A Hospital setting is the most conducive environment for the patients. It has all basic infrastructure to cater the ever growing needs of patients who may present a spectrum of health complications. Certain limitations appear to decrease the quality care which in turn raises concerns among the patients and their family members. Healthcare professionals, especially nurses have a great role to play in contributing to an improved patient care by decreasing the patient concerns. In such context, the present description deals highlighting g a topic on surgical site infections with a special emphasis on its evidence-based management.
Briefly, as the name implies a surgical site infection (SSI) refers to the infection that results following a surgery in a specific body part where the surgery occurs (FAQs about SSIs, n.d). Majority of patients who have undergone surgery do not acquire infections. 3 out of every 100 patients could acquire the SSI. The main symptoms of SSIs are
a) pain and redness in the area where the patient receives surgery
b) leakage of fluid from the wound, and
c) Fever (FAQs about SSIs, n.d).
Our hospital named KENT is prestigious hospital that has nearly 300 beds and basic infrastructure. Daily ten to twenty surgeries occur at this hospital. However, in the recent period the hospital has started registering complaints related to SSIs.
The surgery professionals appear to lack some basic skills in reducing the SSI’s. They should perfectly prepare the patient prior to the surgery. Any failure in that preparation could contribute to SSIs. For instance, many pathogens gain entry into the body through an initial skin surface contact. So a skin preparation for the procedure appears critical (Kiernan, 2012).
The team more likely does not decide which agent would work best for the preoperative skin preparation. Likewise, they also encounter other issues that appear to lead slowly to the infections. Hence, the present process at this hospital setting requires a change.
Evidence mentions that Nurses have a mandatory responsibility to decrease SSIs. As the SSI risk has link with the type of surgical procedure, emphasis should be much directed in modifying or replacing the existing the procedures. They should also note that several patient characteristics enhance the risk of SSI. These include the patients’ a) age b) Increased weight c) smoking d) Diabetes e) Poor nutritional status (Kiernan, 2012).
So nurses should motivate patients to proceed for a planned surgery to decrease their SSI risk. On every occasion and for every patient, nurses must guarantee the vital interventions.
In the recent period, there is a growing attention on the use of evidence-based guidelines or literature to modify the existing the procedure and optimize the care.
Prior to the proceeding for a change, the nurse administrators could institute a query to determine the type of personnel involved in the procedure.
So, a questionnaire was prepared. This involved questions such as
a) How many hours the procedure will continue?
c) How many nurses were involve in the procedure?
d) Who lead the team for the overall procedure?
e) What are the agents used for the preventing infection? Example, their names, composition, etc.
f) How well in advance the team is preparing the patient for surgery with care instructions.
Based on such questionnaire, it was revealed that the surgical professional and a nurse have prepared the basis for the procedure. They were falling short of guidelines that aid in preparing the patient for surgery some days in advance of the surgery.
The decision makers decided to implement a change in this setting. They noticed that suitable evidence-based criteria are missing for recommending appropriate changes. They notices that SSI rates in the present hospital are higher compared to the other hospital settings. Apart from this, the decision makers noticed that organization drawbacks are contributing to an abnormal workflow and development of poor awareness on the SSI prevention strategies.
The decision makers’ rationale is that they observed nurses and other surgery professionals lack some preoperative procedures that could help in preventing SSIs. In addition, they also observe the nurses lack proper educational awareness in implementing the pre-operative care regimen.
At the same moment, the decision makers also understood the surgery professionals lack some continuing medical education (CME) in terms of preventing SSIs.
So, the practice change appears multifaceted. The changes are skin preparation: When patients reach the surgery theatre, nurses should disinfect the skin with an antiseptic agent prior to the incision. The reason is that skin flora such as Staphylococcus aureus could cause SSIs.
Based on the available evidence, the most frequent skin preparation agents in the current day practice are the products composed of chlorhexidine gluconate or iodophors (Hemani and Lepor, 2009). Conventional iodophors in aqueous forms could be safe on the surfaces of mucous membranes. Example, povidone-iodine. Likewise, alcohol solutions provide instant and prolonged antimicrobial activity for lengthy open surgeries where there is a risk of surgical spillage. Such surgeries include retroperitoneal lymph node dissection, radical prostatectomy and cystoprostatectomy (Hemani and Lepor, 2009). Some recent findings reveal that a 2% alcoholic chlorhexidine is more efficacious compared to than aqueous povidone-iodine when skin preparation is the case (Kiernan, 2012).
