Running head: DECREASING SURGICAL SITE INFECTIONS
Decreasing Surgical Site Infections
Deanna Haxton
University of South Florida
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DECREASING SURGICAL SITE INFECTIONS
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Abstract
Clinical Problem: Patients undergoing surgery are at risk for developing surgical site infections.
Post-operative infections increase costs of hospital care and prolong the length of hospitalization
in surgical patients (Edminston, Okoli, Graham, Sinski, & Seabrook, 2010).
Objective: To evaluate if patients who received pre-surgical skin cleansing with chlorhexidine
based products have a lower risk of developing post-surgical infections. An exhaustive search
was completed using PubMed, CINAHL, and Ovid to identify peer reviewed randomized
controlled trials. Search terms used were surgical site infections, chlorhexidine, and surgical
skin prep. Two randomized controlled trials and one prospective cohort study were selected and
reviewed.
Results: Darouiche et al. (2010) found that the chlorhexidine group had an infection rate of 9.5%
compared to the povidone-iodine group at 16.1% (p=0.004). Graling and Vasalt (2013) found an
overall reduction of SSI with seven infections found in the treatment group using CHG cloths
and 18 infections in the historical group who did not received CHG (p= 0.01). Paocharoen,
Mingmalairak, and Apisarnthanarak (2009) found a statistically significant reduction in both
colonization (CI 2.15-3.55) and infection (CI 1.40-1.81) among participants in the chlorhexidinealcohol group.
Conclusion: The use of chlorhexidine products reduces the risk for the development of surgical
site infections. However, there are a limited number of quality studies investigating the use of
chlorhexidine as a pre-surgical skin cleanser. More research is needed to determine the most
affective application and concentration needed to maximize the effectiveness of chlorhexidine
skin cleansing.
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Decreasing Surgical Site Infections
Surgical site infections (SSI) occur in the United States at a rate of around 750,000 to 1
million times per year (Edminston, Okoli, Graham, Sinski, & Seabrook, 2010). As the third
most common type of hospital acquired infection, SSIs contribute to 3.7 million extra days of
hospital care and costs of over $1.6 billion in extra charges (Edminston et al., 2010). Edminston
et al. (2010) states that the use of pre-operative skin cleansing with Chlorhexidine Gluconate
(CHG) prior to standard peri-operative skin preparations will reduce the number of colony
forming units on the skin and in turn reduce the risk of SSI. CHG is a known bactericidal agent.
By binding to negatively changed bacterial cell walls, CHG disrupts osmotic forces and causes
cell contents to leak leading to cell death (Edminston et al., 2010). Current studies have found
that there are only low levels of bacterial resistance to CHG with no instances of high levels of
resistance found (Edminston et al., 2010). There has been a link between the use of
chlorhexidine products and the reductions of both microorganism growth and surgical site
infection (Darouiche et al., 2010; Graling, & Vasaly, 2013; Paocharoen, Mingmalairak, &
Apisarnthanarak, 2009).
PICOT Question
In adult surgical patients, how does the use of pre-surgical chlorhexidine products,
compared to the use of non-chlorhexidine products, affect the rate of post-surgical site infections
occurring in a one month post-surgical period?
Infrastructure to Support Practice Change
Tampa General Hospital supports biomedical discovery and health service delivery
research by partnering with the University of South Florida as well as other academic facilities
(Tampa General Hospital, 2015). To promote evidence based practice, Tampa General
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Hospital’s Office of Clinical Research provides a number of resources to include medical writing
services, protocol guidelines, bio-statistical assistance and grants management. Once approved,
infectious disease nurses will present the proposed practice change to the nursing staff on all
units where pre-surgical patients are cared for. The pre-surgical checklist will be updated to
reflect the current practice change and nursing staff on all post-surgical units will collect
infection indicating data, in accordance with the Guideline for Prevention of Surgical Site
Infection, as part of the current post-surgical assessment practices (Mangram, Pearson, Silver, &
Jarvis, 1999).
