Importance of Infection Prevention from SSI and Use of Care Bundle Checklist

The bundle approach to providing medical care has become increasingly popular in recent years. A care bundle is a group of interventions which when delivered together lead to a better outcome than performing interventions individually, representing an improvement over a non-structured approach.

A care bundle is a group of three to five evidence-based interventions which, when performed together, have a better outcome than if performed individually. Care bundles can be used to ensure the delivery of the minimum standard of care. 

Key Focusing points about Care Bundles:

•      A care bundle is a group of three to five evidence-based interventions which, when performed together, have a better outcome than if performed individually.
•      Care bundles can be used to ensure the delivery of the minimum standard of care.
•      They can be used as an audit tool to assess the delivery of interventions but do not assess how well individual interventions are performed.
•      Care bundles should encourage the review of evidence and modification of clinical care guidelines, engendering staff education in best practice.
•      The sepsis care bundle, part of the international Surviving Sepsis campaign, is the most widely utilized bundle.

Meaning of Surgical Site Infection (SSI):

This refer to infections that show evidence of purulent discharge around the surgical wound, the insertion site of the drain, or spreading cellulitis from the wound. The incidence of surgical site infections varies from 0.5 to 20% depending upon the type of surgical procedure and the underlying patient condition. They pose a significant risk and limit timely recovery and potential benefits of surgical procedures.  There is also is a considerable impact on hospital costs and post-operative length of stay (between 3 to 20 additional days).

Usually, the infection is acquired during the surgical procedure itself from exogenous sources (e.g. Air, Equipment, Dressing Material, Surgeons etc.).

Endogenous sources (e.g. Flora on the skin, within the operative site or rarely from the blood used during surgery). The infecting microorganisms could be many according to the type and location of surgical procedure and the antibiotics received by the patient.     

Definition of Surgical Site Infection:

Surgical Site Infection can be defined as “Infection on the surgical site that occurs within 30 days of the surgical procedure or within one year if there is an Implant or foreign body, such as Prosthetic Heart Valve or joint Prosthesis”.  

Common organisms causing SSIs:

Staph. aureus, E. coli, Klebsiella spp., Enterococcus faecalis, Pseudomonas spp., anaerobic bacteria such as Bacteroides spp.

Surgical Wound Classification:

Clean:

Operation where no inflammation encountered, Respiratory, Alimentary, Genital, Urinary Tract not entered. Operation following non penetrating trauma, Primary closed with no open drainage.     

Example: Lumpectomy, Mastectomy and Laparoscopy etc.

Clean Contaminated:

Operation entering respiratory, Alimentary, Genital, Urinary Tracts, No evidence of infection, no major break in techniques, no usual contamination encountered.

Example: Cholecystectomy with chronic inflammation.

Contaminated:

Operation following open, fresh, accidental wounds, operation with major breaks in sterile techniques (e.g. Open Cardiac Massage) or gross spillage from GI Tract, Includes operation where acute, non-purulent inflammation encountered.

Example:  Cholecystectomy or Appendicectomy for accurate inflammation.

Dirty:

Operation involving old traumatic wounds with retained devitalized tissues, or existing clinical infection or perforated viscera, Definition suggests the organisms causing post-op infection were present before the operation.

Example: Infected Surgical procedures incision and drainage of perirectal abscess.

Risk Factors Related to Procedure:    

• Gender
• Age
• Surgical Wound Classification: Clean, Clean Contaminated, Contaminated and Dirty
• Duration of Surgery: From Incision to Wound Closure Time
• Type of Case: Planned, Emergency and Trauma
• Type of Surgery: Endoscopy decrease risk, e.g. Chances of HAI are less in case of Hysterectomy done Laparoscopically than Laparotomy.
• Procedure Based: Spinal Anaesthesia or General Anaesthesia, Hip Prosthesis – Total or Partial, Knee Prosthesis – Primary or Revision.
• Co Morbidities: Diabetes, Smoking etc.

Signs and Symptoms:

• The common clinical features of surgical wound infection are localized Pain, Redness and Discharge.
• Fever that occurs within 4 weeks of surgery, without other localizing features, is likely to be caused by infection at the surgical site.
• Deeper or Organ Space infection may require imaging for diagnosis, surgical drainage and antimicrobial therapy guided by culture of the purulent material. 

Strategy for Surgical Prophylaxis: As Per Centre For Disease Control (CDC)

• Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines within 1 hour prior to incision select appropriate agents on basis of surgical procedure, most common SSI pathogens for the procedure as per published recommendations.
• Discontinue antibiotics within 24 hours after surgery ( 48 Hours for Cardiac Surgery)
• Identify and treat remote infections when possible
• Hair Removal (Do Not remove hair at the operative site unless it will interfere with the operation)
• Do Not Use Razors for Hair removal ( if necessary, remove by clipping or by use of depilatory agent)
• Maintain Immediate post-operative normothermia
• Surgical wound Dressing: Protect primary closure incisions with sterile dressing for 24 to 48 hours in Post op.
• Control Blood glucose level during the immediate post operative period. (Maintain post op blood glucose level at less than 200mg/dL.   

Written by:

Dr. Praveen Bajpai

Director of Ingenious Healthcare Consultants Pvt. Ltd.
Founder of Skill Sathi

MBA in Hospital administration, PG Diploma in Quality Accreditation, PG Diploma in Medico Legal System, M. Phil in Hospital Mgmt. from BITS Pilani, P.hD in Management, Certified NABH Auditor, Certified NABL Auditor, Certified Auditor for Clinical Audits, Green Belt in Six Sigma, Certified in Hospital Infection Control Practices, Certified trainer for International Patient Safety Goals, Certified Auditor for JCI 7th Edition Standards 

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