AORN Journal
Volume 91, Issue 1 , Pages 175-182, January 2010

Clinical Issues—January 2010

Perioperative Nursing Specialist, AORN Center for Nursing Practice

Article Outline

This Month

Identifying wound infections and classifying surgical site infections

Key words: surgical site infection (SSI), wound classifications, superficial incisional SSI, deep incisional SSI, organ space SSI.

Establishing an ASC infection prevention and control program

Key words: infection prevention and control program, health care-associated infection, ambulatory surgery center, infection surveillance.

Guidelines for design and construction of health care facilities

Key words: construction guidelines, American Institute of Architects, Facility Guidelines Institute.

 

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Identifying wound infections and classifying surgical site infections 

Question 

What are the different wound classifications? Do we need to use the National Healthcare Safety Network (NHSN) definitions from the Centers for Disease Control and Prevention (CDC) with the wound classifications when we are determining whether there is a surgical site infection (SSI) postoperatively?

Answer 

The CDC has four classifications that are used for determining the status of wounds and documenting them on the intraoperative record during the surgical procedure. The NHSN definitions assist health care providers in determining whether a wound is infected and correctly classifying an SSI. The NHSN, formerly known as the National Nosocomial Infection Surveillance System, is a part of the CDC. It has an online risk-adjusted system that enables infection preventionists to identify and then compare their data on health care-associated infections (HAIs) with those of other facilities.1 By comparing HAI data, the infection preventionist can determine whether the health care organization is doing as well, the same, or better than other facilities. The comparison also helps them recognize patient safety problems in a timely manner and implement appropriate interventions. This system is used by facilities that have applied and been accepted to the NHSN program to enter mandatory, as well as volunteered, data on HAIs.

The four CDC wound classifications are:

■Class I (clean)—“an uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed and, if necessary, drained with a closed drainage device. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.”2(p259) Examples of clean wounds are those that occur during total hip arthroscopy, mitral valve replacement, and breast biopsy.3

■Class II (clean-contaminated)—“an operative wound in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.2(p259) Examples of clean-contaminated wounds are those that occur during tonsillectomies, nonperforated appendectomy, hysterectomy, and thoracotomy,3 as well as procedures in which a Penrose drain is inserted for postoperative drainage.

■Class III (contaminated)—“open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.”2(p259) A contaminated wound could be a traumatic penetrating wound such as a stab wound to the chest involving the lung.3

■Class IV (dirty infected)—“old traumatic wounds with retained, devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative site before the operation.”2(p259) An example of a dirty infected wound might be one caused by delayed primary closure after a ruptured appendix.3

The NHSN uses superficial, deep, and organ/space definitions in combination with wound classification to describe surgical site infections.4 Following are condensed versions of the NHSN definitions used by infection preventionists when reporting SSIs.

■Superficial incisional SSI—an infection that occurs within 30 days after the surgical procedure and involves only skin or subcutaneous tissue of the incision, with at least one of the following conditions:
■“purulent drainage noted from the superficial incision”4(p313);

■“organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision”4(p313);

■at least one sign or symptom of infection (eg, pain or tenderness, localized swelling, redness, heat) and the superficial incision is deliberately opened by the surgeon if an incisional culture is positive4; or

■diagnosis of a superficial incisional SSI made by the surgeon or attending physician.”4(p313)


Although the following conditions may be reported, they should not be reported as superficial incisional SSIs:

■a stitch abscess that has minimal inflammation and discharge and is confined to the points of suture penetration;

■an infection of an episiotomy or newborn circumcision (NHSN does not considered these to be surgical procedures);

■a burn wound that becomes infected; or

■an incisional SSI that extends into the fascial and muscle layers (ie, deep incisional SSI).

Note: Specific criteria are used for identifying infected episiotomy and circumcision sites and burn wounds.

