Special Edition on Operating Room Imperatives Special Edition- Operating Room Imperatives | Page 26

Surgical Stewardship:
A New Frontier in
Preventing Surgical
Site Infections
By Peter B. Graves, BSN, RN, CNOR, and Maureen Spencer, MEd, BSN, RN, CIC, FAPIC
P
reventing surgical site infections (SSI) requires a signif-
icant investment by patients, healthcare professionals,
and institutions. SSI prevention begins with entry into the
healthcare system, through their successful discharge and
return of their optimum health. This process in total, is
surgical stewardship. Surgical stewardship focuses upon
improving each patient’s outcomes by applying the best
evidence-based practices and research with every patient.
A multidisciplinary approach is vital to the success of a
robust surgical stewardship program, with all members
contributing to prevention measures throughout the three
perioperative phases.
Surgical stewardship requires action by everyone. This
is accomplished through advocacy, education, implemen-
tation of evidenced-based practices, the measurement and
assessment of patient outcomes, and in the dissemination
and sharing of results.
In order to capitalize on the benefits of a surgical
stewardship program, there are key evidence-based
activities the entire care team should utilize. A seven-step
evidence-based bundle can be used as a foundation for a
surgical stewardship program.
➊ Safe Operating Room
The foundation of every surgical stewardship program
is having a safe perioperative environment where care is
delivered and received. A key aspect of establishing a safe
operating room is the implementation of national standards,
recommendations and guidelines by the healthcare team
and institution. The Association of periOperative Registered
Nurses (AORN) has published numerous peer-reviewed
guidelines focused on preventing surgical site infection and
establishing a safe operating room. The entire care team
should be knowledgeable about the national standards that
are related to infection prevention within the perioperative
setting, which include:
Aseptic Practices
Sterilization and
Disinfection
—Patient Skin
Antisepsis —Flexible
Endoscopes
—Environmental
Cleaning —High Level
Disinfection
—Hand Hygiene —Instrument Cleaning
—Surgical Attire —Packaging Systems
—Sterile Technique —Sterilization
Patient and
Worker Safety
—Sharps Safety
—Transmissible
Infections
—Environment of
Care
➌ Pre-Surgical Showers
Source: AORN, Guidelines for Perioperative Practice, ed. R. Connor. 2020, Denver,
CO: AORN, Inc.
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➋ Pre-admission Screening for Risk Factors and
Colonization with Staphylococcus aureus
Preadmission risk factors
During the preoperative period, the goal is to fully prepare
the patient for surgery by identifying risk factors that must
be corrected in order to have the patient in the best possible
health prior to surgery. Addressing and correcting these risk
factors should be the focus of the preadmission care plan.
Once the patient has achieved their health goal, they
are ready for education and counselling. 1 Patients should
receive individualized education and written instructions
regarding their specific surgical preparation, not simply the
surgical procedure. Delivery of individualized education/
counseling should be focused on assisting the patient with
meaningful lifestyle modifications that can influence SSI risk
reduction (e.g., smoking cessation, alcohol consumption,
and/or nutritional support). 2-5
Preoperative education and counseling is focused on
reinforcing SSI reduction measures by lowering their anxiety
and promoting better retention of education provided. 6-9
Maintaining normothermia is a proven strategy to reduce
SSI and other complications. “There are many methods
described to conserve body temperature, including pre-warm-
ing and humidification of anesthetic gases, warming IV
and irrigation fluids, and forced air-warming blankets and
devices.” 10 However, there is some controversy about the
safety of forced air-warming (FAW) since contaminants
may be dispersed into the air and land in the surgical field.
Although ECRI Institute and AORN have stated that FAW
is safe, there are a few articles and a guideline questioning
the safety of FAW and the increased risk of surgical site
infection. 10-16
Screening for Staph aureus
Mitigating the risks of methicillin-resistant Staphylococcus
aureus (MRSA) and methicillin-sensitive S aureus (MSSA)
by using active surveillance, preoperative nasal screening,
and selective decolonization protocols is common in many
hospitals, especially for high-risk surgeries such as prosthetic
joint implants. Patients found to be colonized in their nares
are at a higher risk of developing an SSI. If a patient is
found positive, then a preop nasal and body decolonization
protocol would be implemented. If they are colonized with
MRSA, the surgical prophylaxis is adjusted for coverage of
the resistant strain.
To decolonize the skin prior to surgical admission, a
preoperative shower is recommended the night before and
morning of surgery. The shower can be done with liquid
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