Slashing surgical site infections (SSI)
Bundle Supporting Documents
In response to Hospital Compare data indicating that Minnesota hospitals report higher SSI than the national
average, the Collaborative Healthcare-Associated Infection Network (CHAIN) convened a Surgical Site Infection
subgroup to learn more about the infections being reported, and design an action plan to decrease the number of
surgical site infections in Minnesota.
The CHAIN SSI subgroup is multi-disciplinary, with surgical and infection prevention professionals from Mayo
Clinic, Allina Health, Regions Hospital, Essentia Health-Duluth, University of Minnesota Medical Center, District
One Hospital, Park Nicollet Methodist Hospital, North Memorial Medical Center, Glencoe Regional Health
Services, Hennepin County Medical Center, Cuyuna Regional Medical Center, Grand Itasca Hospital and Sanford
Bemidji Medical Center.
Due to a lack of sound scientific evidence suggesting the absolute benefit of every surgical site infection
prevention strategy individually, national SSI experts are encouraging groups of hospitals, systems, or surgical
practices to select and implement a group of interventions, or “bundle” that is derived from scientific evidence
where it exists, as well as theoretically sound practices that make good common sense.
Findings from an analysis of over 60 abdominal hysterectomy surgical site infection cases reported to NHSN, a
review of the literature and current best practices, implementation costs, and current surgical site infection
practices at the participating hospitals were all considered as the Slashing SSI Bundle was developed. Surgeon
leadership was provided throughout the course of the project, and rural hospitals were included to ensure rural
relevance.
The Slashing SSI Bundle is being piloted at Glencoe Regional Health Services, Hennepin County Medical Center,
North Memorial Medical Center, Cuyuna Regional Medical Center, Grand Itasca Hospital, and Sanford Bemidji
Medical Center. Feedback from the pilot sites has been invaluable and influenced the final bundle element
selection.
The Slashing SSI Bundle elements are listed below followed by pertinent references for each practice.
Defined population: patients of all ages having surgery in the OR that involves a skin incision
Showering/bathing recommendation (CDC):
 Patients are to be advised to shower or bathe (full body) with either soap (antimicrobial or nonantimicrobial) or an antiseptic agent, once the evening before and once the morning of the surgical
procedure.
 Upon admission to the preoperative area, an FDA approved antiseptic solution is to be applied in full
strength to the operative site.
 Adherence to instructions for preoperative antiseptic showering or bathing at home is to be assessed
upon admission to the preoperative area as a part of a preoperative bundle/checklist. If a patient reports
that he or she was unable, an antiseptic shower, bath or full body wipe is to be completed pre-operatively.
 Hospital inpatients requiring surgery are to receive an antiseptic shower, bath, or full body wipe prior to
surgery whenever possible.
Association of Operating Room Nurses. (2014). Perioperative standards and recommended practices:
Recommended practices for preoperative patient Skin Antisepsis, Recommendation I. AORN.
Centers for Disease Control Healthcare Infection Control Practices Advisory Committee (CDC HICPAC)
http://www.jscva.org/files/CDC-SSI_Guideline_Draft2014.pdf
http://www.cdc.gov/hicpac/pdf/ssiguidelines.pdf
Engemann JJ, Yehuda C, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin
resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis. 2003; 36:592-598.
Society for Healthcare Epidemiology of America (SHEA)
http://www.jstor.org/stable/pdfplus/10.1086/676022.pdf?acceptTC=true&jpdConfirm=true
Veiga, D. F., Joel Veiga‐Filho, M. D., Ricardo Góes Figueiras, M. D., Roberto Bezerra Vieira, M. D., Edgard Silva
Garcia, M. D., Silva, V. V., & Ferreira, L. M. (2009). Randomized controlled trial of the effectiveness of
chlorhexidine showers before elective plastic surgical procedures. Infection Control and Hospital Epidemiology,
30(1), 77-79.
Veiga, D. F., Damasceno, C. A., Veiga Filho, J., Silva Jr, R. V., Cordeiro, D. L., Vieira, A. M., ... & Ferreira, L. M.
(2008). Influence of povidone-iodine preoperative showers on skin colonization in elective plastic surgery
procedures. Plastic and reconstructive surgery, 121(1), 115-118.
