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Problem-Based Research: Surgical Site Infections

Tracey Wilson

Department of Nursing, Delaware Technical and Community College

NUR340: Nursing Research

Tammy Layer

October 11, 2020

Problem-Based Research: Surgical Site Infections

Medicine and healthcare are two fields where discoveries are being made and new

technologies are emerging at a rapid pace. What was once a standard practice may now have to

be reviewed and revised. Problems can arise at any time when caring for our many patients.

Through research and studies, new knowledge is generated which can be used to improve our

nursing practice and in turn allow us to provide patients with the best care possible.

Since becoming a nurse, I have worked in two departments, the Operating Room (OR) as

a circulating nurse/scrub nurse and in Sterile Processing Services (SPS) as a Reusable Medical

Equipment (RME) coordinator/educator. In researching a healthcare issue, I wanted to find a

topic that impacts both areas. Healthcare associated infections (HAIs) is an issue that not only

affects the OR and SPS, but the whole hospital. It is an issue of such importance that the U.S.

Department of Health and Human Services has made reduction of HAIs an agency priority goal

by instituting the National HAI Action Plan. Healthcare associated infections are “those

infections that patients acquire while receiving health care (Haque et al., 2018). Some common

infections under this heading include CAUTIs (catheter-associated urinary tract infections),

CLABSIs (central line-associated bloodstream infections), VAP (ventilator-associated

pneumonia) and SSIs (surgical site infections). The CDC reports that “nearly 1.7 million

hospitalized patients annually acquire HAIs while being treated for other health issues and that

more than 98,000 of these patients (one in 17) die due to HAIs” (Haque et al., 2018). This is not

just a concern here in the United States, but throughout the world.

Statement of the Problem

HAIs occur in departments throughout the hospital and the profession of nursing can play

a large role in reduction and prevention. To narrow this topic down further and bring the OR and
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SPS together, I began to look at SSIs (surgical site infections). A surgical site infection is an

“infection at or near surgical incisions within 30 days of an operative procedure” (Reichman &

Greenberg, 2009), “affecting both the incision site and deeper tissues around the surgery

location” (Haque et al., 2018). The surgeries where SSIs occur most often include cardiac,

orthopedic, abdominal, and ophthalmic with orthopedic being the most devastating. Many

protocols, policies, and procedures have been examined and implemented to help prevent

surgical site infections such as administering preoperative antibiotics, liming operating room foot

traffic, preoperative hair removal using clippers and different types of skin preparations

(Reichman & Greenberg, 2009), and yet these infections still occur. All these measures take

place in the perioperative setting, before, during and after the surgical procedure. What about

instrumentation? Each procedure performed in the Operating Room requires some type of

equipment or surgical instrumentation. Some instruments are disposable, but the vast majority

are reusable requiring cleaning, decontamination, disinfection, or sterilization processes. With

that being said, my research questions are: What if surgical instruments were not cleaned

properly? How many cases of SSIs have been linked to contaminated surgical instruments and

what can be done to help eliminate this? Since these infections are still occurring, are there

further guidelines or protocols that nurses can implement to prevent SSIs?

Literature Review

To begin the research process, a search was made through Google to see what kind of

information was available. This provided me with news articles concerning cases against

hospitals where issues were found resulting from “dirty instruments”. A search for scholarly

articles was then conducted using Google Scholar, CINAHL, Medline and PubMed. Many

articles appeared concerning surgical site infections, but only a few appeared related to
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contaminated instruments, sterilization practices and decontamination failures. It appeared my

work was cut out for me as this was a topic rarely thought of or no one wanted to talk about.

