Abstract
Abstract
Background:
Surgical site infection (SSI), the third most common type of nosocomial infection in Sweden, is a patient injury that should be prevented. Methods of reducing SSIs include, for instance, disinfecting the skin, maintaining body temperature, and ensuring an aseptic environment. Guidelines for most of these interventions exist, but there is a lack of studies describing to what extent the preventive interventions have been implemented in clinical practice. We describe the daily clinical interventions Swedish operating room (OR) nurses performed to prevent SSIs following national guidelines.
Methods:
A descriptive cross-sectional study using a Web-based questionnaire was conducted among Swedish OR nurses. The study-specific questionnaire included 32 items addressing aspects of the interventions performed to prevent SSI, such as preparation of the patient skin (n = 12), maintenance of patient temperature (n = 10), and choice of materials (n = 10). The response format included both closed and open-ended answers.
Results:
In total, 967 nurses (43% of the total) answered the questionnaire; of these, 77 were excluded for various reasons. The proportions of the OR nurses who complied with the preventive interventions recommended in the national guidelines were high: skin disinfection solution (93.5%), sterile drapes (97.4%) and gowns (83.8%) for single use, and the use of double gloves (73.0%). However, when guidelines were lacking, some interventions differed, such as the frequency of glove changes and the use of adhesive plastic drapes.
Conclusion:
To standardize OR nurses' preventive interventions, implementing guidelines seems to be the key priority. Overall, OR nurses have high compliance with the national guidelines regarding interventions to prevent bacterial growth and SSIs in the surgical patient. However, when guidelines are lacking, the preventive interventions lose conformity.
P
Surgical site infection is an adverse patient event, an injury that should be prevented. A report by the Swedish Association of Local Authorities and Regions showed that among nosocomial infections, the third most common type was SSIs [8]. Swedish law regarding patient safety (2010:659) states that the caregivers shall lead and control the activity in such a way that good care is sustained and also provide needed measures to prevent patient injury [9]. There are more strategies to prevent SSIs in operating departments than the care bundles suggest, such as the use of basic hygiene procedures, controlled operating room (OR) ventilation with limited traffic [10], sterile material, surgical techniques, and pre-operative hand disinfection and adherence to guidelines [1]. Sustaining good care for the surgical patient includes preparing the skin, maintaining normal body temperature, maintaining an aseptic environment, and so forth [11]. Guidelines exist, but we have not found any studies describing the practical work and whether on a national level the work performed conforms to the guidelines and provides equally good care for surgical patients, resulting in a reduction of SSIs.
Internationally, differences exist as to which profession is responsible for preparing the patient with hygienic procedures such as skin disinfection and draping for surgery in the OR; this work may be performed by nurses with different educationals or by the surgeon. In Sweden, it is mostly the OR nurse that prepares the patient for the surgical procedure, but this may be driven by surgical specialties. However, preparing the patient anesthesia is the responsibility of the team of anesthesiologists and nurse anesthetists [12]. In Sweden, the OR nurse must have a minimum of four years of education: Three years to achieve a bachelor's degree in nursing, followed by one year of post-graduate education in OR nursing care. The OR nurses' duties encompass providing a secure place for the patient in the form of a hygienic, aseptic environment; preparing the patient's skin; draping the patient; and maintaining the patient's body temperature. Other duties include instrument care and circulating roles, that is, as a non-sterile person assisting the sterile surgical team [11].
National guidelines and regulations regarding patient care in Sweden can be found in the Handbook for Healthcare, which resembles the international guidelines written by NICE [3] and the CDC [1]. The Handbook for Healthcare is based on the Swedish Health and Medical Service Act and Social Services Act. Fundamental guidelines regarding OR departments consist of several preventive interventions, both for patients and for staff, such as sterile gowns and gloves, which should be worn by all persons within the sterile area of surgery, and preferably double gloves to prevent cross-infection. Furthermore, the Handbook describes the type of solution to be used for surgical hand disinfection, the type of solution to be used for skin disinfection of the patient, and the method and duration of the skin disinfection procedure. Swedish guidelines recommend that surgical skin disinfection be performed with chlorhexidine 5 mg/mL in 70% ethanol for two minutes at the planned surgical site, with disinfection of the skin from the incision site outward to the periphery [13].