Literature Search
CINAHL, Pubmed, and Ovid were searched using the terms surgical site infection,
chlorhexidine gluconate, skin prep, and wipes or cloths. The search was limited to peer
reviewed, randomized controlled trials (RCTs) published within the last five years. After
difficulty finding sufficient studies, the search was expanded to include non-RCT studies with
sufficient sample sizes.
Literature Review
Two RCTs and one prospective cohort study were selected to evaluate the use of
chlorhexidine products to reduce the incidence of SSIs in adult surgical patients (Table 1).
Darouiche et al. (2010) proposed an RCT to investigate if the use of chlorhexidine-alcohol
during pre-operative skin cleansing would reduce the number of SSI in adult patients. A sample
of 897 adults undergoing clean-contaminated surgery was divided into an experimental group of
431 participants using a chlorhexidine-alcohol scrub and a control group of 466 participants who
used a povidone-iodine scrub and paint combination. The primary goal of this study was to
evaluate the rate of SSI; the secondary goal was to evaluate the types of SSI. Results found that
DECREASING SURGICAL SITE INFECTIONS
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the chlorhexidine group had an infection rate of 9.5% compared to the povidone-iodine group at
16.1% (p=0.004).
The strengths of the Darouiche et al. (2010) study include random assignment of
participants into experimental or control groups, explanation of why subjects did not complete
the study, and both participants and investigators were blinded to assigned study group. The trial
follow up period of 30 days from the date of surgery was sufficient to identify the onset of SSI
symptoms. Each study group had similar demographics and p values were based on Fisher’s
exact test. Weaknesses include the inability to keep participating surgeons blind to study group
due to color differences in the skin cleansing solution. The operating surgeons did however
remain blinded until the patient was brought into the operating room.
Graling and Vasalt (2013) completed a prospective cohort study to evaluate the use of
CHG cloths in reducing the incidence of SSI. A total of 335 participants were placed in the
treatment group and were given a 2% CHG cloth bath prior to surgery. A historical control
group of 284 patients were found to meet criteria for evaluation. The primary measure of this
study was the incidence of SSI with a secondary measure investigating the type of SSI divided
into deep, superficial, and open space infections. Overall, a reduction of SSI was found to be
statistically significant with seven infections found in the treatment group using CHG cloths and
18 infections in the historical group who did not received CHG (p= 0.01).
Strengths of the Graling and Vasalt (2013) study include a large sample size, valid
instruments were used to measure outcomes, and subjects were analyzed in the group to which
they were assigned. The two group’s demographics were found to be similar with the exception
of age and incidence of emergency surgery. The identified weaknesses are the inability to assign
participants into experimental or control groups and the investigators were not blinded to the
DECREASING SURGICAL SITE INFECTIONS
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study group. Furthermore there was an interruption in the study due to a recall of CHG bath
products resulting in a delay of study for several months. It is unknown how many participants
dropped out of the study or for what reasons.
Paocharoen, Mingmalairak, and Apisarnthanarak (2009) completed a prospective
randomized trial to compare the efficacy of a chlorhexidine-alcohol scrub versus a povidoneiodine scrub and paint pre-operatively in reducing SSI and bacteria colonization. A sample of
500 participants was divided into two groups. A total of 250 participants were placed in group
one and treated with povidone iodine. Group two, containing the remaining 250 participants,
was treated with chlorhexidine-alcohol. All participants were adults with clean, cleancontaminated, or contaminated wounds. The primary measures were post-operative bacteria
colonization and postoperative surgical wound infection. The results found a statistically
significant reduction in both colonization (CI 2.15-3.55) and infection (CI 1.40-1.81) among
participants in the chlorhexidine-alcohol group.