Contamination of Surgical Instruments

Some studies have been conducted to look at the risk of contaminated surgical

instruments depending on the type of instrument and surgery as well as investigation into a

sudden increase in SSIs following what were considered clean procedures. In a hospital in

Glasgow, UK, a study was held to investigate an increase in SSIs in 15 orthopedic patients and 5

ophthalmic patients within a short period of time. Researchers used epidemiologic and patient

analyses, environmental and clinical audits of patient locations and a visit to the sterilization

plant to find answers. Dancer et al. (2012) found that basic sterile processing techniques were

not being followed. Cleaning processes were inadequate as skin and environmental flora was

found on the surgical sets which matched what was found on patient specimens. It was further

discovered that OR staff noticed defective packaging, missing and broken instruments that were

still used during operations. Recommendations were made and instituted to improve practices

for the sterile processing provider with rigorous inspections conducted as well as OR staff was

advised to conduct better quality control. The conclusion made was that SSI risk is increased

when contaminated instruments are used for surgery. Everyone is responsible to report what is

seen. Not every patient may have been affected, but even one is one too many. The study

conducted in Japan looked at forceps used in elective abdominal cases, 60 pairs of tissue forceps

and 80 pairs of DeBakey forceps. These instruments were selected as they are commonly used in

most operations and are in contact with skin and other organs. Tissue forceps are used to grasp

skin and DeBakey forceps are used to grasp organs. (Saito et al., 2014). Through

microbiological analysis, it was discovered that surgical instruments will become contaminated
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intraoperatively despite measures taken to prevent SSI. Gram-positive cocci and rods, gram-

negative rods and fungi were recovered with Staphylococcus epidermidis being the most

common. Microbes that naturally live in skin and organs gradually recover and can cause

contamination of surgical instruments even though antibiotics are administered, skin preparation

is done preoperatively, and the sterile surgical field is maintained (Saito et al., 2014).

Unsuccessful Decontamination Processes and Sterilization Practices

Everyday thousands of surgical procedures are performed at hospitals, outpatient surgery

centers and clinics throughout the world. Infections are a major risk if reusable instrumentation

is not reprocessed properly. “Reprocessing medical instruments is a series of steps involving

transfer, pre-cleaning and decontamination, preparation and maintenance, packaging,

sterilization, and storage until the moment of use” (Percin, 2016). International as well as

national guidelines are established to ensure that standards are being met and maintained by

manufacturers of medical devices. These manufacturers are required to provide instructions for

use (IFUs) to outline how to properly reprocess instrumentation. To ensure that rules are being

followed by all staff members, standard operating procedures (SOP) need to be written. “Well-

written SOP help staff members to do their jobs well” (Percin, 2016).

Southworth (2014) conducted a review looking for “reported outbreaks and incidents

associated with inappropriate, inadequate or unsuccessful decontamination of surgical

instruments” worldwide. After a database search, 21 articles were identified fitting the search

parameters. Many of the articles reported attempted disinfection rather than sterilization. The

World Health Organization (WHO), UK and US guidelines recommend “that reusable surgical

instruments should be sterilized between uses” (Southworth, 2014). Overall, there were failures

reported in cleaning, disinfecting, sterilizing, and rinsing with many of the instruments involved
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with eye surgery. With only 21 articles being found for instruments versus 147 found in a

review of flexible endoscopes, the author found this “likely to be only the tip of the iceberg, due

to reluctance to publish failure” (Southworth, 2014), or that some decontamination breeches

were not noticed. It was revealed that guidelines were not followed causing a rise in infection

rates.

Feelings of those working in the Operating Room and Sterile Processing Services

Qualitative research can be conducted which allows us to hear from individuals who may

be affected by an issue or who work in departments where issues are occurring. Two studies

where conducted interviewing employees in the OR and SPS. The first study was conducted in

Sweden looking at intraoperative prevention of SSIs from the nurse’s perspective. The nurses

were all asked, “What does SSI prevention mean to you in your everyday work as an OR nurse?”

(Qvistgaard et al., 2019). Three themes were found throughout the interviews. The nurses felt

that there is a struggle against an invisible threat for which all members of the team must follow

guidelines. It is important to establish teams and to feel confident in each member’s abilities. A

sense of comradery and trust creates a comfortable and safe work environment where team

members feel connected (Qvistgaard et al., 2019). Legitimacy improves stability where efforts

are backed by leadership. Everyone needs to be held accountable and prevention of SSIs starts

with effective leadership. From the top of the ladder to the bottom, everyone is important in

accomplishing set goals. The second study was conducted in the United States looking “to

understand the importance of culture and the role of facilitators and barriers to improving patient