■Deep incisional SSI—an infection that occurs within 30 days after the surgical procedure if an implant is not inserted or within one year if an implant is inserted, appears to be related to the surgical procedure, and involves deep, soft tissues (eg, fascia, muscle) of the incision, with at least one of the following conditions:
■“purulent drainage is noted from the deep incision but not from the organ/space component of the surgical site”4(p313);

■a deep incision spontaneously dehisces or is deliberately opened by a surgeon and organisms are isolated from an aseptically obtained culture of fluid or tissue in the organ/space and the patient has one or more sign or symptom of infection (eg, fever greater than 38° C [100.4° F], localized pain or tenderness)4;

■“an abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathological or radiological examination”4(p313); or

■“a diagnosis of deep incisional SSI is made by a surgeon or attending physician.”4(p313)


Note: Report infection that involves both superficial and deep incision sites as a deep incisional SSI. Report an organ/space SSI that drains through the incision as a deep incisional SSI.
■Organ/space SSI—an infection that occurs within 30 days after the surgical procedure if an implant is not inserted or within one year if an implant is inserted and the infection appears to be related to the surgical procedure. The infection involves any part of the anatomy (eg, organs or spaces) other than the incision, fascia, or muscle layers, which are opened or manipulated during a surgical procedure, and at least one of the following occurs:
■“purulent drainage is noted from a drain that is placed through a stab wound into the organ/space”4(p313);

■“organisms are isolated from an aseptically obtained culture of fluid or tissue in the organ/space”4(p313);

■“an abscess or other evidence of infection involving the organ/space is found on direct examination, during reoperation, or by histopathological or radiological examination”4(p313); or

■“a diagnosis of an organ/space SSI [is made] by a surgeon or attending physician.”4(p313)


Wound classifications and definitions help infection preventionists and perioperative staff members understand SSIs and document them correctly. Surgical site infections are more accurately identified using these classifications and definitions.

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Establishing an ASC infection prevention and control program 

Question 

We have been informed that our facility needs a written infection prevention and control program in order to meet the new Centers for Medicare & Medicaid Services infection control requirements for ambulatory surgery centers (ASCs). What is the reason for this?

Answer 

On May 18, 2009, revisions to the ASC conditions for coverage (42 CFR 416.2-416.52) went into effect.1 The conditions for coverage state that an ASC must have a designated individual performing infection prevention and control activities who has knowledge and training in infection prevention and control. The CMS also requires a written infection prevention and control program for ASCs. Table 1 provides an example that can be used as a template and may be adapted to fit any ASC's practices. In addition, the following resources may help the infection preventionist set up the infection prevention and control program:

■State Operations Manual (SOM); appendix l, ambulatory surgical centers (ASC) comprehensive revision. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf. Accessed December 3, 2009.

■Guidelines for Environmental Infection Control in Health-Care Facilities. Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf. Accessed December 3, 2009.

■Recommended practices for environmental cleaning in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009:439-453.

■Recommended practices for high level disinfection. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009:579-594.

■Recommended practices for sterilization in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009:647-670.

■Guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html. Accessed December 3, 2009.

■Tuberculosis Training and Education Resource Guide. Centers for Disease Control and Prevention. http://www.cdcnpin.org/Guides/tbguide.pdf. Accessed December 7, 2009.

A written infection prevention and control program that is tailored to the individual setting serves as a guide in addition to meeting the CMS requirements.

TABLE 1. Sample Ambulatory Surgery Infection Prevention and Control Program1, 2, 3, 4
Purpose
To reduce the number of health care-associated infections (HAIs) and to take measures to prevent and control the spread of infection and communicable diseases within an ambulatory surgery center (ASC). To comply with regulatory, recommending, and accrediting agencies, such as

■the Centers for Disease Control and Prevention (CDC),

■the Association for Professionals in Infection Control and Epidemiology (APIC),

■AORN,

■the Society for Healthcare Epidemiology of America (SHEA),

■the Occupational Safety and Health Administration (OSHA),

■the National Institute for Occupational Safety and Health (NIOSH),

■the Centers for Medicare & Medicaid Services (CMS), and

■local and state public health departments.

Scope
An infection control program is an ongoing process that monitors infection prevention and control practices as it relates to all health care personnel (eg, employees, physicians, contract personnel, vendors, students) as well as volunteers and visitors.
Responsible person
Infection preventionist
Goals

■Implement measures to prevent and control infection and communicable diseases using the latest information and guidelines from the CDC, APIC, AORN, SHEA, OSHA, NIOSH, CMS, local and state public health departments, and accrediting agencies.

■Reduce the number of HAIs through education, information-sharing, and surveillance.

■Protect the patients and health care personnel, visitors, family members, and others in the ASC environment from transmission or acquisition of HAIs.

Risk assessment

■Define patients, ages, and ethnicities.

■Identify microorganisms and infections and communicate findings.

■List types of procedures and other services performed.

■Identify environmental issues (eg, cleanliness and safety, laundry services, hazardous waste disposal, disposal of hazardous medications).