Identified strengths of the Paocharoen et al. (2009) study include random assignment to a
treatment group, a sufficient follow up period of 30 days from date of surgery, subjects were
analyzed in the group to which they were randomly assigned, and no significant difference
existed between the two groups. Weaknesses found were lack of a control group. The study was
composed of two treatment groups. It is unknown if the subjects, providers, and analyzers were
blinded to the study group. The study does not state if any participants dropped out of the study.
Wood and Conner (2014) presented guidelines for skin antisepsis in preoperative
patients. These guidelines were written to provide a framework for preparation of skin through
preoperative bathing and specific application techniques. Included in these guidelines are
application techniques and the selection of skin antiseptics. A systematic review of MEDLINE,
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CINAHL, and the Cochrane database was conducted. A total of 166 English language sources
were reviewed and measured using a systematic review with evidence tables, as well as, a review
of published meta-analyses. Expert consensus was used to formulate the final recommendations.
In these guidelines the use of a bath or shower with an antiseptic agent is recommended.
Strengths of the Wood and Conner (2014) guidelines include the use of a systematic
literature review, the rating of evidence based on strength and quality with an appraisal score.
Also included are potential benefits, harms and contraindications with the proposed practice
changes. Weaknesses noted were the review of only English language studies which could
exclude other valid sources of information.
Synthesis
Darouiche et al. (2010) found a statistically significant reduction in SSI of 41% in the
group treated with chlorhexidine-alcohol prior to surgery (p=0.004). Graling and Vasalt (2013)
found an overall a reduction of SSI in the group receiving a 2% CHG bath preoperatively (p=
0.01). Lastly, Paocharoen et al. (2009) found a statistically significant reduction in both
colonization (CI 2.15-3.55) and infection (CI 1.40-1.81) among participants who were treated
with chlorhexidine-alcohol pre-surgically.
These studies have shown that the use of chlorhexidine products pre-surgically results in
a significant decrease in SSIs. However there are a limited number of quality studies
investigating this intervention. Further study is needed to identify which formulation,
concentration, and application technique should be used to maximize the impact of chlorhexidine
on the reduction of SSIs.
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Proposed Practice Change
Implementing pre-operative cleansing with chlorhexidine wipes is a low risk intervention
which can be done to reduce the risk for development of post-surgery site infections. Surgical
patients should be bathed with a chlorhexidine containing no-rinse cloth within three hours of
scheduled surgery as part of a pre-surgical cleanse. This intervention is not intended to replace
the peri-operative skin preparation normally performed within the surgical suite.
Change Strategy
Develop a Vision for Change
By building a team of stakeholders who are passionate about change, it is possible to
impact a greater culture of change within the clinical environment (Melnyk & Fineout-Overholt,
2015). When introducing change it is best to focus on short term, attainable goals with only a
minimal increase in labor required (Melnyk & Fineout-Overholt, 2015). By recruiting change
champions in each unit and uniting them with clinical experts and the support of the administration, it
is possible to increase the awareness of the need for change in pre-surgical skin preparation.
Furthermore, by presenting real scenarios of complications resulting from surgical site infections that
occurred at Tampa General, it is possible to stress the need for change.
Roll Out Plan
Tampa General Hospital currently follows the Iowa model of evidence-based practice to
promote quality care. In accordance with this model, the roll out plan for this proposed practice
change in pre-surgical skin cleansing will be completed as seen below.
Roll Out Plan
Steps
Identify Triggers
Definition
Identify the clinical question
by looking at triggers. A
trigger may be identified by
Timeframe
Completed January 2015
DECREASING SURGICAL SITE INFECTIONS
Organizational Priorities
Forming a Team
coming across a problem in
the clinical setting or
obtaining new knowledge.
