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CE Article: Overcome challenges to reduce surgical site infections*

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After reading this article, you will be able to:

  • Identify five barriers to reducing surgical site infections
  • Recognize the importance of interaction between perioperative nurses and infection control professionals (ICPs)
  • Describe strategies to prevent surgical site infections (SSIs)
  • Identify measures to prevent various hospital-acquired infections

The OR can be a world unto itself. It's physically separated from the rest of the hospital, entry is restricted to authorized and properly attired personnel, and the OR often has a unique culture, says Linda Greene, RN, MPS, CIC, director of infection prevention at Rochester (NY) General Health System. As a result, the OR can be an intimidating place for ICPs—also known as infection preventionists (IP)— to visit.

But for facilities to get a handle on surgical site infections (SSI), ICPs must be regularly present in the OR and forge strong bonds with OR nurses.

However, several barriers may strain interactions between OR staff members and ICPs. The following are the five top challenges OR nurses and ICPs may encounter as they try to reduce SSIs and tips for overcoming them:

  • Lack of interaction between perioperative nurses and ICPs. Although independence can be a strong attribute, it may also be a barrier to a good working relationship between perioperative nurses and ICPs. "Both ICPs and perioperative nurses are strong leaders in their organizations. At times, each can become so focused on problem solving that they act in silos, never crossing disciplines to learn from the other," says Libby Chinnes, RN, BSN, CIC, a consultant at IC Solutions, LLC, in Mount Pleasant, SC.

To compound the problem, the surgical suite may be foreign to many ICPs. However Chinnes suggests experienced perioperative nurses mentor ICPs. "The perioperative nurse can teach the IP much about aseptic technique, sterilization, sterile storage, etc., and the IP can teach the perioperative nurse much about emerging diseases and multidrug-resistant organisms, infection control standards and regulations, and interventions to reduce SSIs," she says.

To reduce this silo effect, it's important for OR nurses to feel they are part of the organization and serve a larger purpose, says Greene. Giving nurses feedback on infection rates is one way to link them into the organization, she says.

Multidisciplinary teams can also strengthen nurses' bond with infection control efforts and prevent SSIs. Read tips from the Institute for Healthcare Improvement for forming effective SSI prevention teams.

  • Lack of familiarity with one another's roles. Because the OR is such a unique environment, OR staff must be educated on IC issues and ICPs must educate themselves on the inner workings of the department.

Having the ICP shadow a perioperative nurse is a good way for the ICP to learn how the department functions and offer suggestions for improvement when appropriate.

"The perioperative nurse may be surprised to learn that the IP has much to share about many aspects of infection prevention and control, including IV care, prevention of pneumonia, rare ailments such as Creutzfeldt-Jakob Disease, wound classifications, and much, much more," says Chinnes.

To foster these interactions, ICPs should be rounding regularly in the OR, says Greene.
ICPs should also read up on surgical literature so they can become familiar with OR trends. Staff members should be provided with quick, easy-to-read excerpts from newsletters or journals that educate them on IC topics.

In addition, OR staff should be kept up to date on new federal guidelines, as well as recommended practices from organizations such as the Association for Professionals in Infection Control and Epidemiology, Greene says. Read about the Centers for Disease Control and Prevention (CDC) guidelines.

  • Incorrect wound classification. Ensuring that OR staff members use correct wound classifications is important because incorrect classifications can skew the facility's infection data, which is a particular problem for organizations that have mandatory reporting requirements, says Greene.

Wounds should always be classified at the end of the operative procedure, says Chinnes. A circulating nurse working with a surgeon will typically perform this classification.
Because nurses are so involved with this process, it's critical they are trained in this area.

"Our staff developed a competency program to help nurses understand wound classification," says Greene.

Meetings with surgeons and OR staff members can help form consensus on classification of surgical wounds and reeducate the OR staff on correct wound classifications according to the definitions, says Chinnes.

It's a good idea to post examples in each OR of procedures based on the definitions, having a perioperative team member check the classifications every day for accuracy, she adds.

  • Razors on the units. Shaving leads to more SSIs than clipping, yet staff members at some hospitals may be reluctant to get rid of razors, says Chinnes. For example, some facilities may occasionally use razors in neurosurgery, where staff members are working with thick scalp hair, she says.

The CDC recommends the use of clippers or other methods for hair removal in the area of skin incisions to avert SSIs. Read more SSI preventative methods.

Chinnes suggests perioperative professionals and IPs take the following actions to remove razors from the hospital supply chain:

  1. Talk with the products or value analysis committee about this issue
  2. Watch for staff members hoarding razors when they are doing unit rounds and observation in the ORs
  3. Educate staff members and surgeons on the problems associated with using razors
  4. Make alternatives, such as clippers available, along with instructions for use and cleaning and disinfection
  • Flash sterilization faux pas. Flash sterilization is a challenge for many facilities, and as hospitals cut back on resources to save money, it might become increasingly problematic, says Greene.

Staff members should use flash sterilization only in very limited circumstances, such as when a surgical instrument is dropped or contaminated during a procedure, she says. Often, facilities use this sterilization method routinely because they don't have enough equipment for the procedures they're performing.

The perioperative nurse and ICP should monitor this practice at their facility by reviewing flash cycles together, says Chinnes. They should look at what equipment was flashed and by whom. Look for patterns that need to be corrected, she adds.

The perioperative nurse and ICP should also develop policies and procedures to ensure that flash sterilization is used appropriately and consistently. Providing feedback on flash sterilization rates to staff members may help convey the need for improved practice. Training should present real scenarios when flashing was used to illustrate correct and incorrect use of the process.


  1. "Healthcare-associated infections." Agency for Healthcare Research and Quality. Accessed February 10, 2009. Available at
  2. AORN Journal. (2000). "Preventing surgical site infections: Guiding practice with evidence." Available at
  3. "Forming the team." Institute for Healthcare Improvement. Accessed February 10, 2009. Available at

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