Alcohol-based agents carry increased efficacy, flexible application, enhanced
durability, and inexpensive when compared with conventional aqueous-based agents.
Nurses could choose an antiseptic skin solution, DuraPrep solution, an antiseptic skin solution that consists of iodine povacrylex in isopropyl alcohol. It has a proven long –term implications in the surgical environment and improves adhesion between prepared skin surface and surgical drapes thus minimizing the distribution of microbes on the surgical area (Kiernan, 2012).
Nurses must adhere to evidence-based Perioperative antibiotic prophylaxis to reduce SSI.
Since prophylaxis in most procedures is necessary, an agent that has works against community-acquired organisms will be more suitable. Nurse could anticipate a significant change with proper antibiotic prophylaxis. If such administration becomes abnormal, there will be harmful consequences to the patient. The implications of these procedures are that they could delay the onset of development of SSIs. Say, the localization of predominant pathogens such as Acinetobacter baumannii, Staphylococcus aureus, Escherichia coli, and Enterococcus spp would come down (Asensio et al., 2008).
Further implications are that on the practice settings, it would enable the surgical professionals and surgical nurses to reduce the time in searching for a reliable preoperative skin protection agent. The choosing of specific skin agent has an association with the surgeon’s knowledge. They could standardize the skin preparation procedures and sustain it for a good number of surgical procedures. So, a change in the skin preparation procedure could yield ideal benefits.
The change could have a positive impact on patients who undergo surgeries such as vascular, general, and orthopedic surgery and cesarean deliveries as well.
A cohort study determined the efficacy of preoperative bathing with chlorhexidine gluconate (CHG) in 619 patients who have undergone various surgeries. Following the bathing procedure, patients had decreased infection rates (Antiseptic, 2014). Similarly, a retrospective study investigated the efficacy of various antisepsis protocols in patients undergoing cesarean section. They study reveals that chlorhexidine-based antisepsis regimen could significantly decrease the SSI rate compared to that of povidone-iodine (Antiseptic, 2014).
Involvement of stakeholders:
The hospital administration or the nurse administrators could engage key stakeholders such as the care providers, and financial managers of the hospitals. The administration team could explain to stakeholders about the issues frequently encountered by the patients. Here, a statistical data of SSI’s collected over a period of one year would be presented accompanied with the financial burden incurred by the patients and the hospital management. They could detail about the reliability involved in switching to a modified therapy, and risks involved in continuing with the older, inferior methods. The stakeholders could be given demonstrations on the expected outcome in view of already available significant findings obtained in other studies.
The team may provide assurance to the stakeholders about the expected SSI reduction rates of all the patient data in the center once they implement the change.
Barriers:
The nurse administrator or the hospital authorities could encounter the barriers while implementing changes. These could be improper adherence to evidence-based guidelines or lack of overall awareness in managing SSIs. The obstacle could involve a) workflow b) inconvenience c) low priority d) role perception, and d) organizational communication.
Here role perception and work-flow could serve as the important obstacles (Tanza, Naik & Lingard, 2006).
Others may be continuous failures in the adequate timing in the administration of antibiotics.
Despite having knowledge of guidelines, participants perceived consistent failure in the proper timing of antibiotic administration. Thematic analysis revealed a number of obstacles to the observance of guidelines including: These are
1) Low priority
2) Inconvenience
3) Workflow
4) Organizational communication, and
5) Role perception.
Workflow and role perception were the dominant obstacles (Tan, Naik & Lingard, 2006). Workflow could have a link with burnout. Hence, nurse burn out may also be a barrier (Cimiotti et al., 2012).
Nurses could overcome these barriers by:
a) Carrying out group interviews or discussions.
b) Seeking help from the stakeholders.
