Surgical Site Infection Surveillance: Analysis of Adherence to Recommendations for Routine Infection Control Practices
Objective. To evaluate the application of surgical site infection control procedures in general surgery departments in hospitals in the Piemonte region of Italy.
Design. The descriptive study entailed 1 week of observation in the general surgery departments and 1 week of observation in the operating rooms of 49 hospitals in Piemonte; the survey was conducted in 2003.
Methods. Data collection forms were designed to record information about presurgical patient preparation (form 1) and infection control practices routinely used by surgical teams (form 2).
Results. A total of 856 patients were observed; 88% of operations were surgical wound class I or II; 70.6% of patients had hair removed, 28.8% showered the day before the operation; antimicrobial prophylaxis was administered in 63.3% of cases (68.4% on induction of anesthesia and 26% on the day of the operation) and was continued into the postoperative period in 43% of cases. A total of 799 operations were observed; the mean number of healthcare personnel in the operating room was 6; doors were opened an average of 12 times during an operation; 88% of the surgical team members wore a cap/hood and mask correctly; 25% of surgeons and 41% of instrument nurses wore an eye shield; preoperative hand and forearm scrubbing technique was correct in 78% of cases (surgeons, 74.6%; instrument nurses, 86.6%; and anesthesiologists, 73%).
Conclusions. A comparison between the survey data and the international recommendations for SSI prevention highlighted practices that could be improved with corrective interventions. The study provided an opportunity for sharing feedback on appropriate data with healthcare personnel and was an effective instrument to audit infection control practices.
Received August 2, 2005; accepted November 3, 2005; electronically published July 20, 2006.
Studies of surgical site infections (SSIs) in Western countries report a relative frequency of 15%‐20% in prevalence studies and an incidence in general surgery that varies between 2%‐3% and 12%‐15%, depending on the class of operation. The causes of SSIs are multiple; they may include the patient’s clinical condition (eg, advanced age, nutritional status, or obesity) and incorrect patient management. Improving the patient’s clinical condition is not always possible, whereas prevention measures taken before, during, and after surgery can effectively control and prevent the transmission of infection.1
The Study on the Efficacy of Nosocomial Infection Control (SENIC) has reported that approximately 6% of all nosocomial infections could be prevented by implementing a minimum of control interventions and that 32% could be prevented by use of infection control and surveillance programs, personnel trained in infection control, and a system through which surgeons can report infection rates.2
A recent overview of 30 studies published between 1990 and 2002 on the outcome of nosocomial infection prevention through intervention programs found that approximately 20% of all infections were avoidable.3 Two of the studies conducted in general surgery departments showed a reduction in the number of the infections by 24%‐25% after implementation of an infection surveillance and control program.4,5
In Italy, a nationwide study of nosocomial infection surveillance and control programs launched in early 2000 reported that only 31% of surgery departments had established protocols for infection prevention.6 Since 2000, in the Piemonte region (where there are 550,000 hospital admissions per year and 28,000 healthcare workers) the Piemonte Nosocomial Infection Study Group has directed particular attention to SSI prevention. Between October and December 2000, a study of SSI prevalence was conducted that involved 60 hospitals throughout the region; approximately 3000 patients were observed.7 SSIs accounted for 8.3% of nosocomial infections; the prevalence was 0.7%. Data analysis showed that the modes of administration of antimicrobial prophylaxis do not always meet the criteria for correct and efficacious use of antimicrobial agents; therefore, surgeons were invited to take part in training on the correct use of antimicrobials in surgical care.8‐10
In 2003, a survey was conducted to evaluate the application of procedures recommended for the prevention of SSI. Healthcare workers were not always complying with procedures recommended for reducing the risk of infection. For this reason, application of the Centers for Disease Control and Prevention (CDC) category IA and category IB recommendations for SSI prevention1 was evaluated.
Methods
Design
The study entailed 1 week of observation in the general surgery departments and 1 week of observation in the operating rooms of 49 hospitals in the Piemonte region. The survey was conducted from October 20, 2003, to November 15, 2003. Two special data collection forms were designed: one to record information about methods of surgical patient preparation (form 1) and one to record information about the infection control practices routinely used by surgical teams (form 2). Data were collected by nursing staff responsible for nosocomial infection control.