Webster, J., & Osborne, S. (2007). Preoperative bathing or showering with skin antiseptics to prevent surgical
site infection. Cochrane Database Syst Rev, 2.
Postoperative wound care recommendation (AORN, CDC, JC):
 Surgical sterile dressings are to be left intact 24 – 48 hours unless there is bleeding or a reason to
suspect early infection.
 Where postoperative dressing changes are necessary, sterile gloves and dressings should be used.
 Patient education on the importance of hand hygiene in preventing SSI is to be provided preoperatively,
and hand hygiene products will be provided at the patient bedside.
 Hand hygiene products should be provided at the patient bedside.
Centers for Disease Control Healthcare Infection Control Practices Advisory Committee (CDC HICPAC )
http://www.jscva.org/files/CDC-SSI_Guideline_Draft2014.pdf
http://www.cdc.gov/hicpac/pdf/ssiguidelines.pdf
Cima, R., Dankbar, E., Lovely, J., Pendlimari, R., Aronhalt, K., Nehring, S., & Quast, L. (2013). Colorectal
surgery surgical site infection reduction program: a national surgical quality improvement program–driven
multidisciplinary single-institution experience. Journal of the American College of Surgeons, 216(1), 23-33.
Climo MW, Sepkowitz KA, Zuccotti G, Fraser VJ, Warren DK, Perl TM, Speck K, Jernigan JA, Robles JR, Wong
ES. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus
aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a
quasi-experimental multicenter trial. Crit Care Med. 2009 Jun;37(6):1858-65.
Joint Commission Center for Transforming Health Care
http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf
Society for Healthcare Epidemiology of America (SHEA)
http://www.jstor.org/stable/pdfplus/10.1086/676022.pdf?acceptTC=true&jpdConfirm=true
The Joint Commission (TJC)
http://www.jointcommission.org/assets/1/18/SEA_28.pdf
Closing trays for class II and higher open surgeries (AORN)
 For all class II and higher clean/contaminated open laparotomies, including extracorporeal bowel
anastomoses, clean instruments, water, and gloves/gowns are to be utilized for wound closure.
 The need for closing trays is to be added to the preoperative briefing or timeout script.
Association of Operating Room Nurses. (2014). Perioperative standards and recommended practices:
Recommended Practices for Sterile Techniques, Recommendation V. AORN. (bowel surgery only)
Cima, R., Dankbar, E., Lovely, J., Pendlimari, R., Aronhalt, K., Nehring, S., & Quast, L. (2013). Colorectal surgery
surgical site infection reduction program: a national surgical quality improvement program–driven multidisciplinary
single-institution experience. Journal of the American College of Surgeons, 216(1), 23-33.
Antibiotic dosing recommendations (IDSA):
 Intra-operative re-dosing of surgical prophylactic antibiotics is to be performed for procedures that last
longer than two half-lives of the drug.
 Intra-operative re-dosing of surgical prophylactic antibiotics is to be performed for procedures involving
blood loss >1500cc.
 A weight based dosing protocol is to be implemented per AHSP/SHEA guidelines
Infectious Disease Society of America
http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/2013%20Surgical%20Prophylaxis%20ASHP,%20IDSA,%20SHEA,%20SIS(1).pdf
American College of Obstetricians and Gynecologists. (2011). ACOG Practice Bulletin No. 120: Use of
prophylactic antibiotics in labor and delivery. Obstetrics and gynecology, 117(6), 1472.
Bratzler, D. W., Dellinger, E. P., Olsen, K. M., Perl, T. M., Auwaerter, P. G., Bolon, M. K., & Weinstein, R. A.
(2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American journal of health-system
pharmacy, 70(3), 195-283.
Dale, W. B., & Peter, M. H. (2004). Antimicrobial prophylaxis for surgery: an advisory statement from the National
Surgical Infection Prevention Project. Clinical Infectious Diseases, 38(12), 1706-1715.
Engelman, R., Shahian, D., Shemin, R., Guy, T. S., Bratzler, D., Edwards, F., & Bridges, C. (2007). The Society
of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part II: antibiotic choice.
The Annals of thoracic surgery, 83(4), 1569-1576.
Joint Commission Center for Transforming Health Care
http://www.centerfortransforminghealthcare.org/assets/4/6/SSI_storyboard.pdf
Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for prevention of
surgical site infection, 1999. American journal of infection control, 27(2), 97-134.
