Society of Health-System Pharmacists, Infectious Diseases Society of America, Sanford Guide to Antimicrobial Terapy or Surgical Infection Society.3


SCIP — Infection 9: Urinary catheter removed on postop- Hospitals with epidemiologists on staff should


consult with them for recommendations on endemic pathogens and antimicrobial prophylaxis. Vancomycin should not be routinely used for surgical proce- However, sometimes it may be the best choice for pro-


dures.2,3


phylaxis. For example, vancomycin may be used when a patient has a documented beta-lactam allergy, is colonized with meth- icillin-resistant S. aureus or is at high risk for MRSA because of an acute inpatient hospitalization or nursing home stay within a year before admission, has an inpatient stay of more than 24 hours before the surgery or is in a facility with a high rate of MRSA infections.3


Te average adult dose of vancomycin is 15 mg/kg.


Obese patients can be dosed at the same weight-based amount plus an increase of 40% for excess weight.3 Te number of patients with MRSA has increased significantly


in U.S. hospitals. Some physicians prescreen the patient for nasal microorganisms by preoperative nasal culture and then treat


with antimicrobial mupirocin cream (Bactroban) accordingly.3 SCIP — Infection 3: Prophylactic antibiotics discontinued


within 24 hours after the end of surgery Discontinuing prophylactic antibiotics within 24 hours after


surgery (except cardiothoracic surgery, when 48 hours is appropri- ate) is recommended. Evidence shows that continuing antibiotic prophylaxis beyond 24 hours after the incision is closed offers no additional benefits. In fact, prolonged use of antibiotics can lead to infection with Clostridium difficile and the emergence of antibiotic-resistant organisms.3


Clinicians on the healthcare


professional team can use protocols and standard order sets to ensure that antibiotics are stopped after 24 hours. Surgeons are advised to avoid using antimicrobial sutures


coated with triclosan as a routine measure. Researchers are reviewing the relationship between this product and the devel- opment of antibiotic resistance. Additional studies are ongoing to determine the effect of triclosan within the human body since


it has been found in urine and breast milk.5 SCIP — Infection 6: Appropriate hair removal


Te nicks and scrapes from preoperative razor shaving are


linked to an increased risk of SSIs from skin-associated bacteria. Even with conscientious skin preparation, up to 20% of skin-as- sociated bacteria remain on the skin beneath the surface in hair follicles and sebaceous glands. Shaving allows these bacteria to penetrate the microscopic cuts in the skin.3


To reduce SSIs,


current practice recommends no hair removal, or if hair removal is necessary, removal in the immediate preop period with elec- tric clippers and a disposable, single-patient-use cutting head. Clipping should not be performed in the immediate area where the surgery is done. Particulate-bearing microorganisms could become airborne and enter the incison.5 Razors should be removed from OR supply carts and surgical


shave prep kits so they are not used on patients. Healthcare professionals should educate patients not to shave operative or other body sites before surgery.3


erative day 1 or 2 with day 0 being the day of surgery Device-associated infections are a problem with all patients


and can be reduced by eliminating or minimizing the prolonged use of invasive devices. Numerous studies have demonstrated the benefits of prompt removal of urinary catheters after surgery when there are no indications to leave the catheter in, such as after bladder surgery or the need to measure strict output. In one study, postoperative patients who had indwelling urinary catheters beyond the second day were twice as likely to develop a urinary tract infection.3,5


Many hospitals have a nurse-driven


protocol to encourage the timely removal of urinary catheters. SCIP — Infection 10: Surgery patients with immediate


postoperative normothermia (36 C to 38 C) within the first hour after leaving the OR Hypothermia (a core body temperature less than 36 C, or 96.8


F) almost always occurs in unwarmed patients during surgery. It develops from exposure to the relatively cool OR and the effects of anesthesia. General or major regional anesthesia impairs the body’s normal thermoregulation and causes a shift of heat from the body’s core to its periphery. In the first hour after induction, the core temperature drops by 1.0 C to 1.5 C. It drops another 1.1 C during the subsequent two to three hours of anesthesia time, reaching a plateau at about 34 C, or 93.2 F. As the body becomes hypothermic, vasoconstriction reduces the perfusion of subcu- taneous tissue. Tis reduces the oxygen supply to the wound and impairs immune function, including T-cell mediated antibody production and the oxidative killing of pathogenic bacteria by neutrophils. As an illustration, in colon resection patients, a 1.9 C drop in core temperature (core temperature of 34.7 C) triples the incidence of surgical wound infections and increases the length of stay by a week or longer.3


Mild hypothermia also increases time


in the hospital for uninfected patients. While this performance measure is used to apply only to col-


orectal surgery, all patients should maintain temperatures as close to 37 C (98.6 F) (normothermia) as possible when they undergo surgery. Tis is done by keeping the OR warm and by using pre- operative and intraoperative measures to warm the patient, such as warmed IV fluids.2,3,5 Although some SSIs are unavoidable, surgical complications can


be significantly reduced and patient safety improved by following the SCIP performance measures and other evidence-based practice recommendations. Preliminary studies on the success of SCIP suggest that adherence to all of the measures has more impact than adherence to a single measure and indicates better overall quality care. Healthcare professionals as a team, including nurses, surgeons, surgical technologists, infection control practitioners and pharmacists, have a responsibility to follow these recommendations to make sure that patients receive the safest surgical care possible. •


Nancymarie Phillips, PhD, RN, RNFA, CNOR(E), is a professor and head of the department of perioperative education at Lakeland Community College, Kirtland, Ohio. Connie C. Chettle, MS, MPH, RN, is an epidemiologist living in St. George, Utah. Barbara Barzoloski-O’Connor, MSN, RN, CIC, is the infec- tion control manager at Howard County General Hospital in Columbia, Md.


To see the references and take the test, go to CE.Nurse.com/Course/CE734 2016 • Visit us at NURSE.com 33


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