Consensus Statement on Surgical Site Infections Released

Diana Swift

December 08, 2016

A new consensus statement from the broadly representative Council on Patient Safety in Women's Health emphasizes comprehensive teamwork, communication, and standardization, using checklists and order sets, to reduce surgical site infections after major gynecologic surgery.

Published online December 2 and in the January 2017 issue of Obstetrics & Gynecology, the consensus bundle "is not designed to be prescriptive or to introduce new guidance, but serves to compile existing guidelines and evidence-based recommendations into a consumable product that can be easily and rapidly implemented based on the resources available within an individual organization," the authors explain.

The council's working group included representatives from the American Association of Nurse Anesthetists, the American College of Obstetricians and Gynecologists, the American College of Osteopathic Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American Urogynecologic Society, the Association of Women's Health, Obstetric and Neonatal Nurses, and the Society of Gynecologic Oncology.

At its core, the safety compilation emphasizes the importance of interdisciplinary cooperation and shared responsibility. "Foremost among these shared responsibilities is the relationship and communication between the surgeon and the anesthesia provider in ensuring that all surgical site infection prophylactic measures are in place," write Joseph E. Pellegrini, PhD, CRNA, program director of the Nurse Anesthesia Program and an associate professor at the University of Maryland School of Nursing in Baltimore, and colleagues.

Crucial prophylactic measures include antibiotic selection, administration, and readministration; temperature regulation; and above all, the building of teams and communication lines.

The statement is a response to a long-recognized need for institutional improvement in safety prophylaxis, Dr Pellegrini told Medscape Medical News.

"Basically, most centers had been following guidelines in place since 2004 and geared to colorectal, not abdominal, surgery, and especially not to gynecologic patients," he said. "And people were following a multitude of different guidelines. They were using different skin preparations and different approaches to prophylactic antibiotic administration and timing."

The bundle's recommendations comprise four domains: readiness, recognition and prevention, response, and reporting and systems learning. The recommendations include:

  • Establish standards of regulation for ambient operating room temperature and patient normothermia.

  • Standardize the selection, administration, and discontinuation of prophylactic antibiotics, using checklists.

  • Assess patient risk for infection preoperatively by such criteria as blood glucose levels and body mass index, as well as immune, methicillin-resistant Staphylococcus aureus, nutritional, and smoking status.

  • Allow for intraoperative "time-outs" to discuss antibiotic dosage and timing and other prophylaxis issues.

  • Continue to reassess patient risk for surgical site infection.

  • Provide education and postoperative care instructions to patients.

  • Establish a "culture of huddles" for high-risk patients.

  • Share physician-specific surgical site infection data with all surgeons as part of ongoing professional practice evaluation.

Central to the safety bundle's effectiveness is communication: "The whole approach was to ensure adequate communication, and we empowered every person on the surgery team, including the office staff, to have a say," Dr Pellegrini said. "Every single patient has contact with the office staff. They are [the] common bridge of communication between all parties, and they are the ones who send out the written instructions to patients and to the surgical sites."

The authors note that US rates of infection in gynecologic surgery range from 3.9% for open hysterectomy to 1.4% for minimally invasive procedures.

The majority (54.2%) of US hysterectomies are still performed abdominally, although 16.7% are performed vaginally, 8.6% laparoscopically, and 8.2% robotically.

Earlier this year, a study at the Mayo Clinic in Rochester, Minnesota, reported that an infection-reduction bundle decreased the overall surgical site infection rate from 6.0% to 1.1% (P = .01) in patients undergoing high-risk surgeries for gynecologic cancers.

Dr Pellegrini noted that gynecologic surgery is unique, in that there is a risk that pathogens from the vaginal and cervical areas may migrate to surgical sites in the abdomen. That can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses.

In the new recommendations, everyone, from office staff to operating room personnel and postsurgical caregivers, is encouraged to be a watchdog. All team members should identify deviations from standardized procedures without fear of repercussions and should report all lapses.

"Coupled with this empowerment, the bundle stresses the importance of ownership by each team member in reducing surgical site infection through adherence to the recommendations and use of the resources outlined within the body of the bundle," the authors write.

Dr Pellegrini is confident the new guidelines will be well-received and quickly implemented, as they were compiled and approved by so many representative stakeholders. "The council represents every discipline and it made specific recommendations for changes before finalization. There was a huge vetting process," he said.

In terms of applicability, he added, "We tried to make the recommendations as generalizable as possible, but we also stressed that you can make changes based on your individual clinical interpretation and the needs of your institution." Standardization within institutions is encouraged.

Surgical site infection is the most common complication of surgery, the authors note, with an estimated 157,500 inpatient infections occurring annually in the United States.

The council representatives were supported by their respective organizations. The authors have disclosed no relevant financial relationships. This article will appear concurrently in the January 2017 issue of Anesthesia & Analgesia, the January/February 2017 issue of the Journal of Obstetric, Gynecologic, & Neonatal Nursing, and the February 2017 issue of the online version of the American Association of Nurse Anesthetists Journal.

Obstet Gynecol. 2017;129:50-61. Abstract

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