Surgical Site Infections
Various Micro Organisms Involved in SSIs
A surgical site infection is a type of health care associated infection in which a wound gets infected after a surgical or invasive procedure. It occurs after surgery, in those parts of the body where the invasive procedure took place (Rao and et.al., 2011). I am a nurse in the surgical ward. My area of work covers the duties and responsibilities of a surgical nurse. This includes preparing the patient and equipments for various procedures so that, assistance could be provided to the surgeon. Basic bedside care is provided by me to the pre and post-surgical patients (Dohmen, 2006). It is my duty to use aseptic techniques during wound care and dressings.
The present report will be addressing the issue of surgical site infections (SSI). Infection of surgical site is a serious issue because it can involve tissues under the skin, organs and implanted materials and therefore can cause harm to them. In this report, an introduction of a SSI will be provided. Common organisms which cause the underlying infection will be identified. There will also be discussion on the common procedures that predispose a person to surgical site infection. Further, in the report, risk factors concerned with the endogenous and exogenous routes of transmission will be analyzed. NICE guidelines will be referred for finding solutions for prevention of SSI. A model of change will be used according to its suitability to the nature of the proposed improvement.
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A surgical site infection is the one which 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 et.al., 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.
A normal wound health process comprises of three stages. These are the following:
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 remodeling phase and is the final stage.
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 innoculum 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 theater environment. Sometimes, the microorganisms gain access on the wound before the skin is sealed.
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.
SSIs are one of the most important causes of health care associated infections. According to 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 significantly impact the quality of life of a patient. 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.
The most common organisms which cause wound infections are Staphylococcus Aureus, Streptococcus pyogenes, eterococci and pseudomonas aeruginopsa.
Methicilin 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 (Hawn and et.al., 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.
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.
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 et.al., 2013). These cause infections in the surgical sites.
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:
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.
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 et.al, 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 et.al., 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.
Moreover, in a normal healthy individual, the wounds heal through an orderly sequence of physiologic events including inflammation, epithelialization, fibroplasia and maturation (Abdul-Jabbar and et.al, 2012). However, there has been observed wider discrepancy in the incidence of incisional SSI after a colorectal surgery. This is because colonic surgery is subject to other sources of bacterial contamination as well. One source can be skin colonization. This source is responsible for surgical site infections which result from gram positive bacteria.
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:
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:
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 hyperglycemia (Richards and et.al., 2012).
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Patients who experience acute perioperative hyperglycemia 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 defense 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 et.al., 2011). This is because malnourished patients are found to have less competent immune response to infection.
Sometimes the patients may harbour indolent dental, urinary of soft tissue infections of the skin during surgery. Preexisting remote body site infection acts as a source of hematologist spread. It also acts as a contiguous site for bacterial transfer.
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 hemoglobin (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:
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 risk factors include operating room environment, surgical attire and drapes, asepsis and surgical techniques. The operating room may contain lint, skin squalms, microbial laden dust and respiratory droplets. This may increase the chance of infection of the surgical site (Rao and et.al., 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.
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:
There is a need to bring a reduction in the ongoing surgical infections in the surgery ward where I am working. It can be done by adopting various approaches related to change management. In this regard, there can be an application of Kotter’s model related to change management. The selection of model has been justified so as to bring quick as well as continuous transformation and deliver powerful results. This will further aid in generating proper mindset among the healthcare professional so as to lead change.
Creating a sense of urgency- The first step entails for creating a sense of urgency. This can happen by highlighting a case where a surgical infection led to many complications or even death of patient. This will help in making the management and health care workers aware about how urgent is the situation.
Build a Guiding Coalition – The second step will entail for forming a team of employees who can aid in bringing in the requisite change (Dohmen, 2006). These may involve the supervisors, management, head nurses as well as those who are in charge of infection control department present in the hospital.
Form a Strategic Vision and Initiatives- There may further be a need to formulate a strategic vision. It may be to bring a zero percent rate of surgical infection. His vision will aid in taking initiatives by which the will have a likelihood to convert into reality.
Enlist a Volunteer Army – The given step will entail in encouraging volunteers who are ready, willing as well as urgent to drive change. This step will aid to bring change in a substantially faster manner.
Enable Action by Removing Barriers – The given change may lead to generation of many challenges. It may be lack of support from top management, absence of proper finances, work load on supervisors so as to guide change in the proper manner among others. In this regard, several steps can be taken to address the set of challenges. These can be in the form of convincing the management about the advantages of controlling surgical site infections, taking loans from bank as well as adjusting the work load on supervisors by recruiting more health care staff.
Generate Short-Term Wins –The need is to bring a reduction in surgical site infections. Hence, even a small reduction should be celebrated. This will motivate the other staff and healthcare professionals to adhere with the phenomenon of infection control practices (Namba, Inacio and Paxton, 2013).
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Sustain Acceleration – In order to ensure that, the reduction in infection control mechanism is carried out in a sustained manner, the need is to promote and envelop those health care professionals and staff members who can implement the vision. In the same way, steps can be further taken to recruit more staff members so as to bring an improvement in infection control policies.
Institute Change – The given step will assist in articulating the connection between the new behaviors and the organizational success. This will further aid in developing the means to ensure for development of proper policies and practice related to infection control (Shabanzadeh and Sørensen, 2012).
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.
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