Data on compliance with these guidelines for intervention to prevent bacterial growth and SSIs in clinical practice are hard to find. The aim of this study therefore was to describe the daily clinical interventions that Swedish OR nurses perform to prevent SSI, guided by the national guidelines.
Patients and Methods
Study design and participants
This was a descriptive cross-sectional study. A Web-based self-reporting questionnaire was completed by a population of Swedish OR nurses from December 2015 to the end of January 2016.
Questionnaire
The study-specific questionnaire was developed on the basis of an extensive review; on evidence from earlier research produced by the research group regarding skin disinfection effects, both of patient skin [14–16] and of the hands of the staff; and on existing guidelines in Sweden [13]. The following guidelines were selected for the questionnaire:
• Recommended skin disinfection solution, chlorhexidine 5 mg/mL in 70% ethanol or similar, having a prolonged preventive effect on bacterial regrowth; • Duration of the skin disinfection process to be two minutes and then the site allowed to dry; • Sterile draping material for single use, which should stay adherent throughout the surgical procedure; • Two methods for pre-operative surgical hand disinfection: method 1 = rub—the use of plain soap and water and thereafter rubbing of the hands and forearms with alcohol; and method 2 = scrub—the use of soap, containing 4% chlorhexidine or similar solution, and water; • Sterile gowns and gloves to be worn by all persons within the sterile area of surgery with double gloving recommended; • Special work suit designed to prevent spread of bacteria from staff to the surrounding air, that is, a clean-air suit; • Maintenance of patient body temperature peri-operatively by the use of warm fluids and blankets; and • Pre-operative full shower with a chlorhexidine- containing soap at least twice, the cleansing to begin the day before surgery at home and be completed the morning of the surgery on the ward or at home.
Study-specific questions also were based on the research group members' own clinical experience working as OR nurses and nurse anesthetists. The questionnaire addressed the daily activities an OR nurse performs to prevent bacterial growth and SSI, such as preparation of the patient's skin (n = 12), maintenance of the patient's temperature (n = 10), and use of OR materials (n = 10), in which the responses were registered on a five-point scale with the range of answers being always, often, sometimes, seldom, or never (n = 19). Other questions were answered on a four-point scale regarding re-colonization and changes of gloves: large, moderate, small, or none; and puncture of glove: long duration, use single gloves or open-ended (n = 2); a fixed set of three choices with an open-ended alternative regarding guidelines: yes, no, unsure, or open-ended (n = 2); a five-point scale regarding education with respect to patient skin disinfection to be answered with educator (university), supervisor (OR nurse), handbook for healthcare workers, colleagues, unsure, or open ended (n = 1); and finally, eight open-ended questions, such as, “Which preoperative hand disinfection solution do you use?” and “At what controlled temperature is the OR mostly maintained?” The questionnaire also included six socio-demographic variables: age, type of hospital, work experience, education, surgical training, and region of Sweden in which they worked. Three questions were excluded from the present results and will be presented elsewhere. These questions describe the information given by the OR nurse to the patient prior to skin disinfection, the patient's response when receiving skin disinfection, and finally, the OR nurse's assessment of the most important interventions to prevent SSIs.
The questionnaire's appropriateness was evaluated by 10 OR nurses in order to improve the clarity of the questions before the questionnaire was sent out, although corrections were not needed after feedback from these nurses. The questions were formatted as a Web-based questionnaire by a professional Web survey company, which also handled the data collection and compiled the data.
All Swedish county councils were asked to participate. The information technology department of the participating hospitals or region delivered the lists of OR nurses' e-mail addresses to the first author. The questionnaire was distributed by e-mail together with information about the study to 2,264 of the total of 4,000 OR nurses in Sweden. The remaining nurses' e-mail addresses were not available. Information regarding participation in the study also was published in the Swedish journal for OR nurses as well as in a closed Facebook group for OR nurses. The participant inclusion criterion was a specialist degree as an OR nurse. The exclusion criterion was who no longer worked as an OR nurse.