Van Schalkwyk, J., & Van Eyk, N. (2010). Antibiotic prophylaxis in obstetric procedures. Journal of obstetrics and
gynaecology Canada: JOGC= Journal d'obstetrique et gynecologie du Canada: JOGC, 32(9), 878-892.
Glycemic control (HICPAC, CDC):
 Implement perioperative glycemic control and use blood glucose target levels <200mg/dL for diabetic and
non-diabetic patients.
Centers for Disease Control Healthcare Infection Control Practices Advisory Committee (CDC HICPAC )
http://www.jscva.org/files/CDC-SSI_Guideline_Draft2014.pdf
http://www.cdc.gov/hicpac/pdf/ssiguidelines.pdf
Kiran, R. P., Turina, M., Hammel, J., & Fazio, V. (2013). The clinical significance of an elevated postoperative
glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control.
Annals of surgery, 258(4), 599-605.
Kwon, S., Thompson, R., Dellinger, P., Yanez, D., Farrohki, E., & Flum, D. (2013). Importance of perioperative
glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Annals
of surgery, 257(1), 8-14.
Wang, R., Panizales, M. T., Hudson, M. S., Rogers, S. O., & Schnipper, J. L. (2014). Preoperative glucose as a
screening tool in patients without diabetes. Journal of Surgical Research, 186(1), 371-378.
Normothermia (HIC PAC):
 Maintain normothermia (body temperature ≥ 36ºC or 96.8º F) preoperatively, intraoperatively and
postoperatively.
Centers for Disease Control Healthcare Infection Control Practices Advisory Committee (CDC HICPAC )
http://www.jscva.org/files/CDC-SSI_Guideline_Draft2014.pdf
http://www.cdc.gov/hicpac/pdf/ssiguidelines.pdf
Gandhi, G. Y., Nuttall, G. A., Abel, M. D., Mullany, C. J., Schaff, H. V., O'Brien, P. C., & McMahon, M. M. (2007).
Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac SurgeryA
Randomized Trial. Annals of internal medicine, 146(4), 233-243.
Melling, A. C., & Leaper, D. J. (2002). Effect of preoperative warming on wound infection. The Lancet, 359(9304),
445-446.Kurz, et al. NEJM. 1996.
Wong, P. F., Kumar, S., Bohra, A., Whetter, D., & Leaper, D. J. (2007). Randomized clinical trial of perioperative
systemic warming in major elective abdominal surgery. British Journal of Surgery, 94(4), 421-426.
OR traffic
 An assessment of OR traffic, with the intent to reduce unnecessary traffic, is performed upon
implementation of SSI bundle and periodically thereafter.
Association of Operating Room Nurses. (2014). Perioperative standards and recommended practices:
Recommended practices for sterile technique, recommendation VIII. AORN.
Brohus H, Balling KD, Jeppesen D. Influence of movements on contaminant transport in an operating room.
Indoor Air. 2006 Oct;16(5):356-372.
Knobben BA, van Horn JR, van der Mei HC, Busscher HJ. Evaluation of measures to decrease intra-operative
bacterial contamination in orthopaedic implant surgery. J Hosp Infect. 2006 Feb;62(2):174-180. Epub 2005 Dec
15.
Lynch, R. J., Englesbe, M. J., Sturm, L., Bitar, A., Budhiraj, K., Kolla, S., ... & Campbell, D. A. (2009).
Measurement of foot traffic in the operating room: implications for infection control. American Journal of Medical
Quality, 24(1), 45-52.
Pokrywka, M., & Byers, K. (2013). Traffic in the operating room: a review of factors influencing air flow and
surgical wound contamination. Infectious Disorders-Drug Targets (Formerly Current Drug Targets-Infectious
Disorders), 13(3), 156-161.
Scaltriti, S., Cencetti, S., Rovesti, S., Marchesi, I., Bargellini, A., & Borella, P. (2007). Risk factors for particulate
and microbial contamination of air in operating theatres. Journal of Hospital Infection, 66(4), 320-326.
Tammelin A, Domicel P, Hambraeus A, Ståhle E. Dispersal of methicillin-resistant Staphylococcus epidermidis by
staff in an operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing. J Hosp
Infect. 2000 Feb;44(2):119-126.