Practice Guidelines for Surgical Wound Care

Clinical Practice Guideline - Surgical Infection Issue Surgical Infection Issue Clinical Practice Summary: National Collaborating Centere for Women's and Children's Health. (2008, October; reaffirmed in 2011). Surgical site infection: prevention and treatment of surgical site infection. Lodnon (UK): National Institute for Health and Clinical Excellence (NICE).142 p. [256 references]. Scope and Purpose The scope and purpose of the clinical practice guideline entitled "Surgical site infection: prevention and treatment of surgical site infection, is to provide guidance for surgical site infections (SSI).

A surgical site infection is a wound that occurs when an invasive surgical procedure has taken place. The surgical site infection guideline does not address management of the operating theatre environment and environmental factors, nor does the surgical site infection guideline address prophylaxis and management of antibiotic-resistant bacteria. Anesthetic factors relating to the surgical site infection (SSI) are also not addressed by the surgical site infection guideline. The objectives of the surgical site infection guideline are to provide an approach to intervention and practice that covers prevention, treatment, and management.

Specifically, the guideline is intended to provide a structured approach to care with clear, consistent advice for caregivers and patients that addresses pre-operative procedures, the intraoperative phase, and post-operative procedures. The surgical site infection guideline considers the following outcome measures in its recommendations and guidelines for prevention, treatment, and management: 1) The incidence of surgical site infections (SSI); 2) wound healing time; 3) mobidity and mortality; 4) cost effectiveness, as measured by the cost per infection avoided and the cost per life saved each year.

Stakeholder Involvement The methods used to formulate the recommendations for the guideline included expert consensus and informal consensus. Registered stakeholder organizations were given the opportunity to comment on the scope of the guideline in the early development and to comment on the evidence and the recommendations during the concluding stage of the creation of the guideline. Moreover, the Guideline Development Group (GDG), a working group consisting of lay people and professionals who represent different areas, developed the guideline.

The Guideline Development Group was convened by the National Collaborating Centre for Women's and Children's Health (NCC-WCH). The membership in the stakeholder group included the following: Two surgeons, two microbiologists, a theatre nurse, a tissue viability nurse, an infection control specialist, a surveillance coordinator, and two patient / caregiver representatives. Inclusion of patient and caregiver representatives means that the target population was engaged in the development of the document.

In 2011, the National Collaborating Centre for Women's and Children's Health completed a review of this guideline and determined it to be correct and the most current version of the guideline for surgical site infection. Possible conflicts of interest in the development of the surgical site infection guideline include loading the stakeholder group with professionals who are all engaged in some way with the pre-operative, inter-operative, and/or post-operative phases of surgical operations.

Rigor of Development The clinical practice guidelines have strong credibility as they are created by multi-disciplinary teams of professionals and relevant stakeholders, any or all of whom may represent different clinical contexts. The data for the surgical site infection guidelines was collected through hand-searches of published literature (both primary and secondary sources) and searches of electronic databases. Systematic searches were employed for answering the clinical questions formulate and posed by the GDV.

Stakeholder organizations were invited to bring evidence to the GDG for consideration as relevant to the topic and scope, and equivalent or better than evidence provided through search strategies. It is worth noting that grey literature was not part of the search strategy, and journals that were not indexed on the databases were not searched manually. An eight-level table of evidence types was employed to identify the level of evidence used in the study.

The evidence types range from high quality meta-analyses and systematic reviews of randomized controlled trials (RCTs) or RCTs with a very low risk of bias, to expert opinion and formal consensus. Qualitative studies in the form of case series and other non-analytic reports are included. For each clinical question, the highest level of evidence available was selected for consideration in the guideline. The clinical evidences for the individual studies was synthesized for evidence table input and brief descriptions of each study were included in the guideline text.

Both qualitative synthesis and quantitative synthesis (meta-analysis) was performed wherever sufficient research was identified to enable and merit these analyses. Recommendations For every clinical question considered, the recommendations were derived from and explicitly linked to supporting evidence. When the GDG encountered areas for which substantial clinical research could not be identified, the GDG either considered other evidence-based guidelines and consensus statements, or relied on their collective professional experience to determine the criteria for good practice.

When fundamentally no evidence could be identified for consideration to formulate recommendations, the GDG used this gap in the knowledge base as representing a need to conduct research to identify best practice and thereby formulate recommendations. As a result of this approach, five key priorities for future research were identified and ten key priorities for implementation were formulated.

The primary criteria for landing on these key recommendations was a belief that they would have the largest impact on patient care and adult and child patients' outcomes for those undergoing surgical incision through the skin.

The major recommendations for surgical site infection guidelines are as follows: Pre-operative phase: Ensure patients have pre-operative showers; advise electronic removal of hair only as needed; special patient theatre wear that fosters patient dignity and comfort; specific non-sterile wear for all staff and movement in / out of operating area kept to a minimum; avoid routine nasal decontamination with topical antimicrobial agents targeted at Staphylococcus aureus; do not routinely use mechanical bowl preparation; forbid the use of artificial nails and nail polish, and the wearing of hand jewelry by the operating team; provide antibiotic prophylaxis for clean surgery involving placement of a prosthesis or implant, clean-contaminated surgery, and contaminated surgery.

Intra-operative phase: Ensure hand decontamination through the use of aqueous antiseptic surgical solution with single-use brush or pick for fingernails; avoid the use of non-iodophor-impregnated incise drapes routinely; ensure operating team wears sterile gloves in the theatre (preferably two pair when risk of glove perforation or consequences of contamination are serious); prepare the skin at the surgical site with an antiseptic; avoid diathermy; maintain patient homeostasis; avoid wound irrigation and intra-cavity lavage; avoide intraa-operative skin re-disinfection or topical cefotaxime in abdominal surgery; and cover surgical incisions with an appropriate interactive dressing at the end of the operation.

Post-operative phase: Change dressing using aseptic non-touch technique; use sterile salince, tap water, and showering at the appropriate times following surgery; avoid topical antimicrobial agents for wounds healing by primary intention; use appropriate interactive dressing to manage wounds healing by secondary intention, as advised by tissue viability nurse; use appropriate antibiotics when site infection is suspected; avoid debridement; ensure enhanced education and/or sharing of clinical expertise of healthcare workers, patients, and caregivers. In all phases, nurses may carry out recommendations and request consultations with tissue.