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What is Health care associated infections (HCAI)?

Health care associated infections (HCAI) occur due to medical/surgical treatment or while coming in contact with a health care setting. They generally occur in hospitals, care settings and have a tendency to affect both patients and health care workers (Welsh healthcare, 2015). As per the data, 1 in 25 patients of the Welsh hospital present with from health care associated infection on any single day. The data is similar to the hospitals that are spread across UK and Europe (Welsh healthcare, 2015). The reasons for developing this health care associated infection is due to decrease in defence mechanism of patients. This happens as they undergo complex treatment procedures for cancers, leukaemia and organ transplants (McAlearney and, 2013). These make the body more susceptible to microbes. Medical devices such as urinary catheters also provide an entry point for infection. Other than that poor hygienic standards followed in hospital premises, lack of isolation facilities and inadequate hand washing increases the risk of passing on infections (Marfin, 2012).

According to definition by Centres for Disease Control and Prevention Surgical Site infections are those that occur after surgery in the body part where surgery took place (Surgical Site Infection (SSI), 2015). These infections are mostly prevalent after a patient undergoes orthopaedics, GI and Bowel surgery.

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According to revised 2010 NICE, surgical site infections consist of 20 per cent of all the health care associated infections (Surgical site infection: Prevention and treatment of surgical site infection, 2014). Most patients who undergo a surgery do not develop an infection. However, out of every 100 patients who have a surgery, SSI develops in about 1 to 3 of them (Bunn, Jones and Bell‐Syer, 2012).

Surgical site infections can be prevented by following evidence based guidelines related to hand hygiene, administrating prophylactic antibiotics and perioperative patient temperature management (Lee and, 2010). Prevention is further possible by increasing the awareness of patients as well as health care professionals. However, it has been regarded as a problem as these infections are costing a lot to the health care systems across UK. The infection rate has put a high pressure on health care departments to take the safety of patient on a serious note. Surgical site infections significantly impact the quality of life of a patient (Lubin and 2013). They lead to morbidity and extend the stays in the hospitals. Apart from causing a great deal of suffering to the patients, surgical site infection also causes a considerable financial burden to the health care providers (Misteli, 2009).

The registered nurses (RN) play a key role to reduce the risk of infection by providing the requisite amount of care. They are further required to ensure that cleanliness is maintained in the hospital premises (Rao, 2011).

As registered nurses in surgical ward, there area of work covers the duties and responsibilities of a surgical nurse. This includes preparing the patient and equipment’s for various procedures so that, assistance could be provided to the surgeon. Basic bedside care is provided to the pre and post-surgical patients (Dohmen, 2006). It is the duty of registered nurse to use aseptic techniques during wound care and dressings. The registered nurse is further required to have a good knowledge base of SSI and Health care associated infections so as to reduce their spread (Cimiotti and, 2012). They should also have knowledge about the chain of infection so as to bring a reduction in them. The chain of infection is a series of links that include pathogen, reservoir, portal of exit, means of transmission, portal of entry, and the new host. Each link has a unique role to play in the given chain and these can be broken by different means. The registered nurses can play a key role towards breaking the chain of infection (Wick and, 2012) . They can do this by timely washing the hands, preparing patient pre operatively, maintain a clean hospital environment, assessing risks such as underlying disease (Oman and, 2012).

SSI develops after a surgery in the area where the surgery took place. This becomes visible in the form of redness and pain around the area where surgery has been taken place. There also occurs drainage of cloudy fluid from the surgical wound. Another symptom which is accompanied with SSI is fever (Blissmer and, 2006). A common cause of most of the surgical site infections is contamination of an incision with microorganisms which are present on the body of the patient himself (Mu and, 2011). A normal wound healing process comprises of three stages. These are the following:

  • Inflammation
  • Regeneration
  • Maturation (Diabetic foot ulcer, 2015)

Inflammation consists of a cascade of processes which can be further subdivided into early and late phases. During the early inflammation stage, homeostasis and platelet aggression takes place (Scott and Buckland, 2006). Vasodilators are released during the later stages of inflammation. The phase of inflammation ensures that, the wound bed is free of bacteria and other types of contaminants. Over the next few days of weeks, regeneration takes place. Maturation is known as the remodelling phase and is the final stage. Registered nurse in order to minimise wound infection should be knowledgeable about aseptic technique, disinfection practices, chain of infection. They are further required to possess the skills related to promoting the practice of hand hygiene among patients and other health care professionals (Trinkoff and, 2011). They must educate the patient towards wound infection and the rationale for using a particular strategy and treatment. The registered nurse should also be in an excellent position to identify the unexpected signs and symptoms on patients for reducing the infection transmission and expediting patient treatment (Needleman and, 2011)

