agent pooling.
a.2 and 3

b.1, 4, and 5

c.2, 3, 4, and 5

d.1, 2, 3, 4, and 5



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Answer Sheet 

Surgical Site Infection: The Host Factor 

Event #07054

Session #8466

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Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

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2.Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only.

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4.Enclose fee if information is mailed.

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A score of 70% correct on the examination is required for credit.

Participants receive feedback on incorrect answers.

Each applicant who successfully completes this program will receive a certificate of completion.

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Learner Evaluation 

Surgical Site Infection: The Host Factor 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about the host factor's effect on surgical site infections (SSIs).

Objectives 

To what extent were the following objectives of this continuing education program achieved?

1.Discuss causes of SSIs.

2.Identify clinical variables of the patient that affect SSI rates.

3.Describe care that optimizes the patient's condition to help prevent SSIs.

Content 

To what extent

4.did this article increase your knowledge of the subject matter?

5.was the content clear and organized?

6.did this article facilitate learning?

7.were your individual objectives met?

8.did the objectives relate to the overall purpose/goal?

Test Questions/Answers 

To what extent

9.were they reflective of the content?

10.were they easy to understand?

11.did they address important points?

Learner Input 

12.Will you be able to use the information from this article in your work setting?
a.yes

b.no


13.I learned of this article via
a.the Journal I receive as an AORN member.

b.a Journal I obtained elsewhere.

c.the AORN Journal web site.


14.What factor most affects whether you take an AORN Journal continuing education examination?
a.need for continuing education contact hours

b.price

c.subject matter relevant to current position

d.number of continuing education contact hours offered


What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ______________________________________________________________________________________________________________________

Author names and addresses: ___________________________________________________________________________________________________

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References 

  1. Ambulatory and inpatient procedures in the United States, 1996. National Center for Health Statistics . http://www.cdc.gov/nchs/products/pubs/pubd/series/sr13/140-131/sr13_139.htm Accessed September 20, 2007.
  2. Nosocomial infections in surgical patients in the United States, January 1986–June 1992. National Nosocomial Infections Surveillance (NNIS) System . Infect Control Hosp Epidemiol . 1993;14(2):73–80
  3. Surgical site infections (SSIs)  . Centers for Disease Control and Prevention . http://www.cdc.gov/ncidod/dhqp/dpac_ssi.html Accessed September 20, 2007.
  4. Hospital Quality Alliance, improving care through information. Centers for Medicare & Medicaid Services . http://www.cms.hhs.gov/hospitalqualityinits/downloads/hospitalhqafactsheet200512.pdf Accessed September 20, 2007.
  5. Hedrick TL , Anastacio MM , Sawyer RG . Prevention of surgical site infections . Expert Rev Anti Infect Ther . 2006;4(2):223–233
  6. Hospital-acquired infections in Pennsylvania 2005. PHC4 Pennsylvania Health Care Cost Containment Council . http://www.phc4.org/hai Accessed September 20, 2007.
  7. Fry DE . The Surgical Infection Prevention Project: processes, outcomes, and future impact . Surg Infect . 2006;7(Suppl 3):S17–S26
  8. Bratzler DW , Houck PM , Richards C , et al.   Use of antimicrobial prophylaxis for major sur-gery: baseline results from the National Surgical Infection Prevention Project . Arch Surg . 2005;140(2):174–182
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Resources 

  1. Fry DE . The economic costs of surgical site infection . Surg Infect . 2002;3(Suppl 1):S37–S43
  2. Recommended practices for Prevention of transmissible infections in the perioperative practice setting . In: Standards, Recommended Practices, and Guidelines . Denver, CO: AORN, Inc; 2007;p. 707–717

  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 811–812 and then completing the answer sheet and learner evaluation on pages 813–814.The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education.This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

PII: S0001-2092(07)00287-6

doi:10.1016/j.aorn.2007.06.022

AORN Journal
Volume 86, Issue 5 , Pages 801-814, November 2007

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