Preoperative phase

Preoperative consultations are an ideal opportunity for the nurse to maximise the patient’s nutritional and health status before surgery, thereby promoting a prehabilitation ethos. Prehabilitation empowers the patient to optimise their physical condition before surgery and reduce their risk of developing an SSI. Where malnutrition or a nutritional deficiency has been identified as an SSI risk factor, the patient may benefit from nutrition supplements or dietary enrichment. Important nutrients for optimal wound healing include omega-3 fatty acids, vitamins A and C, carbohydrates and proteins (Gushiken et al 2021). Similarly, where obesity has been identified as an SSI risk factor, the nurse could offer support with weight loss before surgery such as guidance on diet and physical activity (Bray and Ryan 2021).

In some situations, hair removal may be required to expose the operative site, however patients should be advised not to remove hair themselves before surgery due to a potential increase in risk of infection. For example, using a razor may cause skin trauma thus enabling colonisation by microorganisms and increasing the risk of developing an SSI (WHO 2018, NICE 2020). If hair removal is required, the nurse should use electric clippers with a single-use head on the day of surgery (NICE 2020). Tanner and Melen’s (2021) systematic review of preoperative hair removal to reduce surgical site infection identified a small reduction in SSI risk when hair was removed on the day of surgery rather than the day before. Depilating creams may also be used to remove hair from a surgical site, although these can cause local skin irritation (Tanner and Melen 2021).

Patients should bathe or shower before surgery to reduce the bacterial load on the skin or should be assisted with a bed bath if they cannot bathe independently (WHO 2018, NICE 2020). A systematic review by Webster and Osborne (2015) noted that bathing with the antiseptic chlorhexidine did not significantly reduce SSI risk. However, NICE (2020) guidelines suggest that nasal mupirocin (recommended because the nose is the most frequent carriage site for S. aureus) may be used in combination with chlorhexidine body wash where S. aureus is likely to cause an SSI, for example in patients who are known carriers of MRSA and who will be undergoing cardiac or orthopaedic surgery.

Intraoperative phase

Intraoperative factors that are known to increase the risk of SSI include open surgery, complex surgery and surgery of extended duration (Wan et al 2021, UKHSA 2022). Therefore, a sterile environment should be maintained during the surgical procedure to limit the risk of spreading microorganisms to the surgical site. This sterile environment encompasses the use of personal protective equipment (PPE) such as masks, gloves and gowns, disinfection of the operating theatre, sterilisation of surgical instruments and limited flow of ‘traffic’, such as staff coming in and out of the operating theatre during surgery (Liu et al 2018). Ventilation systems can be used to filter the air in the operating theatre, thereby reducing the presence of microorganisms in the atmosphere and limiting ingress from other areas.

To reduce the risk of infection from endogenous bacteria on the patient’s epidermis, the skin should be prepared immediately before the surgical incision using an antiseptic skin product that has a broad spectrum of antimicrobial activity. Where possible, an alcohol-based chlorhexidine solution should be used, or aqueous chlorhexidine if the surgical site is next to a mucus membrane to reduce the risk of irritation (NICE 2020). Where chlorhexidine is contraindicated, NICE (2020) recommends the use of a povidone-iodine solution. Prophylactic antibiotics may also be administered intravenously before incision in patients who require a prosthesis or implant, or where the procedure is classed as clean-contaminated surgery (where there is no sign of infection before surgery, but the surgery involves repairing or removing an internal organ such as in appendicitis) or contaminated surgery (open wounds or surgery that involves breaks in sterile technique, for example to undertake cardiac massage, or spillage from the gastrointestinal tract) (NICE 2020).

Following any surgical procedure, tissue oxygenation is required for collagen synthesis and wound repair. Therefore, NICE (2020) recommends maintaining adequate perfusion and oxygen saturation of haemoglobin of more than 95% during surgery and the recovery period.

During surgery, patients are at risk of developing hypothermia from cold operating departments, impaired thermoregulation due to anaesthesia and the use of intravenous fluids. Hypothermia reduces circulation of blood through the skin and may therefore increase the risk of developing an SSI (Tanner et al 2021). The patient’s temperature should be monitored regularly and normothermia should be maintained where this is not contraindicated by the surgical procedure. Nurses should also encourage patients to say if they feel cold and to request additional blankets to ensure normothermia is maintained.

Application of local antibiotics or antiseptics to the surgical wound before closure is only advocated as part of clinical research trials due to the risk of hypersensitive reactions and allergic contact dermatitis (NICE 2020). However, antimicrobial-coated sutures, such as triclosan, are recommended during surgery to reduce the risk of SSIs (WHO 2018, NICE 2020).

Post-operative phase

Dressings can be used to cover the surgical site, providing protection and preventing contamination until the skin’s continuity has been restored (Dumville et al 2016). WHO (2018) recommends that surgical dressings should remain undisturbed for a minimum of 48 hours once in place, unless there is leakage. If the dressing does require changing, sterile saline should be used for cleaning wounds up to 48 hours after surgery and the dressing should be changed using an aseptic non-touch technique (NICE 2020). After 48 hours, patients may safely shower and tap water can be used to clean the wound if the edges have separated or been surgically opened to drain pus (NICE 2020).