Ethical considerations
The study was performed in accordance with the Helsinki Declaration [17]. Ethical approval was not required according to Swedish law concerning ethical review of research involving humans, as the study did not involve patients, and no sensitive data were obtained [18]. By sensitive data, we mean that no information was retrieved regarding political opinions, ethnicity, religion, union membership, philosophy, health, or sexual preferences. Written information was given regarding the study, and participation was voluntary. The data were stored depersonalized in data files on the hospital's servers, well protected with firewalls and private codes. No key codes existed to connect the answers with any individuals, and the results were presented at a group level with no possibility of identification.
Statistical analysis
Data were entered and analyzed using descriptive statistics computed in SPSS version 22.0 (SPSS Statistics; IBM, Armonk, NY, USA). Descriptive statistics were computed for all variables and were described using mean, median, number, percentage, and standard deviation.
Results
Participants
In total, 967 of 2,264 OR nurses completed the questionnaire (response rate 43%). Of these 967 OR nurses, 77 were excluded because they were not working as OR nurses, but rather, for example, as a chief of staff, giving a total of 890 respondents. The OR nurses represent more than 11 specialities such as orthopaedic, thoracic, vascular, and general surgery (Table 1). The results of the OR nurses' preventive interventions are presented according to guidelines.
SD = standard deviation.
Recommended skin disinfection solution, chlorhexidine 5 mg/mL in 70% ethanol, or similar product having a prolonged effect
Chlorhexidine 5 mg/mL in 70% ethanol was most commonly used for skin disinfection, being employed by 93.5% (806/862) of the OR nurses. The use of Chloraprep®, which is a combination of chlorhexidine 20 mg/mL in 70% isopropanol, was used by 2.3% (n = 20). Finally, both 70% ethanol and Sterillium® containing 75% isopropanol were used by 2.1% (n = 18). Previous cleansing of the patient's skin in the OR with a 4% chlorhexidine-containing wipe/sponge (Descutan®) was sometimes performed prior to the full pre-operative skin disinfection by 37.0% (329/890) of the nurses (Table 2).
Duration of the skin disinfection process to be two minutes and then the site allowed to dry
The majority of the nurses reported that they performed the pre-operative disinfection of patient skin for two to five minutes (Fig. 1). Most, 41.1% (n = 366), often let the skin dry before draping; and to enhance adherence of the drapes to the patient's skin, 34% (n = 303) of the nurses often wiped the skin dry in the site where the drapes should adhere using sterile paper towels (Table 2).
Operating room nurses' (n = 877) assessment of duration of time spent on skin disinfection of a patient abdomen.
Sterile draping material for single use, which should stay adherent throughout the surgical procedure
Sterile draping for single use was employed by 97.4% of the nurses, and 75.8% (675/890) checked often to be sure the draping material had stayed adherent to the patient skin (Table 2). Adhesive plastic drapes were sometimes used by 54.5% (n = 48), and iodine-impregnated adhesive plastic drapes always were used by 33.7% (n = 300) (Table 2). A microbial sealant such as Integuseal® was never used according to 89.4% (n = 796) of the nurses (Table 2). Most of the nurses responded that they had learned to perform patient skin disinfection from their supervisors (another OR nurse) or at the clinical practice during in-service education (48.9%; n = 435), while 41.7% (n = 371) learned the technique from the educator at a university. The remaining 9.4% of the nurses stated either that they had learned it from colleagues or the Handbook for Healthcare Workers or that they did not remember. The assessment of the skin disinfection efficiency by nurses regarding the proportion of patients who became free from bacteria during the skin disinfection ranged from 0 to 99%. The distribution was fragmented. The largest number of the nurses believed that none of the patients became completely free of bacterial growth after skin disinfection (31.7%; 187/589), whereas 5.6% (n = 33) believed 99% of the patients became free of bacteria at the disinfected skin site.
