Prevention of Surgical Site Infections

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preventing-surgical-site-infections

By Samantha Kuplicki MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

Part 2 in a series exploring topics related to surgical site infections. For Part 1, click here.

Identifying the presence of Surgical Site Infections (SSIs) is an important, basic skill for the wound specialist, and even more essential is understanding how to apply evidence-based, risk-reducing interventions. SSIs are particularly problematic because of the multiple factors contributing to their development, including those that are directly patient-related (modifiable or non-modifiable), and non-patient related (facility, procedure, pre-op, intra-op, and post-op). Due to the multifaceted nature of SSIs, we must address specific issues simultaneously in order to successfully reduce the patient’s risk.

Surgical Site Infections and Patient-Specifc Risk Factors

Patient-specific risk factors are arguably some of the most challenging to tackle. We must attempt to compensate for those elements we cannot augment, including advanced age, past medical interventions (such as radiation), and personal history/propensity for actual infection. For this installment, we will limit our discussion to modifiable patient-specific risk factors.

Diabetes Mellitus

  • Optimal blood glucose values are encouraged in the immediate preoperative period when possible.
  • High HgbA1C values are not independent predictors of SSI risk.
  • No evidence to demonstrate that improving HgBA1C value in an individual will decrease SSI risk (short term normalization of blood glucose values is more important than control of HgBA1C).

Obesity

  • Morbidly obese (BMI > 40kg/m2) individuals are at 1.3x higher risk of SSI compared to normal weight (BMI 18.5-25 kg/m2), with procedures involving the abdominal wall being subject to the highest risk.
  • Abdominal wall thickness is an independent risk factor for SSI (thicker->higher risk).

Alcohol Abuse

  • A 3-year study of 142 institutions revealed alcohol abuse to be an independent risk factor for SSI.

Tobacco Abuse (current or history of)

  • Smokers have the highest risk of SSI.
  • Former smokers still at higher risk than non-smokers.

Serum Albumin

  • Preoperative serum albumin levels below 3.5mg/dL (normal 3.5-5.0 mg/dL), which could be suggestive of protein-calorie malnutrition or hepatic compromise, put patients at higher SSI risk related to problems with wound healing.

Serum Bilirubin (total)

  • Total serum bilirubin levels below 1.0mg/dL indicate underlying hepatic issues and subsequent concerns related to protein synthesis and wound healing.

Immunosuppression

  • Patients with therapeutically-induced immunosuppression for various conditions, and patients with disease states that predispose them to being in an immunosuppressed state, are at increased SSI risk

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I’m sure you recognize that these risk factors are not unique to SSI development. A patient with any of the above would carry a heightened risk of a plethora of other complications in the surgical environment alone. Nevertheless, it is vital to recognize these risk factors, and understand that we must address as many pieces of the puzzle as possible at every juncture.

As wound specialists, we must be intimately involved in not only the practice of treating and managing patients with wounds, but also prevention.

Unfortunately, there is a paucity of evidence regarding wound management practices post-discharge and the relationship to SSI prevention. This is clearly an area that deserves more research! For now, we must use the tools we have to address what we know to be prominent risk factors for development of SSI. We can empower patients by emphasizing the importance of their role in impacting their own health outcomes, and subsequently reap the benefits of actively involving the patient in his or her own plan of care.

It is imperative to individualize patient education with a combination of validated techniques such as teachback, written instruction, and caregiver education. Meticulous documentation of how we address patient risk factors - including methods and time spent on patient counseling, response to counseling, and discussion of available resources - is paramount to mitigating the modifiable patient-specific risk factors related to development of SSIs.

In the age of pay-for-performance, we literally (and figuratively) cannot afford to neglect any aspect of prevention if we hope to combat SSI incidence. And while I’m sure Walter Raleigh wasn’t referencing SSIs when he said, “prevention is the daughter of intelligence,” it still rings very true for this subject!

Sources:
Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.
J Am Coll Surg. 2017 Jan;224(1):59-74. doi: 10.1016/j.jamcollsurg.2016.10.029. Epub 2016 Nov 30.

Meijs AP, de Greeff SC, Vos MC, Geerlings SE, Koek MB. The effect of body mass index on the risk of surgical site infection. Antimicrob Resist Infect Control. 2015;4(Suppl 1):O29. doi: 10.1186/2047-2994-4-S1-O29. Epub 2015 Jun 16.

Shabanzadeh DM, Sørensen LT. Alcohol Consumption Increases Post-Operative Infection but Not Mortality: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt). 2015 Dec;16(6):657-68. doi: 10.1089/sur.2015.009. Epub 2015 Aug 5.

About the Author
Samantha Kuplicki is board certified in wound care by both the American Board of Wound Management as a Certified Wound Specialist (CWS) and by the Wound, Ostomy and Continence Certification Board as a Certified Wound Care Nurse (CWCN) and Certified Foot Care Nurse (CFCN). She serves on the American Board of Wound Management (ABWM) Examination Committee and also volunteers for the Association for the Advancement of Wound Care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

Thank you so much for this great blog. I would like to clarify that serum protein such as albumin and prealbumin are not included as defining characteristics of malnutrition. Recent analysis shows that serum levels of those proteins are not considered reliable or specific biomarkers for malnutrition.

Nancy,

Thank you so much for reading, and for your comment! I understand that there is definitely evidence contrary to what is still taught as the 'gold standard' for defining protein-calorie malnutrition. However, low serum albumin values have still demonstrated correlation with increased risk of SSI without regard to actual nutritional status. As I'm sure you well know, low albumin/prealbumin can also be a marker of chronic inflammatory states, which are likely common in individuals with comorbid conditions that would cause this (diabetes, autoimmune diseases, etc). I agree that this area should be further expounded upon in relation to SSI prevention/risk stratification. I am a big fan of ERAS and early feeding after colorectal surgery to combat this risk factor. I hope to elaborate on this further :)

Very nice article! Prevention is indeed preferred, and there are lifestyle changes patients can make weeks prior to scheduled surgeries to minimize their risks of developing surgical site infections (SSIs), such as losing weight, quitting smoking, and eating more protein.

I am looking forward to the next installment of this series, which I anticipate will discuss what we, as health care providers, can do to minimize SSIs. I just completed reviewing the evidence for polymeric membrane dressings (PMDs) and I was stunned at the dramatic decrease in SSIs in the studies I read. In one study of total knee arthroplasty patients, the infection rate dropped from 7% to 0% - no infections in 120 consecutive patients - when PMDs were used postop.

This makes sense, because 1) PMDs are pain-relieving dressings, and pain is a known risk factor for infection. 2) PMDs contain a very effective continuous wound cleansing system, 3) PMDs decrease secondary inflammation, which should result in an increase in circulation to the wound area, and 4) PMDs optimize wound moisture, which enables the body's immune cells to migrate across the wound surface more easily.

The tables of evidence can be found in the appendices of this article, or contact me for a more up-to-date table:
Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Manage. 2016 Jun;62(6):42–50.

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA
Independent Nurse Researcher and
Research & Education Liaison, & Charity Liaison for Ferris Mfg. Corp.
lindabenskin@utexas.edu

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