Development of surgical site infection

The development of an SSI is dependent on contamination of the wound site at the end of a surgical procedure. It is specifically related to the pathogenicity. Another aspect which is important to be considered here is balance between the presence of inoculum of microorganisms and immune response of the host (Anderson, 2011). Mostly, the microorganisms that cause SSI are present on the skin of the patient. Exogenous infection takes place when site of operation is contaminated by microorganisms from the instruments or theatre environment. Sometimes, the microorganisms gain access on the wound before the skin is sealed (Darouiche and, 2009). Surgical site infections are of three types:

Superficial incisional SSI- This type of infections develops only in that area of skin where the surgical incision was made (Surgical Site Infections, 2015). This infection produces pus which is known as purulent discharge.

Deep incisional SSI- In this type of SSI, the infection reaches beneath the incision area. In such situations, the infection develops in the muscle tissue and fascia which was involved in the surgery (Namba, Inacio and Paxton, 2013.). This may consist of the tissue surrounding the muscles. Further, in this type of infection, there may be production of pus. Also, the wound site may reopen on its own.

Organ or space SSI- This type of infection may develop in any area of the body other than muscle, facia and skin. Therefore, the infection may develop in a body organ or space between the organs. This is characterized by discharge of pus from a drain placed through the sin into the body space (Webster and Alghamdi, 2013). When such a wound is reopened, an abscess may be found. The most common organisms which cause wound infections are Staphylococcus Aureus, Streptococcus pyogenes, enterococci and pseudomonas aeruginosa. In order to aid in women healing process, the need is to carry out laparoscopic, open, or percutaneous drainage followed by intake of systemic antibiotics. The antibiotic should have a good tissue penetration so as to reach the wound (Wound infections, 2015).

Infections caused by Staphylococcus aureus: Methicillin Resistant Staphylococcus aureus is an increasingly important pathogen which causes infections of the surgical sites. This leads to decreased frequency of primary healing and delayed healing of wounds. This causes all the three types of surgical site infections being superficial incisional SSI deep incisional SSI organ or space SSI (Hawn and, 2011). Most of the infections caused by this pathogen occur because of contamination of the surgical site after the closure of the site. The exposure of the port operative site to this microorganism is facilitated by prolonged antibiotic pressure. The infection also occurs when the drains are left in place for more than a day. This leads to organism becoming pathogenic when intestinal wall is disrupted and bacterial flora are exposed to interior of body. It may then start to multiply itself.

Registered nurse plays a key role in healing process. They are required to work in close coordination with other health care professionals to ensure that patients get the proper care with respect to wound healing. They are required to evaluate the patient followed by providing them with a long term strategy. In case of complex wounds such as serious burns the nurses are required to undertake its thorough cleaning, sloughing off dead skin and preventing bacteria from making an entry into injury. The registered nurse is further required to provide follow up care. This requires for assessing the progress as well as evaluating the efficiency of medications and other treatments.

Infections caused by Streptococcus pyogenic: Streptococcus pyogenes is responsible for a significant proportion of hospital acquired surgical site infections. The surgical procedures which involve cardio vascular, musculoskeletal, lymphatic, male and female genital and nervous systems may develop infection due to this pathogen (Shabanzadeh and Sørensen, 2012). Surgical patients are vulnerable to infection because they have broken mucosal and cutaneous barriers which facilitate invasive infection. The surgical site infection caused by Streptococcus pyogenes spreads to other sites in the body through lymphatic system. Surgical site infection is most commonly caused due to transmission of this pathogen from a contaminated surface.

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Surgical site infections caused by Enterococci: Enterococci are a part of normal intestinal flora of humans. The species of enterococcus are anaerobic and capable of surviving in temperatures of 60 degree Celsius (Hawn and, 2013). These cause infections in the surgical sites.

Surgical site infections caused by Pseudomonas aeruginosa: P. aeruginosa infections are caused due to contamination of tap water, contaminated patient care equipment, antiseptic solutions etc. this organism does not live on the hands of the health care workers but causes infection when transmitted from an infected object. It is a gram negative bacterium and is aerobic in nature.

There are various procedures which predispose a patient to surgical site infections. Some of them have been discussed below. This section could be about risk factors so link to identifying these prior to surgery and how is this addressed within clinical practice.

