Wound Care Is Not an Afterthought

A Texas hospital reduced infections by making wound closure part of its SSI-prevention bundle.

Houston Methodist Hospital experienced a spike in reportable surgical site infections (SSIs) after open abdominal hysterectomies in 2023. They were able to quickly reverse the trend by incorporating an SSI bundle that included a wound closing protocol.

There were six reportable SSIs among 372 procedures in 2023. After the SSI bundle was implemented, only one SSI was reported from January to August 2024, when 232 procedures were performed.

Improving daily workflow

“Taking the initiative to incorporate the Closing Protocol as part of an SSI bundle was vital in keeping up with evidence-based practice and aiding the prevention of costly surgical site infections,” explains Houston Methodist’s Aimee Pinales-Rodriguez, RN, BSN, CNOR. “The staff has welcomed the change, the surgeons have adapted, and it is now part of our daily workflow.”

The initiative was featured on a poster at last month’s AORN Global Surgical Conference & Expo in Boston. It described a step-by-step wound closure protocol that was created for OR staff to follow. Instructions on how to follow the protocol were placed in every operating room. New closing instrument sets were assembled, including supplies needed to generate a clean environment at the time of wound closure.

Training and education for OR staff included video simulations that were streamed on the department’s digital learning board. OR staff self-reported data about how the new protocol was performing via online surveys taken six and 12 months after implementation. The surveys were designed to assess the usability and workflow of the closing set and protocol.

The six-month post-implementation survey showed that 97.4% of the OR staff believed the education, simulations, instruments provided, custom packs and overall protocol positively impacted their practice and workflow. At 12 months, the survey revealed a 98.3% staff satisfaction rate with the workflow.

‘The big picture, the whole patient’

THREE KEYS Tight closures, adequate blood flow and sterile dressings are crucial to prevent wound infections.

There is a litany of things providers can do preoperatively and intraoperatively to help prevent SSIs, according to Kim Delahanty, BSN, PHN, MBA, HCM, CIC, FAPIC, of San Diego-based Delahanty Infection Prevention Clinical Epidemiology Consulting. “What we do in the operating room matters for postoperative care,” she says. “Keeping the big picture and the whole patient in mind is very important.”

Before elective cases, teams should make sure patients are normothermic, under normal glucose control and are clipped — not shaved — at the surgical site. Shaving can cause micro tears and allow resident flora to get into the surgical wound.

Once in the operative area, aseptic and sterile techniques should be employed to ensure the sterile field is maintained. A good practice is to have dedicated sterile closure trays to remove all the equipment that was used during the procedure and minimize pathogen transmission, says Ms. Delahanty. Another good measure to prevent cross-contamination is to change outer surgical gloves (if double gloving) before closing the incision.

Some teams use irrigation with CHG after tissue closure to help reduce bacterial loads, but studies are mixed on the effectiveness of this practice. The same is true with antibacterial sutures.

Multilayer closure approaches can provide a watertight seal and reduce infection risk, as can using glue instead of sutures or staples. Post-op, dressings should not be lifted and then put back onto the wound. “If you touch the dressing, it needs to be replaced with a sterile dressing, because we don’t want that bioburden to layer up on that surgical site and then potentially cause an infection,” says Ms. Delahanty.

Standardization of SSI prevention bundles is the best way to minimize errors that can occur when there are numerous different products and surgeons in play. “There will always be little nuances, but if we can get everyone to dress a knee wound pretty much the same way, we can significantly reduce surgical site infection rates by using scientific, evidence-based approaches,” she says. Ms. Delahanty says using a checklist is a good way to streamline your wound closure process.

Patients play a role

Preoperative routines get patients optimized and discharge instructions help them recover. Each plays an important role in the healing of the surgical wound.

One of the many benefits of elective surgery is that there is a set amount of time for care teams to help patients prepare properly to reduce their skin flora. This preoperative optimization process plays a fundamental role in how well patients recover from their surgeries.

“We want optimized patients because of the inherent risk that surgery presents,” says Benjamin Galvan, MPH, MLS(ASCP), CIC, CPH, infection prevention director at HCA Florida Brandon Hospital. “You’re breaking the barrier in the human body that creates a portal of entry for bacteria to enter that normally doesn’t exist.”

Essentially, optimizing a patient means getting them healthier temporarily to make sure their body, recovers better, including their surgical wound. As Mr. Galvan says, “Healthy people are at much less of a risk of developing surgical site infections than unhealthy people.”

Patients should eat better and be referred to dieticians if they need help during their pre-surgery window. Patients who are overweight or underweight have higher risks for complications and the immune systems of people with diabetes often aren’t strong enough to ward off infection to the tissue that is damaged by surgery. Medications should be considered, or current ones adjusted, to make improvements in patients’ behavior modification plans.

Patients should quit smoking or reduce how much they smoke to help their wounds heal better and reduce their SSI risk. Nicotine is a vasoconstrictor that decreases blood flow to surgical wounds that need to heal, and patients who smoke are many times more likely to experience an SSI.

Patients should be contacted to make sure they’re on track and be reminded to take their full course of preoperative antibiotics, adds Mr. Galvan.

They should also be educated on how to properly participate in their aftercare. Information given to patients should be standardized and provided to every patient. It should include what an SSI is, how they occur, and what the risks are for acquiring one. It should include a general explanation of how bacteria work, as well as why some patients and some types of procedures have inherently higher SSI risks.

Patients should be on the lookout for SSI symptoms, which include worsening pain at the surgical site, the wound becoming redder and more inflamed than expected, or any yellowish, cloudy discharge coming from the wound. Stitches dissolving before the wound is healing is another concern.

“Of course, they’re also looking for fever, nausea and vomiting — the typical signs and symptoms of infection,” says Mr. Galvan.

To prevent SSIs after the fact, patients should receive detailed instructions on whether to bathe, shower or not bathe in the days after surgery, as well as what type of soap is OK to use. Hand hygiene practices to employ before and after patients change their dressings should be explained in detail. OSM