Two methods for preoperative hand disinfection: Method 1, rub—use of plain soap and water and thereafter rubbing of the hands and forearms fluidly with alcohol; and method 2, scrub—use of soap containing 4% chlorhexidine or similar solution and water
Almost all of the nurses, 96.3% (857/890), stated that guidelines existed at their OR department for how to perform a pre-operative hand disinfection. The most popular hand disinfection solutions were alcohol-based disinfection solutions, 89.6% (763/852), followed by chlorhexidine-based soap, 8.2% (n = 70). Some (1.3% [n = 11]) of the nurses used both alcohol-based disinfection solutions and chlorhexidine-based soap, and only a small minority, 0.9% (n = 8), used only plain soap,. Of the nurses, 47.2% (420/890) expected a small bacterial recolonization of their hands during the wearing of surgical gloves, and 38.4% (n = 342) expected a moderate recolonization. Two per cent (n = 18) expected extensive recolonization, whereas the remaining 12.4% expected that no bacterial recolonization of their hands would occur during the donning of surgical gloves. For those who double gloved, the sterile outer glove was assessed by 83.3% (741/890) of the nurses to reach over the inner glove always, and 41.0% (n = 365) did not indicate any moisture at the glove cuff end (Table 2).
Sterile gowns and gloves to be worn by all persons in the sterile area of surgery, and double gloves recommended
Sterile gowns for single use were employed by 83.8% (746/890) of the nurses. Of the nurses, 40.4% (n = 360) did not know if they had any guidelines regarding the use of double gloves, and 37.1% (n = 330) stated that they knew they did not have any. Double sterile surgical gloves were used by 73.0% (n = 650) of the nurses, and they said other members of the surgical team wore sterile double gloves often (58.5%; n = 521) (Table 2). The reasons for changing the outer gloves differed, but the most dominant reasons were puncture of the glove or the wearing of the outer glove for a long time (Table 3).
Multiple answers were possible for each nurse.
Special work suit designed to prevent spread of bacteria from staff to the surrounding air, that is, clean-air suit
Staff clothing for single use in the OR departments was never worn by 43.8% (n = 390) and always worn by 9.6% (n = 85) (see Table 2).
Maintenance of patient body temperature peri-operatively by warm liquids and blankets
The controlled OR temperature ranged from 18°C–24°C, and the three most common temperatures were 20°C (30.1%), 21°C (28.6%), and 22°C (20.8%). Blankets or mattresses with warm air were used often by 51.9% of the nurses (n = 462), but the incision area was not heated locally by 82.0% (n = 730) (Table 2). Liquids for use in the incision were heated before delivery sometimes by 57.1% of the nurses (n = 508) (Table 2).
The skin disinfection solution always was stored at room temperature by 95.5% of the nurses (n = 850), and the majority of the nurses did not heat the skin disinfection solution before use (86.7%; n = 772). Those who used heated skin disinfection solution had different ways of heating the solution: Warming cupboard (89.1%), microwave oven (4.5%), hot water (3.6%), or by all of the methods (2.8%). The temperature of the solution ranged from 25°C–42°C with a mean of 37°C. The nurses who used heated solutions stated the reasons for warming them as that the patient was awake or was small (child/infant) or that the area to be disinfected was a large portion of the patient's body.
Discussion
The main finding of this study was that the majority of the interventions recommended by the national guidelines were implemented in daily work and that the interventions were performed fairly consistently nationally. However, when guidelines were lacking, variation in the intervention used increased, for example, the application of adhesive plastic drapes.
Recent research has focused on the education and workloads of nurses related to the outcome survival for inpatients. Research by Aiken et al. implies that higher education such as a bachelor's degree reduces the patient mortality rate [19], and one may correlate the high compliance with national guidelines with the high educational level of the Swedish OR nurses. Furthermore, in the light of this research, it is important to maintain high academic educational levels to provide a high standard of care and a good outcome for the surgical patient.