 Identify SSI as an area
of desired
improvement
 Identify current
practices regarding
skin preparation
 Review most up to
date data regarding
prevention of SSI
 Identify the risks of
SSI
 Identify facility
priorities
 Consider the cost of
the intervention needed
 Review new research
available
Determine if this problem is a 1 April 2015
clinical priority. Items which
may be of higher priority
include:
 How many surgical
procedures does TGH
complete annually
 What amount of
income is generate
through surgical
procedures
 How do SSI impact the
hospital’s ratings and
patient outcomes
 High-Cost Procedures
 Is reduction of SSI a
priority to TGH
Form a team from
15 April 2015
stakeholders across the
institution. The team will:
 Select and Review
Research Evidence
 Critique Research
 Synthesize Available
Evidence
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
Piloting a Practice Change
Evaluating the Pilot
Scout for motivated
individuals in pertinent
surgical areas
 Implement a small trial 1 May 2015
before rolling out
procedure change to
the entire institution.
 Collect pre-pilot and
post-pilot data to be
use in the next phase.
Evaluate the data collected
Evaluate:1 June 2015
during the pilot test and decide
if the practice change should
be adopted or if further
modification is needed.
If the pilot was a success, roll Implement: 1 August 2015
out practice changes through
the help of leadership and
stakeholders.
Monitor results and share.
1 October 2015
Evaluating Practice Change
Dissemination
of
results
is
and Dissemination of Results
key. Information should be
shared both inside and outside
of the institution.
AORN Surgical Nurses
April 2016
Conference presentation
The Iowa model of evidence-based practice change (Melnyk & Fineout-Overholt, 2015, p. 285).
Project Evaluation
Beginning in August 2015 all pre-surgical checklists will be updated to include the use of
CHG no-rinse wipes three hours prior to surgery. The nurse assigned to care for each postsurgical patient will collect data in accordance with the Guideline for Prevention of Surgical Site
Infection (Mangram et al., 1999). By comparing the incidence of SSIs prior to intervention with
those following intervention an evaluation of the effectiveness can be made. Follow up on
intervention should be completed every three months to evaluate the continued success of the
proposed process change. This intervention will be considered a success if there is a decline in
the incidence of SSIs of 60% after intervention.
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Dissemination of EBP
For dissemination within the facility change champions will be identified in each unit
affected by the proposed change of practice. These individuals will be an expert and point of
contact for questions and concerns regarding policy change. Information regarding the change in
practice will be posted in unit break areas and distributed via staff email. Furthermore the
evidence supporting change will be presented to all staff during unit staff meetings. In order to
disseminate information to outside hospitals and institutions the collected data will be
synthesized and submitted for presentation at local conferences and for publication in scholarly
journals. A podium presentation will be proposed for review at the AORN’s Surgical Nurse
Conference scheduled for April 2016. During this presentation the clinical problem will be
introduced and the primary purpose of the study will be reviewed. Next, the results will be
presented along with critical appraisal of the evidence. The findings of the study will be
presented and the possibility of future practice changes or needed research will be addressed. A
poster reviewing the study and the results will be created by TGH’s social media team for
presentation at the conference as well as in local and regional publications.
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References
Darouiche, R. O., Wall, M. J., Itani, K. M., Otterson, M. F., Webb, A. L., Carrick, M.
M.,…Berger, D. H. (2010). Chlorhexidine-alcohol versus povidone-iodine for surgicalsite antisepsis. The New England Journal of Medicine, 362, 18-26. doi:
10.1056/NEJMoa0810988
Edminston, C. E., Okoli, O., Graham, M. B., Sinski, S., & Seabrook, G. R. (2010). Evidence for
using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site
infection. Association of Perioperative Registered Nurses Journal. 92, 509-518. doi:
10.1016/j.aorn.2010.01.020
Graling, P. R., & Vasaly, F. W. (2013). Effectiveness of 2% CHG cloth bathing for reducing
surgical site infections. Association of Perioperative Registered Nurses Journal. 97, 547551. doi: 10.1016/j.aorn.2013.02.009
Mangram, A. J., H oran, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline
for prevention of surgical site infection. Infection Control and Hospital Epidemiology.