Here, they could reveal the negative impact of organizational conflicts, professional conflicts, and individual values on the care practice. Such practice could decrease the gaps existing in the care delivery process since the long period. Ultimately, SSI could get reduced.
Secondly, reducing burnout issues and improving the work conditions could be another strategy (Cimiotti et al., 2012).
Burnout issues emerge due to increased work load, poor staffing and low income. These issues require a proper focus from the root level. Nurse administrators could talk to the stakeholders and request them to facilitate a conducive hospital environment.
Implementation:
In view of the available findings, nurse administrators could strive for recommending appropriate stratified to reduce SSI. Initially, they could carry out some educational campaign that aims at providing a more detailed guidance on the use of antibiotics or antibiotic prophylaxis. This approach, more probably a CME could contribute to behavior changes in the physicians and also other professionals.
Nurse administrators could integrate these educational approaches with methodologies of well-documented behavioral change theories or models (Savino et al., 2005). They could include lectures, power point presentations that consist of protocols and earlier published data.
They could collaborate with the medical/ research professionals of other hospitals and seek timely suggestions related to the use of skin preparations and antibiotic prophylaxis. In other words, they must follow cross-hospital verification where they could compare the reliability of their protocols with other hospitals. At the same moment, they must cross-check the outcome of their approaches with the previously published findings to decrease SSIs.
Next, they should promote compliance in the hospital by
a) Providing personalized educational information brochures that have national guidelines, hospital-specific data, evidence-based reviews, and research literature.
b) Obtaining Department of Quality Clinical Resource Management (QCRM) issued monthly report cards that have data on SSI (Savino et al., 2005).
c) Providing reminders, very often, by using phone calls, letters and e-mail about particular areas of the protocol and other approaches that may reduce SSI incidence.
d) Obtaining communications from experts such as i) division chiefs ii) department chairman
iii) Other colleagues who were successful in introducing the protocol
d) Adhering to and establishing eligible ICD-9 codes for protocols of interest before the team implements them.
Other recommendations are that nurse administrators should attempt to promote medical staff sharing by hospitals. Here, the involvement of a shared medical staff could contribute to a joint-collaborative effort and facilitates easy acceptance of the protocol and its implementation.
Similarly, ensuring the use of rotating medical staff of academic centers, could also contribute to a high-level compliance (Savino et al., 2005).
Finally, they must implement the use of care bundles (Leaper et al., 2014). Care bundle strategy is a reliable way of packaging the most efficient evidence-based measures into regular patient care service. It is also equivalent to several guidelines for the SSI prevention. It consists of:
a) Methodology for preoperative hair removal
b) Rational antibiotic prophylaxis
c) Prevention of perioperative hypothermia
d) Management of perioperative blood sugar and
e) Efficient preparation of the skin (Leaper et al., 2014).
References
Antiseptic. (2014). Retrieved http://stopwoundinfection.com/clinicalstudies/antiseptic
Asensio, A., Ramos, A., Cuervas-Mons, V., Cordero, E., Sánchez-Turrión, V., Blanes, M.,
Cervera, C., Gavalda, J., Aguado, J.M. & Torre-Cisneros, J. (2008). Effect of antibiotic
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Cimiotti, J.P., Aiken, L.H., Sloane, D.M. & Wu, E.S. (2012). Nurse staffing, burnout, and health
care-associated infection. Am J Infect Control, 40(6), 486-90.
FAQs about SSIs. (n.d). Retrieved http://www.cdc.gov/hai/pdfs/ssi/ssi_tagged.pdf
Hemani.M.L. & Lepor, H. (2009). Skin Preparation for the Prevention of Surgical Site Infection:
Which Agent Is Best? Rev Urol, 11(4),190–195.
Kiernan, M. (2012). Reducing the risk of surgical site infection. Nursing Times,108, 27, 12-14.
Leaper, D.J., Tanner, J., Kiernan, M., Assadian, O. &Edmiston, C.E Jr. (2014). Surgical site
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Savino JA, Smeland J, Flink EL, et al.(2005). Implementation of an Evidence-based Protocol for
Surgical Infection Prophylaxis. Retrieved http://www.ncbi.nlm.nih.gov/books/NBK20533
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