Preoperative hair removal: There is a relationship between hair removal and surgical site infections. Hair is regarded as associated with lack of cleanliness. Removal of hair before operation is linked to infection prophylaxis. Various methods are used for removing hair such as shaving, clipping and depilatory creams. However, shaving the skin leads to an increased incidence of surgical site infection (Namba, Inacio and Paxton, 2012). This is because shaving causes microscopic cuts and abrasions. This acts as a disruption of the barrier defense of skin against microorganism colonization. Clippers when used incorrectly may accidentally cut into the skin of the patients thus facilitating the entry of microorganisms. SSI can be reduced by undertaking precautionary measures while removing hair. Shaving should be carried within 24 hours as compared to immediately before operation. This leads to decreased SSI rates (Guideline for Prevention of Surgical Site Infection, 2015).
Bowel surgery: Elective colon surgery has the higher rates of infection at the surgical site as compared to any other elective surgical procedures. These infections comprise of mild superficial infections to more serious deep seated infections within the abdominal cavity (Anthony and, 2011). The duration of surgery also predisposes a patient to the surgical site infection. The length of time which is required or a colonic surgery is approximately 3 hours.

Furthermore, colonic lumen is the major source of bacterial contamination of surgical site. The most important variable which predisposes a patient to surgical site infections is the inoculum of bacteria that contaminates the site (Mu and, 2011). It is known that the greater number of bacteria at the surgical; site, the greater is the probability of infection. Human colon is regarded as a repository of a huge number of bacteria. Colon has colony counts of a large number of bacteria per gram of content. Also, there are more than 600 species of bacteria present in the colon. These bacteria are gram negative or positive, aerobic as well as anaerobic species. Surgical efforts to resect and reconstruct human colon result into surgical site infection.

Further, in colon surgery, there is observed occurrence of intra-abdominal infection after resection. Similar to the surgical incision, the intra-abdominal cavity is also exposed to a large number of micro-organisms at the time of surgical entry in the lumen of the colon (Awad, 2012). The microbial contaminants bind to the peritoneal surface. In many cases, the organisms are eliminated through the innate response of the host. However, in some cases, an organ or space infection may occur. This happens when the quantity of bacterial contamination exceeds the capacity of host for clearance. During a colon surgery, dense quantities of colonic contents spill and aggregate into the physiologic drainage basins of abdominal cavity. This causes infection after a bowel surgery. The following are the risk factors for development of a surgical site infection:

Endogenous risk factors: These are also known as patient related risk factors which can affect the risk of a person of developing an SSI. The various patient related risk factors include the following: Pre-existing diabetes: Diabetes mellitus is regarded as the major predictor or post-surgery infections. The adverse outcomes after surgery are found to be related to pre-existing complications of chronic hyperglycaemia (Richards and, 2012).Exogenous infection are spread through patient as well as hospital staff who disperse a large number of bacteria into the environment via skin, sneezing, talking as well as other body movements.

Perioperative hyperglycaemia: Patients who experience acute perioperative hyperglycaemia have an increased risk of developing SSI. This is because of two mechanisms. In the first mechanism, there is a decreased vascular circulation. This not only reduces tissue perfusion but also impairs the functions at the cellular level. The second mechanism is the reduction in the activity of cellular immunity functions (Pear, 2007). The impairments of these two natural host defence mechanisms lead to the risk of infection. Obesity is considered as possessing a body mass index of greater than or equal to 30 kg/m2.obesity increases the risk of surgical site infection. Likewise, the risk of development of an SSI increases due to malnutrition (Zywiel and, 2011). This is because malnourished patients are found to have less competent immune response to infection.

Pre-existing remote body site infection: Sometimes the patients may harbour indolent dental, urinary of soft tissue infections of the skin during surgery. Pre-existing remote body site infection acts as a source of haematologist spread. It also acts as a contiguous site for bacterial transfer.

Recent tobacco use: Cigarette smoking is regarded to interrupt with the wound healing process. It also leads to decreased circulation to the skin. This is cause as a result of micro vascular obstruction from aggregation of platelets and increased non-functioning of haemoglobin (Tanner, Norrie and Melen, 2011). Smoking also compromises of the immune system as well as the respiratory system.

The risk of an SSI increases if the wound class was contaminated or dirty, in the bile duct or liver or pancreas. The exogenous risk factors comprise of preoperative, intraoperative and post-operative issues which increase the risk of infection at the surgical site. These have been discussed below:

Preoperative issues: Lack of preoperative antiseptic showering and improper preparation of patient skin in the operating room increase the risk of infection. Preoperative hair removal through shaving which causes microscopic cuts increases the risk of infection at the site (Galal and El-Hindawy, 2011). If the members of the surgical team do not perform preoperative hand and forearm antisepsis properly, it increases the risk of infection. Furthermore, surgical personnel who have active infections or are colonized with certain micro-organisms also cause surgical site infections.