■Determine health care personnels' knowledge level of infection prevention and control, competencies, hand hygiene compliance, isolation and triage, screening for immunizations, and work restrictions.

■Identify risks associated with geographic location of the community (eg, natural disasters, accidents such as those associated with mass transit, bioterrorism, community infection clusters or outbreaks, socioeconomic levels, unvaccinated populations).

Structure and function

■Obtain and manage data and information including infection surveillance.

■Manage infection risk, prevention, and control strategies to include occupational health, construction, and disaster planning.

■Develop and recommend infection prevention and control policies and procedures.

■Become directly involved with prevention of infections.

■Assist in evaluating products and procedures.

■Provide education for health care personnel, patients, and nonmedical caregivers directed at interventions to reduce infection risks.

■Implement changes from regulatory, accrediting, recommending, and licensing agencies to include reporting communicable diseases to health departments.

■Manage health care personnel work restrictions.

Surveillance

■Develop and implement a process for case finding (eg, signs and symptoms of infection given to patients on discharge).

■Institute postoperative telephone calls or e-mails for follow-up patient evaluation of care, follow-up surgeon surveillance letters, and methods to identify when other facilities admit a patient for that infection.

■Record variables for each patient (eg, medical record number, surgeon, procedure performed, wound classification, American Society of Anesthesiologists physical status classification, duration of the surgical procedure, patient's age, timing of antibiotic administration, OR number).

■Develop a targeted approach to high volume, high risk, and identified problematic procedures.

■Communicate information about infections to the nursing director and the public health department.

■Monitor water quality in the ASC.

Examples of outcome surveillance

■Rates of vaccine-preventable diseases in staff members (eg, hepatitis B, influenza)

■Mycobacterium tuberculosis skin test conversion in staff members

■Hand hygiene compliance based on observations

■Documentation (eg, competency, logs, written procedures) of cleaning, decontamination, sterilization, and storage of instruments

■Documentation of sharps injuries and follow-up for health care personnel

Mandatory education topics

■Bloodborne pathogens

■Mycobacterium tuberculosis

■Standard precautions and isolation precautions

■Hazardous waste disposal to include hazardous medications

■Hand hygiene

Performance improvement

■Maintain communication with identified quality management personnel and risk manager regarding infection prevention and control.

■Assess and improve infection prevention and control continually through surveillance and performance monitors.

■Identify trends or patterns for follow-up review of surveillance data.

1Friedman C. Infection prevention and control programs. In: Carrico R, Adam L, Aureden K, Fauerbach L, Friedman C, eds. APIC Text of Infection Control and Epidemiology. 3rd ed. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2009:1-8.

2Friedman C, Petersen KH. Infection control in ambulatory care. In: Infection Control in Ambulatory Care. 3rd ed. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2004:1-3.

3Mangram AJ, Horan TC, Pearson ML; Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250-280.

4CPL 02-02-069 – CPL 2-2.69—Enforcement procedures for the occupational exposure to bloodborne pathogens. Ocupational Safety & Health Administration. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570. Effective November 27, 2001. Accessed December 3, 2009.

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Guidelines for design and construction of health care facilities 

Question 

I work at an ambulatory surgery center that will be undergoing renovation soon. I have been told to use the American Institute of Architects (AIA) guidelines as a resource for the project. Does AORN use AIA guidelines and construction considerations in any of its recommended practices?

Answer 

The Guidelines for Design and Construction of Health Care Facilities, often referred to as the AIA Guidelines, is actually developed by the Facility Guidelines Institute (FGI) through a formal consensus process at regular intervals.1 AORN's “Recommended practices for a safe environment of care”2 includes information about electrical access panels; lighting; heating, ventilation, and air conditioning; and other physical design considerations related to the perioperative environment that are based on the FGI guidelines. These recommended practices will continue to be updated to reflect the new edition of the FGI guidelines as they affect perioperative facilities.

The FGI serves as the contracting agent for the work performed by the Health Guidelines Revision Committee (HGRC) and by the publisher of the document. In the past, the guidelines were published by the AIA. The 2010 guidelines are published by the American Society of Healthcare Engineers (ASHE). Perioperative nurses may have heard the term “AIA Guidelines,” when in fact the guidelines were always set by the FGI. Now that the publisher will be the ASHE, perioperative nurses need to understand that the 2010 guidelines are an updated version of the same guidelines, not a new and different publication.