Inclusion Criteria
Subjects were patients 10 years of age or older who were admitted to a surgical department during the study period. All types of general surgery were included, including day surgery (ie, surgery performed in the operating room on a patient who was hospitalized for fewer than 24 hours). Excluded from the study were general surgery interventions performed as emergency procedures, diagnostic interventions (except for exploratory endoscopy), and general surgery procedures performed on an outpatient basis (ie, ambulatory surgery).
Form 1: Surgical Patient Preparation
In the general surgery departments, we collected data about methods of hair removal and showering, class of operation performed, National Nosocomial Infections Surveillance system (NNIS) risk index,11 surgical drain system used, and methods of antimicrobial prophylaxis. In the hospitals with only 1 general surgery department, a data collection form was compiled for each surgical patient during 1 week. In the hospitals with 2 or more general surgery departments, a maximum of 30 forms were filled in, to ensure a representative sample of various types of surgery.
Form 2: Infection Control Practices
In the operating room, the observation data collected, on the basis of the standards recommended by the international guidelines,1 were the number of persons in the operating room, the number of times doors were opened, the surgical attire worn, the use of preoperative hand and forearm antisepsis procedures (ie, surgical scrub and antiseptic washing), and the use of aseptic techniques in donning surgical attire. In the hospitals with only 1 operating room used by the general surgery department, operative characteristics of all interventions were observed for 1 week. In the hospitals with 2 or more operating rooms used simultaneously, observation was rotated to verify over the course of the observation week the infection control practices used by the different surgical teams.
Data Recording and Analysis
The data on the forms were recorded and analyzed using Epi Info 2000 software, version 3.1 (CDC).
Results
Form 1: Surgical Patient Preparation
In the evaluation of surgical patient preparation, 856 operations (43.2% of which were day surgery) were observed; 57% were performed on men. Of the 803 operations for which data were available, 133 (16.6%) were laparoscopic procedures. Of 815 patients, 85 underwent multiple interventions. Of 807 operations, 201 (25%) involved placement of a prosthesis, of which 191 (95%) were for hernia repair.
Information on the class of operation was available for 96% of operations, the patient's American Society of Anesthesiologists (ASA) physical status score was available for 93% of operations, and it was possible to calculate the NNIS risk index for 87% of operations. Eighty‐nine percent of surgical wounds were clean (class I) or clean‐contaminated (class II). Eighty‐four percent of patients had an ASA score of 1 or 2, and 81% of patients had a NNIS risk index of less than 3.
A total of 88% patients had hair removed, and 78% had a shower (either on the day before or on the day of the operation). Methods used for presurgical hair removal and showering are shown in the Table: data on showering included patients who underwent day surgery. Of 585 patients, 80% showered with soap, and 20% with an antiseptic product.
A surgical drain was placed in 217 (26.8%) of 811 operations; in 187 (86.4%) of these 217 operations, a closed drainage system was used. In 92 (13.7%) of the 670 nonlaparoscopic operations, the drain was placed through the surgical wound.
Antimicrobial prophylaxis was administered to 526 (63.6%) of 827 patients; of these 526, a total of 68.4% received the antibiotic on induction of anesthesia, 27.7% on the day of the operation (mean ± SD, 
minutes before the operation; median, 30 minutes before the operation [75th percentile, 60 minutes]), 3.4% during the operation, and 2% the night before the operation. Evaluated on the basis of recommendations in the most recent guidelines9,10 the choice of antimicrobial prophylaxis agents was appropriate in 56% of operations, acceptable in 27%, and inappropriate in 4.8%. The most commonly used antimicrobials were cefazolin (23% of operations), amoxicillin–clavulanic acid (17%), and ampicillin‐sulbactam (16%). A combination of 2 antimicrobials was administered in 8% of operations; taking the spectrum of activity of the antimicrobials as the criterion for appropriateness of selection, the choice of agents was appropriate in only 10% of operations, completely inappropriate in 50% (ie, the antimicrobials had the same spectrum of activity), and questionable in 40% (ie, the antimicrobials had overlapping spectra of activity). In 2.8% of operations, an additional dose of antimicrobial prophylaxis was administered during the operation. In 42.5% of operations, prophylaxis was continued into the postoperative period. Prophylaxis was continued for 24 hours in 104 (48%) of operations (42 surgical wound class I operations, 49 class II operations, and 10 class III operations) and for longer than 24 hours in 114 operations (27 surgical class I operations, 61 class II operations, and 11 class III operations).