Dressings should be selected on their ability to absorb exudate and prevent bacterial contamination from the external environment. There is increasing research interest in the prophylactic use of negative pressure wound therapy (NPWT) – dressing systems that apply sub-atmospheric pressure to the surface of a wound to promote healing – because it results in reduced oedema and faster tissue healing (Long et al 2022). There is encouraging evidence from a systematic review that NPWT may reduce SSI incidence in wounds healing by primary intention (where the wound edges are closely re-approximated), although there was limited difference in the reported incidence of wound dehiscence using NPWT compared with standard dressings (Norman et al 2022).

The WHO (2018) recommends the use of prophylactic NPWT in adult patients with surgical incisions that are healing by primary intention. However, the benefits of NPWT are not universal and may vary by patient, procedure and wound type. NICE (2022) guidelines have been updated to reflect new evidence that prophylactic NPWT should not be recommended routinely for all patients. Nurses should access tissue viability services for individualised, up-to-date and specialist advice on dressings with the appropriate properties to manage a patient’s wound and prevent SSIs.

Classification

SSIs are classified as an incisional infection (superficial or deep) or as an organ and/or space infection (Dumville et al 2016, WHO 2018, UKHSA 2022):

Osteomyelitis (bone infection) may also occur due to contamination from a contiguous source (where infection spreads from the surgical site to a nearby bone) or from haematogenous spread (where infection is transported by the blood) (Graan and Balogh 2022).

Delayed wound healing

An understanding of the normal healing process will assist the nurse in early identification of a wound that is not healing as anticipated following surgery. Delayed healing may be due to patient comorbidities, such as inflammatory or autoimmune conditions, medicines, for example corticosteroids, non-steroidal anti-inflammatory medicines and chemotherapeutic medicines, or the presence of infection, including SSI (Gushiken et al 2021).

The nurse should assess the patient’s wound at every dressing change, inspecting the surgical incision and any drain sites for signs and symptoms of infection (Table 1). The assessment and wound care provided should be clearly documented in the patient’s care plan and photographs of the wound can be used to supplement this documentation. Where the nurse suspects an SSI, the wound’s infection parameters, such as increased temperature, erythema and swelling and/or unexpected pain or tenderness, should be closely monitored.

Where an SSI has been identified, targeted antibiotic therapy may be used; however, prescribers should adhere to the principles of antimicrobial stewardship, such as regularly reviewing the need for continued antibiotic use and stopping antibiotics when there is no evidence of infection (Public Health England 2013, NICE 2020).

Holistic approach

It is important that nurses take a holistic approach to preventing and managing SSIs. The presence of an SSI can adversely affect the physical, psychological and social well-being of the person and their overall quality of life (Avsar et al 2021). Andersson et al (2010) reported that mental distress, depression, isolation and anxiety are commonly associated with SSIs. Similarly, Tanner et al’s (2013) exploration of patient narratives related to SSIs noted that the odour and exudate associated with infected wounds can cause shame and embarrassment. Consequently, SSIs can make it challenging for patients to interact with other people, which may have a negative effect on their ability to access their social networks and support (Avsar et al 2021).

SSIs also have economic implications for patients, including potential loss of work or reduced productivity due to extended wound treatment and functional decline, and the financial costs associated with wound care, such as dressings, prescriptions and travel to appointments (Andersson et al 2010). However, research on patients’ experiences of SSIs is limited and nurses would benefit from further qualitative exploration to inform best practice.

Before discharge, nurses should provide patients with clear information about caring for their wound, the signs and symptoms of an SSI and who to contact if they have any questions or concerns. Providing an information leaflet on SSIs can assist patients in retaining information and enable them to revisit this at a later point. The use of digital technology such as smartphones has been shown to be effective in relation to assessing wounds, enabling triage and assisting with early recognition and treatment of SSIs (McLean et al 2021).

Nurses have an important role in preventing SSIs and monitoring for signs and symptoms of infection throughout the patient’s surgical journey. Due to their close clinical relationships with patients, nurses are ideally placed to take a person-centred and holistic approach to ongoing assessments or reviews, thereby minimising the risk of developing SSIs and promoting patient satisfaction. An assessment should consider the context in which the patient lives and any psychosocial factors, such as the care setting, the patient’s motivation, occupational status and financial circumstances, and the support available to them. For example, patient education on diet before or following surgery should consider the person’s ability to eat and drink independently, their access to food of nutritional value and their ability to store or prepare food appropriately. For the nurse, using a clear individualised approach can assist in relieving the patient’s anxiety and promoting positive outcomes (NICE 2021).

Prevention and management of SSIs requires a multidisciplinary approach. Preventative interventions should be implemented based on patient risk factors and used to supplement standard infection control precautions, such as appropriate hand hygiene, respiratory hygiene and the use of PPE. Alongside the use of antimicrobials, these measures will assist in reducing the risk of environmental contamination of a patient’s open wound. Where an SSI does occur, surveillance systems such as that provided by the UK’s Health Security Agency (www.gov.uk/guidance/surgical-site-infection-surveillance-service-ssiss) can be used to monitor the frequency and type of infection, patterns of infection and any instances of antibiotic resistance. Such monitoring can assist in the development of an evidence-based approach to care of patients with an SSI.