The FGI was formed in 1998 and includes eight board members who represent various facility perspectives. Their main objective is to facilitate the review and revision cycle of the guidelines document, which involves experts from the federal, state, and private sectors. AORN has a designated representative on the HGRC who actively participates with more than 100 clinicians, administrators, architects, engineers, and individuals from regulatory agencies. The committee meets three times within an 18-month period to reach consensus on the guidelines, which then undergo a public review process.1

Perioperative nurses who are involved in construction projects and who have questions about the interpretations of FGI guidelines can access information from the FGI at http://www.fgiguidelines.org/interpretations.html. Building codes vary by location, therefore, state and local authorities with jurisdiction should be consulted. The review cycle for the 2014 edition of the guidelines will begin in early 2010, with public review expected to start by June 2012. The AORN representative to the HGRC was elected to serve on the steering committee for the 2014 revisions.

Perioperative nurses involved in the planning, design, and construction of health care facilities should be aware of how to access interpretations for the FGI guidelines, understand how they relate to the building codes required by their state and local jurisdictions, and anticipate how the review cycle may affect their planning process. For more information about the FGI, call (214) 969-3344 or send an e-mail to info@fgiguidelines.org.

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Learner Evaluation. Continuing Education Program 

1.6 

Clinical Issues 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below.

Purpose/Goal 

To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum.

Objectives 

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

1.Discuss practices that could jeopardize safety in the perioperative area.Low 1. 2. 3. 4. 5. High

2.Discuss common areas of concern that relate to perioperative best practices.Low 1. 2. 3. 4. 5. High

3.Describe implementation of evidence-based practice regarding perioperative nursing care.Low 1. 2. 3. 4. 5. High

Content 


4.To what extent did this article increase your knowledge of the subject matter?Low 1. 2. 3. 4. 5. High

5.To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High

6.Will you be able to use the information from this article in your work setting?1. Yes 2. No

7.Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.How will you change your practice (Select all that apply)
1.I will provide education to my team regarding why change is needed.

2.I will work with management to change/implement a policy and procedure.

3.I will plan an informational meeting with physicians to seek their input and acceptance of the need for change.

4.I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5.Other:


7B.If you will not change your practice as a result of reading this article, why? (Select all that apply)
1.The content of the article is not relevant to my practice.

2.I do not have enough time to teach others about the purpose of the needed change.

3.I do not have management support to make a change.

4.Other:



8.Our accrediting body requires that we verify the time you needed to complete this 1.6 continuing education contact hour (96-minute) program:

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 recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

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.

Event: #10005; Session: #1386 Fee: Members $8, Nonmembers $16

The deadline for this program is January 31, 2013.

Each applicant who successfully completes this program will be able to print a certificate of completion.

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References 

    Identifying wound infections and classifying surgical site infections
  1. Perla RJ, Peden CJ, Goldmann D, Lloyd R. Health care-associated infection reporting: the need for ongoing reliability and validity assessment. Am J Infect Control. 2009;37(8):615–618
  2. Mangram AJ, Horan TC, Pearson ML Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250–280
  3. McEwen D. Wound healing, dressings, and drains. In:  Rothrock JC editors. Alexander's Care of the Patient in Surgery. 13th ed.. St Louis, MO: Mosby; 2006;p. 235–236
  4. Horan TC, Andrus M, Dudeck M. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in acute care setting. Am J Infect Control. 2008;36(5):309–332
    Establishing an ASC infection prevention and control program
  1. State Operations Manual (SOM); appendix l, ambulatory surgical centers (ASC) comprehensive revision. Centers for Medicare & Medicaid Services http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdfAccessed December 3, 2009
    Guidelines for design and construction of health care facilities
  1. Status update: 2010 edition of the Guidelines for Design and Construction of Health Care Facilities. FGI—Facilities Guidelines Institute http://www.fgiguidelines.orgAccessed October 7, 2009
  2. Recommended practices for a safe environment of care. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010;217-239

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Resource 

  1. Fry DE, Howard RJ. Surgical site infection. In:  Carrico R,  Adam L,  Aureden K,  Fauerbach L,  Friedman C editor. APIC Text of Infection Control and Epidemiology. 3rd ed.. Washington, DC: APIC; 2009;p. 1–11

  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online learner evaluation at http://www.aornjournal.org/ce. The contact hours for this article expire January 31, 2013.

 The authors of this column have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.

PII: S0001-2092(09)00773-X

doi:10.1016/j.aorn.2009.11.001

AORN Journal
Volume 91, Issue 1 , Pages 175-182, January 2010

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