Form 2: Infection Control Practices
For the evaluation of infection control practices, 799 operations were observed, with a mean of 16 operations per hospital. In the operating room, the infection control procedures practiced by 4,933 surgical personnel (1,727 surgeons, 736 anesthesiologists, 798 instrument nurses, 1346 nurses, and 386 observers) were observed.
The mean number of persons in the operating room during the operation was 6. During the operation, doors were opened an average of 12 times (75th percentile, 15 times); in 3% of operations, doors were opened more than 50 times. In teaching hospitals, the number of persons present in the operating room was significantly higher (
, Student's t test for independent samples) than in nonacademic hospitals.
Surgical attire. A cap/hood was worn by surgical personnel, except for 1 anesthesiologist (0.1% of observed anesthesiologists); 87.5% wore a cap/hood correctly so that it fully covered head hair; 97% wore a mask correctly so that it fully covered the nose and mouth, as well as the beard (when present). The percentage of healthcare personnel who did not wear a cap/hood or mask correctly is shown in Figure 1. Notably, 14% of surgical team members and 37.9% of anesthesiologists did not change their mask between operations even when it was visibly soiled.
Figure 1. Percentages of healthcare personnel in the operating room who did not correctly wear a surgical mask and cap/hood or wore jewelry (rings, bracelets, and/or wristwatch).
A surgical gown was worn by 98% of persons present in the operating room; 1% of persons in the operating room wore garments other than those considered part of surgical attire (eg, t‐shirts), and for 1%, the information was missing. Operating room clogs or shoe covers were worn by 96% of persons in the operating room (data were missing for 2% of persons); 6.8% of anesthesiologists did not wear either type of footwear.
Safety shields for protecting eyes and mucosa were worn by 24.6% of surgeons, 41.4% of instrument nurses, and 10.4% of anesthesiologists. Only normal eyeglasses were worn by 5.3% of surgeons, 3.5% of instrument nurses, and 4.1% of anesthesiologists.
Jewelry (ie, neck jewelry, earrings, rings, bracelets, and/or wristwatches) was worn by 11.6% of surgeons, 22.1% of instrument nurses, 56.1% of anesthesiologists, and 45% of other persons in the operating room. The percentage of healthcare personnel wearing a ring, wristwatch, or bracelet is shown in Figure 1. Some 15.5% of anesthesiologists wore 2 pieces of jewelry, and 2.4% wore 3 pieces. A total of 96% of surgery team members adhered to the principles of asepsis for donning gloves and sterile gowns.
Presurgical hand and forearm antisepsis. A total of 95% of persons present in the operating room had short fingernails (98% of surgery team members). Antiseptic hand washing was performed by 97.1% of anesthesiologists, 98.1% of nurses, and 85% of other persons present in the operating room. Of these personnel who performed antiseptic handwashing, 48.4% of anesthesiologists, 57.4% of nurses, and 30% of other healthcare personnel performed the scrubbing technique correctly.
A total of 99.7% of surgical team members (data were missing for 0.3%) and 1.9% of anesthesiologists performed preoperative hand scrubbing. Of these, 74.6% of surgeons, 86.8% of instrument nurses, and 73.3% of anesthesiologists scrubbed in the correct sequence and for the correct amount of time. Major divergences from the scrubbing technique guideline recommendations are shown in Figure 2.
Figure 2. Percentages of healthcare personnel in the operating room who neglected to observe correct surgical scrubbing technique.
Discussion
An analysis of our data in comparison with CDC category IA and IB recommendations for the prevention of SSI1 revealed several situations that merit discussion and warrant corrective action. With respect to presurgical preparation of the surgical patient, divergences from the international guideline recommendations were found in the timing of and methods used for hair removal. This procedure should be performed immediately before the operation, preferably using a hair clipper (recommendation category IA), whereas the data from our study showed that, in 60% of operations, hair removal was performed the day before the operation, and in 75% of operations was performed by razor shaving. The lack of personnel does not always allow optimal patient management, as regards timing, and clippers were not available in some surgery departments.
Preoperative showering, which should be performed using an antiseptic detergent the night before the operation, at the earliest (recommendation category IB), was correctly timed in 78% of operations, but an antiseptic agent was used in only 20% of operations and in far fewer (8.3%) of day surgeries. Preoperative showering and hair removal are 2 procedures that carry organizational and economic implications and involve both the nursing staff and hospital administrators.