Intraoperative issues: Intraoperative risk factors include operating room environment, surgical attire and drapes, asepsis and surgical techniques. The operating room may contain lint, skin squamous, microbial laden dust and respiratory droplets. This may increase the chance of infection of the surgical site (Rao and, 2011). Scrub suits are worn by the surgical team may be subjected to different policies of wearing, covering and laundering. These may act as a source of pathogens. The staff may lack adherence to the principles of asepsis. This may increase the risk of infection. Use of common syringes and contaminated infusion pumps lead to postoperative infections. Uses of inappropriate surgical techniques which are not capable of maintaining effective homeostasis or avoiding inadvertent entries increase the risks of infection.

Post-operative issues : The risk factors under this category include incision care and discharge planning. Further, Lack of adequate postoperative incision care leads to SSI. If the patient is discharged too early, it may also increase the risk of infection (Kon and Rai, 2014). This is because the integrity of the healing incision may not be maintained at home due to lack of education of the patient and his family. The risk factors can be prevented through following ways:

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  1. The patient should be given a preoperative antiseptic showering so that, the counts of skin microbial colony decrease. The hairs should be removed just before surgery by using electric clippers. Before initiating the skin preparation of patient, it should be free of gross contamination.
  2. The members of the surgical teams who come into direct contact with the sterile operating field or sterile instruments should clean their hands and forearms properly by using effective antiseptic (Hakim, 2007.). The use of long nails and artificial nails should be strictly prohibited. There should be effective policies for preventing the spread of microorganisms from personnel to patents. There should further be a dissemination of information about how spread of microorganisms from personnel to patients can be prevented. Training, education as well as the necessary equipment’s should further be provided to the staff members.
  3. spread of microorganisms from personnel to patents
  4. Efforts should be made to minimize the personnel traffic during operations to the minimum. This is because; microbial level in the air of the operating room is directly proportional to the number of people who moves in the room.
  5. As per the NICE guidelines, flash sterilization of surgical instruments should not be used as a routine sterilization method.
  6. Scrub suits should be changed when they become visible soiled and should be laundered only in an approved and monitored laundry facility (Press, 2007).
  7. Principles of asepsis should be adhered to in a rigorous manner.
  8. Emphasis should be laid on providing proper incision care to the patient. Also, discharge planning should include educating the patient and his family.


From the report, it can be concluded that surgical site infection is a serious concern in health and social care practice. It accounts for 20 per cent of all hospital acquired infections. There are various micro-organisms which cause SSIs. These include Staphylococcus Aureus, Streptococcus pyogenes, Enterococci and Pseudomonas aeruginosa. Procedures such as hair removal through shaving and bowel surgery also predispose patients to surgical site infections. There are various risk factors of SSI, which may be endogenous or exogenous. In order to bring a reduction in the ongoing surgical infections in the surgery ward, certain changes need to be introduced. This can be done by using Kottler's model of change to improve and reduce the number of SSI’s.


  • Awad, S. S. (2012), ‘Adherence to surgical care improvement project measures and post-operative surgical site infections’Surgical infections.
  • Blissmer, B., Riebe, D.,Dye, G.,Ruggiero, L.,Greene, G. and Caldwe, M. (2006), ‘Health-related quality of life following a clinical weight loss intervention among overweight and obese adults: intervention and 24 month follow-up effects’, Health Qual Life Outcomes.
  • Bunn, F., Jones, D. J. and Bell‐Syer, S. (2012), ‘Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery’,The Cochrane Library.
  • Cimiotti, J. P., Aiken, L. H., Sloane, D. M. and Wu, E. S. (2012), ‘Nurse staffing, burnout, and health care–associated infection’, American journal of infection control.
  • Darouiche, R. O., Wall, M. J., Itani, K. M. F., Otterson, M. F., Webb, A. L., Carrick, M. M., Miller, H. J., Awad, S. S., Crosby, C. T., Mosier, M. C., AlSharif, A., and Berger D, H. (2010). ‘Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis’, New England Journal of Medicine.

Intraoperative issues: Intraoperative risk factors include operating room environment, surgical attire and drapes, asepsis and surgical techniques. The operating room may contain lint, skin squamous, microbial laden dust and respiratory droplets. This may increase the chance of infection of the surgical site (Rao and, 2011). Scrub suits are worn by the surgical team may be subjected to different policies of wearing, covering and laundering. These may act as a source of pathogens. The staff may lack adherence to the principles of asepsis. This may increase the risk of infection. Use of common syringes and contaminated infusion pumps lead to postoperative infections. Uses of inappropriate surgical techniques which are not capable of maintaining effective homeostasis or avoiding inadvertent entries increase the risks of infection.


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