There is a need for more guidelines, such as to address why and when surgical gloves should be changed and for more specific requirements to prevent individual interpretations. There is a lack of guidelines in Sweden regarding criteria for when changes of both single gloves and the outer of double gloves should take place. Puncture holes often occur unnoticed [20–22], and their rate increases with time [22]. In this study, the reasons for changing outer gloves are described from the nurses' point of view, but there were no guidelines to support clinical practice; and it was left to the individual to decide. The Association of periOperative Registered Nurses (AORN) has guidelines that recommend changes of the outer glove every 90 minutes in the absence of other indications [23].
Regarding the nurses' attention to visible moisture at the end of the glove cuff, the majority of the nurses did not, or seldom, noticed this, which may reflect a rather low grade of attention to this problem. Studies have addressed the glove cuff and gown interface as an area of weakness in sterile surgical attire and a possible route of bacterial transmission [24–27], and one manufacturer mentions the moisture at the sleeve as unsterile [28]. The problem with condensation and possible perspiration under surgical gloves, which can be seen in the area of the wrist where the outer gloves overlap the inner gloves is that the moisture may contain bacteria [24; Wistrand C, Falk-Brynhildsen K, Soderquist B, Nilsson U. Bacterial growth and re-colonization after surgical hand disinfection and surgery. (submitted 2017)].
It is of importance, and according to manufacturer descriptions, that the outer glove reaches over the inner glove [28]. According to our result, 83.3% of the nurses confirmed that they always had the outer glove reaching over the inner glove (Table 2).
The nurses estimated bacterial re-colonization under the gloves to be minor or moderate. Interestingly, 12.4% thought there was no re-colonization. However, it is not easy to determine the normal amount of bacterial growth on the hands before or after surgical hand disinfection and after wearing the gloves, not even after extensive review. The problem is complex because the methods used to discover bacterial growth were different in different studies, and the variation in bacterial growth is large from one individual to another [29].
Consensus regarding the effectiveness of adhesive plastic drapes is lacking [30, 3], but the current evidence is against their use [3], with possibly more contamination in the surgical incision occurring with such drapes [16]. The varied extent of use of adhesive plastic drapes with or without iodine in our study perhaps can be explained by the absence of national guidelines. However, the reasons for the use of adhesive plastic drapes were not explored. The national guidelines state clearly that the gowns, gloves, and patient drapes should be for single use, a rule with which the nurses showed high compliance (Table 2).
Many OR departments have warming cupboards where fluids for intravenous and intracavity administration can be heated before use. The nurses sometimes (57.1%) used warmed fluids in the incision/cavity (Table 2). The reason for not using warmed fluids was not investigated, and several reasons may be considered, such as that fluids tend to cool off quickly if not used immediately; it may be planned for the patient to be hypothermic, as in heart surgery; or the choice may depend on the amount of fluid used. The information regarding the value of heating the skin disinfection solution such as chlorhexidine 5 mg/mL is somewhat contradictory. The chlorhexidine 5 mg/mL in 70% ethanol should be stored at room temperature, no higher than 25°C, according to the Swedish Environmental Classification of Pharmaceuticals [32]. But according to the manufacturer, the solution can be heated in a warming cupboard as high as 40°C for one week without any negative effects on the package or the product [33]. In earlier studies, our research group addressed the positive impacts of heated chlorhexidine 5 mg/mL in 70% ethanol, which results in a more pleasant patient experience, less heat loss as judged by skin temperature, and equally effective skin disinfection [14,15,34]. To increase the use of heated skin disinfection solution, nurses may need support from national guidelines, which could clearly state the potential value of heating the solution.
Those nurses who reported heating the skin disinfection solution stated the reasons for their choice as the patient being small, the patient being awake during the skin disinfection, or there being a large area of the body to be disinfected. These reasons probably arise from the idea that heated solution should reduce heat loss and promote patient comfort. The prevention of heat loss by the use of warm-air blankets and mattresses was the most popular technique, which is recommended explicitly in the national guidelines (Table 2). This shows that the nurses were aware of the importance of keeping the patients warm and also that the nurses acted on that knowledge. Warming the incision site locally was almost never done (82%), probably because of the scarce evidence and low attention to this technique for preventing SSI.