The timing of antimicrobial prophylaxis was correct to ensure efficacious tissue concentrations of the drugs in 84% of operations, although a margin for improvement existed in the 25% of operations in which prophylaxis was given more than 60 minutes before the operation. The choice of antimicrobial agent was not always in line with current guidelines and was incorrect in 5% of operations. The use of third‐generation cephalosporins (ceftazidime in 0.2% of operations and ceftriaxone in 2.9%), antibiotics reserved for therapeutic use (piperacillin‐tazobactam in 1.5% of operations and ticarcillin–clavulanic acid in 0.4%) and glycopeptides (teicoplanin in 0.2% of operations) was reasonable. In class I and class II operations, the administration of antimicrobial prophylaxis should be reserved for immediately before the operation and continued for no longer than 24 hours after the operation. In our study, we found that antimicrobial prophylaxis was continued for more than 24 hours in 20% of operations, in 25% of which prolonged administration might have been warranted by an elevated ASA score (ie, a score of 3 or more). Since multidose prophylaxis has not been shown to be more effective than single‐dose administration in preventing infections, and since the prolonged use of antibiotics is associated with the emergence of resistant bacterial strains, it would be wise to decrease the number of operations in which antimicrobial prophylaxis is prolonged for more than 24 hours.
An open surgical drain system was placed in 13% of operations. Although recommendations (category IB) call for placement of a drain through a separate incision, in approximately 14% of nonlaparoscopic procedures, the drain was placed through the surgical wound; only in approximately half of these might this have been justified by the type of operation.
With respect to the infection control practices that healthcare personnel routinely use in the operating room, concern arises about the number of times the doors of the operating room are opened. The CDC guidelines advise (category IB) limiting the number of times doors are opened to allow passage of personnel, equipment, and patient. Our study found that doors are often opened during the operation and that doors are not closed in 26% of operations. Here, too, a revision of the logistics and work organization (especially the work of anesthesiologists and nurses) should be included among the more critical situations.
The mean number of persons present in the operating room was that expected for a typical operation (6 or 7 persons), although in 5% of operations there were 5‐7 surgeons, and in 6% there were 4‐10 persons classified as “other personnel” because the setting was a teaching hospital (with medical or nursing students) or a hospital where more complex operations that require a big staff were done.
There is a margin for improvement in the performance of surgical scrubbing (recommendation category IB), especially in cleaning underneath fingernails, duration of antiseptic use, and rinsing and drying.
With respect to the wearing of surgical attire and jewelry, the surgical personnel category that least adhered to recommendations was the anesthesiologists, who did not correctly wear a cap/hood or a mask (recommendation category IB) in 20% of operations and wore jewelry (rings, wristwatches, and/or bracelets) in 30% of operations. Although not wearing jewelry is rated as category II in the CDC recommendations, it is important to observe this recommendation, because jewelry does not allow adequate hand washing, can be an obstacle in emergency maneuvers, can impede the correct putting on of gloves, and may injure the patient.
A notable divergence was observed in the rate of use and the ways of use of individual safety devices for protecting the skin and mucosal tissues. Italian law12 and international guidelines should provide a basis for evaluation of this procedure, by means of audits with feedback to healthcare workers and by means of continuing education in medicine.
In addition to furnishing regional data, our study provided an opportunity for the individual hospital staff in charge of nosocomial infection prevention to meet and share feedback of appropriate data with healthcare workers. It was found to be a valuable instrument for evaluating the application of prevention procedures, and it holds potential for use in future before‐after studies on this question, after specific training of the surgical team.