safety” in the sterile processing department (Brooks et al., 2019). 22 employees working in

sterile processing from 12 hospitals were interviewed. Four primary factors impacting sterile

processing work were revealed. Most sterile processing departments (SPD) are in the basement
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which gave staff a feeling of isolation as well as feeling underappreciated, invisible, or

misunderstood. Communication with OR staff needs to be improved. In most cases, the SPD is

ignored or overlooked until problems arise. The OR staff as well as other departments in the

hospital do not fully understand what takes place in Sterile Processing. Management styles are

vastly different throughout with some managers focusing on education to reinforce information,

marketing the department by holding an open house to educate hospital staff about the work

done in SPD, installing cameras to see what is being done on shifts they may not be there for and

only hiring people with experience and requiring certification within the first year. Technical

problems will arise and it is important for solutions to be made for example alerting OR staff that

pre-cleaning starts in the OR, notifying manufacturers when discrepancies are found in

instructions, and looking at unnecessary instrumentation to cut back on work hours. Conclusions

were made that it is important to look at nonclinical professionals, in addition to those providing

direct care, as their work can have a significant impact on efforts to reduce patient harm.

Improvements made to current guidelines

Many studies are conducted to improve upon current protocols or guidelines. One such

study conducted in Switzerland wanted to see if preoperative decolonization of Staphylococcus

aureus would reduce SSIs in elective orthopedic surgery. Groups were made of carriers, non-

carrier with intervention and control arms. Treatments were established using intranasal

mupirocin, chlorhexidine gluconate soap and regular soap. Unfortunately, the study was too

small, therefore the findings were inconclusive with no benefit of decolonization being found in

either group (Rohrer et. al, 2020). Lastly, the Centers for Disease Control and Prevention (CDC)

issued Guideline for the Prevention of Surgical Site Infection, 2017. This new guideline

supersedes the one issued in 1999. An extensive systematic review was conducted in databases
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from 1998 through April 2014. 5759 titles and abstracts were screened eventually leading to 170

studies being found acceptable. The guideline specifically addresses ways in which to prevent

surgical site infections breaking the document down into 2 parts, a Core Section which is

generalizable across surgical procedures and Prosthetic Joint Arthroplasty which is a surgical

procedure with the greatest human and financial burden. Topics outlined were antimicrobial

prophylaxis both parenteral and non-parenteral, glycemic control, normothermia, oxygenation,

antiseptic prophylaxis, and blood transfusion. The final statement supports the fact that

healthcare is not a static environment as future revisions “will be guided by new research and

technological advancements for preventing SSIs” (Berrios-Torres et al., 2017).

Analysis

In looking at methodologies, I found most of my articles to be reviews of some type.

When trying to establish guidelines, it is important to look at all existing research, so a

systematic review is essential. All possible studies need to be gathered and then sorted to help

provide answers and show what interventions will work to produce favorable outcomes. When

looking for incidents of process failures, a review of literature was done to see if anything had

been published, not to place blame, but to help others so further mistakes or failures do not

occur. There were quite a few qualitative studies done which investigated the human experience

allowing us to examine feelings, culture, and social phenomena and how that affects the way we

work with others. One study was a prospective, randomized, controlled, interventional, single-

blinded trial which can be difficult to conduct as the size of the study will determine whether the

findings can be used or not. A great deal of preparation and work went into the study for the

findings to be considered inconclusive, but the potential is there if another group wishes to try

with a much larger group. Microbiological studies were conducted looking for the causes of
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infection or the risk of infections. Through it all, the conclusions were that contaminated

instruments can obviously increase the rate of surgical site infections. Infections can still occur

even when all preoperative measures have been taken to prevent SSI. Surgical instruments can

become contaminated with the microbes that live naturally on the skin and organs because they

can gradually recover in the surgical field. It is important to look at all aspects of a process from

following instructions written by manufacturers for reprocessing instrumentation and outlined in

standard operating procedures to implementing measures established by CDC guidelines.