According to this study, many OR nurses used a sponge containing chlorhexidine soap 4% to wash the surgical area before the skin disinfection (Table 2). This intervention in the OR has no support in the Handbook for Healthcare Workers [13] or in recent research [35,36]. The disinfection solution manufacturer and the national guidelines, namely the Handbook for Healthcare Workers, emphasize the importance of the correct duration for the disinfection solution to be in contact with the skin [33,37]. The majority of the nurses assessed the time it took to perform the pre-operative skin disinfection as between two and five minutes, as the guidelines recommend [13]. The patient's skin should dry completely before draping, with the intention being for the solution to affect the skin and for the drapes to adhere properly, but also for patient safety, considering that ethanol is flammable [13,23]. The results of this study show that nurses do not let the skin dry completely before draping the patient, extrapolated from the fact that wipes often were used by 34% of the nurses to ensure the skin is dry prior to draping.
Using sterile paper towels to wipe the skin dry may increase the risk of undetected bacterial contamination from the surrounding area into the surgical area, but this idea has no supporting evidence and needs to be investigated further. However, the underlying reason for wiping was not investigated. Did the nurses wipe because they believed they were stressed or pressured to work fast and save time, or was the wiping of the skin something they had learned from clinical practice? The skin disinfection process was learned mostly from the supervisor (OR nurse) in clinical practice or from the instructors at the university, which requires updated supervisors and instructors to provide the nursing students with evidence-based clinical interventions to prevent inappropriate but traditional behaviors.
Strengths and Limitations
Using a Web-based self-reporting questionnaire offered an environmentally friendly and inexpensive alternative to the conventional paper-based questionnaires. A limitation of a self-reporting questionnaire is that the results are based on assessments rather than clinical facts. To facilitate answering and to control answers, for example, regarding which disinfection solution was used in the department, the questionnaires were sent to the OR nurses' e-mail addresses at work. To increase the validity of the study, specific questionnaire face validity test was performed by 10 nurses, which supported a finding that the questions appeared to measure what they were reported to measure. No analyses of differences in the answers according to education or work experience were performed. The education level and its content have changed over time, and it is therefore difficult to differentiate education from work experience.
No collective database for retrieval of nurses' e-mail addresses existed, and the retrieval of addresses depended on the ability of the different counties and regions to disclose e-mail lists. However, the survey had respondents from all counties and regions in Sweden. One region had only five respondents, and this was attributable to the difficulties of getting access to the e-mail addresses. The largest numbers of respondents were from two regions, one in the south and the other in the middle of Sweden, with 178 and 155 respondents, respectively. Apart from these three regions, the rest of the respondents were fairly evenly distributed among the counties and regions. The 890 respondents worked at 64 hospitals from the north to the south of Sweden.
Non-response to this survey could be explained by the possibility to pause and “save” the questionnaire while answering it. In addition to saving the answers, the respondents had to press a “send” button. This seems to have been misunderstood, which became apparent when, in response to reminders that were sent out, respondents notified us by e-mail that they already had answered the questionnaire. In these cases the questionnaire was most likely only saved, but never sent. Some respondents also replied that they were told not to open a Web link of unknown origin. These issues might have been avoided by using a paper-based questionnaire.
Conclusions
Overall, the compliance of OR nurses with the national guidelines was high. However, when guidelines were lacking, the preventive interventions that OR nurses perform lost conformity. Guidelines are lacking regarding when the outer gloves should be changed, whether adhesive plastic drapes should be used, and the possibility of heating chlorhexidine 5 mg/mL in 70% ethanol. To standardize OR nurses' preventive interventions, implementing guidelines seems to be the key priority.
Footnotes
Author Disclosure Statement
No competing financial interests exist, according to the policy of the journal.