Piemonte Nosocomial Infection Study Group
G. Arditi, A. Biglino, V. De Micheli, G. Marchiaro, A. Moiraghi Ruggenini, R. Reale, S. Romagnoli, R. Serra, and M. L. Soranzo (Regional Study Group, Direzione 27, Assessorato alla Sanità [ASL]); G. Attanasio, S. Fantino, and G. Zanon (ASL 2); P. Caramello, P. Bianco, and L. Pani (ASL 4); N. Gentile, V. Rolando, and B. Viviani (ASL 5); N. Pasetto and A. Buono (ASL 6); T. Bassani and R. Musca (ASL 7); A. Pasqualucci, G. Chiozza, and P. Castagno (ASL 8); F. Arnoletti, M. Boux, and E. Mattea (ASL 9); B. Nucci, M. C. Allochis, and P. Costantino (ASL 10); S. Gatti, E. Pastorelli, M. Franchino, and C. Signoris (ASL 11); F. Chieppa, C. Colono, and M. Daglio (ASL 12); E. Pagani, B. Bacchetta, L. Signorotti, and L. Zanetti (ASL 13); O. Ossola, L. De Giorgis, M. Bignamini, and R. Pesce (ASL 14); M. Salvatico and L. Ghiglia (ASL 16); M. Rebora, N. Rosati, and S. Gerbaudo (ASL 17); G. Corso, S. Cabutti, and M. Noè (ASL 18); L. Bernini, G. Marchese, and M. Pozzebon (ASL 19); O. Dellalibera and A. Pernecco (ASL 20); G. Parovina, E. Ferrando, and C. Degiovanni (ASL 21); D. Balestrino, L. Bisogni, and E. Pesce (ASL 22); E. Guglielmi, N. Piccin, and A. Di Leo (Azienda Sanitaria Ospedaliera [ASO] S. Giovanni Battista); F. Gremo, G. Guidi, and S. Bagnato (ASO CTO–CRF–Maria Adelaide); G. Guareschi and R. Demartino (ASO O.I.R.M.‐S. Anna); P. Silvaplana and A. Lazzarin (ASO S. Luigi); S. Borrè, E. Coppini, and E. Morici (ASO Maggiore della Carità); P. Pellegrino and P. Occelli (ASO S. Croce e Carle); G. Lomolino and F. Piccio (ASO SS Antonio e Biagio e C. Arrigo, Alessandria); R. Sacco and V. Rigobello (Casa di Cura “Ospedale Cottolengo”); and C. Macchiolo and A. Clarichetti (Presidio Sanitario “Gradenigo”).
Acknowledgments
We thank Kenneth Britsch for translating the manuscript.
Supported by a grant from the Piemonte regional government, 2002.
References
- 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999; 20:250‐278.
- 2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121:182‐205.
- 3. Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003; 54:258‐266.
- 4. Delgado‐Rodriguez M, Gòmez‐Ortega A , Sillero‐Arenas M, et al. Efficacy of surveillance in nosocomial infection control in a surgical service. Am J Infect Control 2001; 29:289‐294.
- 5. Gastmeier P, Brauer H, Forster D, Dietz E, Dascner F, Ruden H. A quality management project in 8 hospitals to reduce nosocomial infections: a prospective, controlled study. Infect Control Hosp Epidemiol 2002; 23:91‐97.
- 6. Moro ML, Petrosillo N, Gandin C, Bella A. Infection control programs in Italian hospitals. Infect Control Hosp Epidemiol 2004; 25:36‐40.
- 7. Zotti CM, Messori Ioli G, Charrier L, et al. Hospital‐acquired infections in Italy: a region wide prevalence study. J Hosp Infect 2004; 56:142‐149.
- 8. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706‐1715.
- 9. SIGN—Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery. July 2000. SIGN Publication 45. Available at: http://www.sign.ac.uk/guidelines/fulltext/45/index.html. Accessed July 13, 2006.
- 10. PNLG— Programma Nazionale Linee Guida. Antibioticoprofilassi perioperatoria nell’adulto. Linea Guida. Milan, Italy: 2003. Available at: http://www.pnlg.it/LG/. Accessed July 13, 2006.
- 11. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004; 32:470‐485.
- 12. Decreto Legislativo N° 626 del 19/09/1994. Attuazione delle direttive 89/391/CEE, 89/654/CEE, 89/655/CEE, 89/656/CEE, 90/269 /CEE, 90/270/CEE, 90/394/CEE, 90/679/CEE, 93/88/CEE, 97/42/CEE e 1999/38/CE riguardanti il miglioramento della sicurezza e della salute dei lavoratori durante il lavoro.
-
Presented in part: 1st SIMPIOS (Società Italiana Multidisciplinare per la Prevenzione delle Infezioni nelle Organizzazioni Sanitarie) National Conference 2004 (Bergamo, 20–22 May 2004) (poster and abstract A13). The abstract was published in Giornale Italiano delle Infezioni Ospedaliere 2004; 11(Suppl):19 [Abstract A13].