20,247-278. Retrieved from http://www.cdc.gov/hicpac/pdf/SSIguidelines.pdf
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing & Healthcare
(3rd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Williams.
Paocharoen, V., Mingmalairak, C., & Apisarnthanarak, A. (2009). Comparison of surgical
wound infection after preoperative skin preparation with 4% chlorhexidine and povidone
iodine: A prospective randomized trial. Journal of the Medical Association of Thailand,
92(7), 898-902. Retrieved from
http://www.mat.or.th/journal/files/Vol92_No.7_898_5146.pdf
Tampa General Hospital. (2015). About OCR. Retrieved from https://www.tgh.org/ocrabout.htm
DECREASING SURGICAL SITE INFECTIONS
Wood, A. & Conner, R. (2014). Guideline for preoperative patient skin antisepsis. Retrieved
from National Guideline Clearinghouse website:
http://www.guideline.gov/content.aspx?id=48860&search=aorn
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Table 1
Literature Review
Reference
Darouiche, R. O.,
Wall, M. J., Itani,
K. M., Otterson,
M. F., Webb, A.
L., Carrick, M.
M.,…Berger, D.
H. (2010).
Chlorhexidinealcohol versus
povidone-iodine
for surgical-site
antisepsis. The
New England
Journal of
Medicine, 362, 1826. doi:
10.1056/NEJMoa0
810988
Graling, P. R., &
Vasaly, F. W.
(2013).
Effectiveness of
2% CHG cloth
bathing for
reducing surgical
site infections.
Association of
Perioperative
Registered Nurses
Journal. 97, 547551. doi:
10.1016/j.aorn.201
3.02.009
Paocharoen, V.,
Mingmalairak, C.,
&
Apisarnthanarak,
A. (2009).
Comparison of
surgical wound
Aims
Design and
Measures
To determine Prospective
if
randomized
chlorhexidine- clinical trial.
alcohol or
Microbiologic
povidonesamples were
iodine will be taken in those
more effective suspected of
at preventing
infection.
surgical site
infections.
Sample
To determine
if the use of
2% CHG norinse cloth
bath
performed
within three
hours of
surgery will
reduce the
number of
SSIs.
Prospective
cohort study.
Infection was
determined by
the Centers for
Disease
Control and
Prevention
operation
definitions.
619 adult surgical
patients: 335 in the
2% CHG cloth
group and 284 in
the no bath group.
CHG group: 7
infections
No bath group: 18
infections (p=
0.01).
To determine
the efficacy of
chlorhexidine
over
povidoneiodine in
reducing
Prospective
randomized
trial. Infection
determined by
skin culture,
purulent
drainage and
500 adult patients
with cleancontaminated or
contaminated
wounds. The
Chlorhexidine
alcohol group
Chlorhexidine
group skin
colonization
reduced 31.2%
and povidone
iodine group
reduced 14.4%
849 adult surgical
patients: 409
treated with
chlorhexidinealcohol, 440 treated
with povidoneiodine.
Outcomes/
Statistics
Chlorhexidine
group had an
infection rate of
9.5%.
Povidone-iodine
group infections
occurred in 16.1%
(p=0.004)
DECREASING SURGICAL SITE INFECTIONS
infection after
bacterial
preoperative skin
growth and
preparation with
SSIs.
4% chlorhexidine
and povidone
iodine: A
prospective
randomized trial.
Journal of the
Medical
Association of
Thailand, 92(7),
898-902. Retrieved
from
http://www.mat.or.
th/journal/files/Vol
92_No.7_898_514
6.pdf
surgeon’s
judgement.
15
contained 91
females and 159
males. The
povidone-iodine
group contained
122 females and
138 males.
(CI 2.15-3.55).
There were five
SSI in the
chlorhexidine
group and eight
SSI in the
povidone-iodine
group (CI 1.401.81).