Everyone is important in the prevention of SSIs, not just those who provide direct patient care,

but those who work behind the scenes as well, and they need to feel appreciated and a part of the

team. In some instances, shortcuts were taken which can lead to failures that can cause patient

harm. We must have a strong work ethic and do what we know to be right. The gaps I seemed

to find were that not much is being done concerning instrumentation as it seems to be forgotten

and not many reports are being published.

Recommendations

It is hard to say what can be done for future research on this topic. To get a better

understanding of what we are dealing with, an extensive study may need to be conducted looking

at all hospitals in a given region and their incidents of SSI, where the infection occurred, what

type of surgery was conducted, length of surgery, microbe growth, instrumentation used, and

preoperative measures taken to find common issues or factors. It would require a great deal of

data collection and would probably be considered a retrospective study. Anonymity would need

to be maintained with the use of code numbers rather than patient names. If the hospital is going

to continue to collect data for an infinite amount of time, perhaps a statement needs to be made

in the consent form informing patients of data collection and allowing them to decide whether or
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not their information can be used. Nurses need to continue following established guidelines,

keep up to date with the newest procedural techniques and research findings, educate others and

use evidence-based practices to guide actions so patients receive high quality care.
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References

Berrios-Torres, S.I., Umscheid, C.A., Bratzler, D.W., Leas, B, Stone, E.C., Kelz, R.R., Reinke,

C.E., Morgan, S., Solomkin, J.S., Mazuski, J.E., Dellinger, E.P., Itani, K.M.F., Berbari,

E.F., Segreti, J., Parvizi, J., Blanchard, J., Allen, G., Kluytmans, J.A.J.W., Donlan, R., &

Schecter, W.P. (2017). Centers for Disease Control and Prevention Guideline for the

Prevention of Surgical Site Infection. JAMA Surg., 152 (8), 784-791, doi:

10.1001/jamasurg.2017.0904

Brooks, J.V., Williams, J.A.R., & Gorbenko, K. (2019). The work of sterile processing

departments: An exploratory study using qualitative interviews and a quantitative process

database. AJIC: American Journal of Infection Control, Vol. 47, Issue 7, Pages 816-821

Dancer, S.J., Stewart, M., Coulombe, C., Gregori, A., Virdi, M. (2012). Surgical site infections

linked to contaminated surgical instruments. Journal of Hospital Infection, doi:

10.1016/j.jhin.2012.04.023

Haque, M., Sartelli, M., McKimm, J., Bakar, M.A. (2018). Healthcare-associated infections – an

overview. Infection and Drug Resistance, 11, 2321-2333

Percin, D. (2016). Sterilization practices and hospital infections: Is there a relationship? IJADS

International Journal of Antisepsis Disinfection Sterilization, 1(1):19-22.

Qvistgaard, M., Lovebo, J., & Almerud-Osterberg, S. (2019). Intraoperative Prevention of

Surgical Site Infections as Experienced by Operating Room Nurses. International

Journal of Qualitative Studies on Health and Well-Being, 14:1, 1632109,

https://doi.org/10.1080/17482631.2019.1632109

Reichman, D.E., Greenberg, J.A. (2009). Reducing Surgical Site Infections: A Review. Reviews

in Obstetrics & Gynecology, 2(4), 212-221, doi: 10.3909/riog0084

Rohrer, F., Notzli, H., Risch, L., Bodmer, T., Cottagnoud, P., Hermann, T., Limacher, A.,

Fankhauser, N., Wagner, K., & Brugger, J. (2020). Does Perioperative Decolonization

Reduce Surgical Site Infections in Elective Orthopedic Surgery? A Prospective

Randomized Controlled Trial. Clinical Orthopaedics and Related Research, 478:1790-

1800. doi: 10.1097/CORR.0000000000001152

Saito, Y., Kobayashi, H., Uetera, Y., Yasuhara, H., Kajiura, T., Okubo, T. (2014). Microbial

contamination of surgical instruments used for laparotomy. American Journal of

Infection Control, 43-7. http://dx.doi.org/10.1016/j.ajic.2013.06.022

Southworth, P.M., (2014). Infections and exposures: reported incidents associated with

unsuccessful decontamination of reusable surgical instruments. Journal of Hospital

Infection. https://dx.doi.org/10.1016/j.jhin.2014.08.007