1. Patrick Boyle, BSN, RN, Major, USAF, CNOR

2. Background Surgical site infections (SSIs) occur every year and contribute to increased LOS, reduced quality of life, and result in death (Joint Commission [JC], 2013) SSIs within 30 days of the operative procedure contribute substantially to surgical morbidity and mortality each year (Reichman, 2009) SSIs extend average hospital length of stay by 9.7 days while racking up an additional $20,842 per occurrence (de Lissovoy, et al. 2009; Klevens, et al. 2007) SSIs are attributed to causing more than 8,000 deaths annually (U.S. Department of Health and Human Services [HHS], 2013)

3. Nursing Relevance Perioperative nurses play a vital role in the prevention of SSIs (Lee, Agarwal, Lee, Fishman, & Umscheid, 2010) The Association of periOperative Nurses (AORN) has issued recommended practices related to prevention of SSIs (AORN, 2014) The Centers for Disease Control and Prevention (CDC) provides perioperative nurses a comprehensive formulary of evidence-based practice recommendations for the prevention of SSIs (Beyea, 2000)

4. Military Relevance Surgical site infections can have adverse effects on the Military Health System (MHS) to include: A decline in operational readiness Resource expenditures Burdensome financial costs (de Lissovoy, Fraeman, Hutchins, Murphy, Song, & Vaughn, 2009) The impact of SSIs on patient outcomes and financial expenditures has led the MHS to EBP guidelines from the Institute for Healthcare Improvement (IHI) in order to prevent SSIs in its healthcare facilities (Institute for Healthcare Improvement [IHI], 2012) SSIs in the deployed environment can have a major impact on mission accomplishment and patient outcomes

5. Contributing Factors to SSI There are several factors that can contribute to an SSI: Aseptic/sterile technique OR traffic patterns Patient co-morbidities Surgical site/procedure Wound classification Type of surgical skin prep solution (Harrop, Styliaras, Ooi, Radcliff, Vaccaro, & Wu, 2012)

6. Surgical Skin Preparation Definition Techniques Some of the most common solutions Povidone iodine (PI) Chlorhexidine gluconate (CHG) Can combine either with alcohol (PIA, CHA, respectively)

7. Clinical Question For adult patients undergoing surgical procedures, is a surgical skin preparation antisepsis solution of chlorhexidine gluconate with alcohol compared to povidone iodine more effective at decreasing the incidence of superficial incisional surgical site infection (SSI) within 30 days post-procedure?

8. Search Terms: Chlorhexidine gluconate, povidone iodine, surgical, site, infection, alcohol Boolean Terms: “AND” & “OR” Limitations: English language, articles within last 5 years, peer- reviewed academic journals, adult subjects >18 years old PubMed 37 CINAHL 12 TOTAL 49 Duplicates -7 Discarded - 32 RETAINED 10 Excluded N=32 Title irrelevant to search criteria: n=29 Excluded after reading abstract n=3

9. Evidence Appraisal Level I 5 of 10 articles SR/Meta-analysis or RCT Quality rating A Level II 1 of 10 articles Quasi-experimental Quality rating B Level III 4 of 10 Retrospective cohort Quality rating B Quality Overall quality was good Studies were well-designed and executed Limitations were clearly addressed Quantity Limited availability of comparative studies Consistency Studies were consistent in design respective to type; investigated same research question; Inconsistency with the type of procedure, pt population, wound class, ASA, etc. (Dearholt, & Dang 2012)

11. Literature Synthesis 40% (three of five Level I/A studies) CHA More effective in reducing the rate of SSIs compared to other solutions PI not as effective at reducing SSIs when compared to other solutions One SR was inconclusive, one SR no statistically significant difference, one retrospective cohort PI was more effective Incidental findings Common theme: there needs to be a large RCT comparing all solutions/formulations CDC surgical wound classifications (SWCs) Surgical sites, procedures, patient heterogeneity (ASA, comorbidities, etc.)

12. Conclusion The evidence in the literature is inconclusive No one solution better than other SSIs are a big issue across healthcare, drain on resources, patient outcomes, etc. Recommendations/implications for practice Is there one that is the most effective? What about standardization? Moving forward…. Recommendations There needs to be a large RCT comparing all variables What role does alcohol play when used alone and in conjunction w/CHG, PI, etc?

13. References Beyea, S. C. (2000). Preventing surgical site infections—Guiding practice with evidence. AORN Journal, 72(2), 305-307. doi:10.1016/S0001-2092(06)61945-5 Burlingame, B., Denholm B., Link, T., Ogg, M.J., Spruce, L.,…Wood, A. (2014). Recommended practices for preoperative patient skin antisepsis. In R. Conner (Ed.), Perioperative Standards and Recommended Practices (pp. 73- 87). Denver, CO: AORN, Inc. Centers for Disease Control and Prevention [CDC]. (2015). CDC/NHSN Procedure-associated module: SSI. National Healthcare Safety Network, Washington. Retrieved from http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf Dearholt, S. L., & Dang, D. (2012). Johns Hopkins Nursing Evidence-Based Practice : Models and Guidelines (2nd Edition). Indianapolis, IN, USA: Sigma Theta Tau International. Retrieved from http://www.ebrary.com de Lissovoy, G., Fraeman, K., Hutchins, V., Murphy, D., Song, D., & Vaughn, B. B. (2009). Surgical site infection: Incidence and impact on hospital utilization and treatment costs. American Journal of Infection Control, 37(5), 387-397. doi:10.1016/j.ajic.2008.12.010 Harrop, J. S., Styliaras, J. C., Ooi, Y. C., Radcliff, K. E., Vaccaro, A. R., & Wu, C. (2012). Contributing factors to surgical site infections. Journal of the American Academy of Orthopaedic Surgeons, 20(2), 94-101. doi:10.5435/JAAOS-20-02-094 Institute for Healthcare Improvement [IHI]. (2012). How-to Guide: Prevent Surgical Site Infections. Retrieved from http://www.ihi.org Joint Commission [JC]. (2013). The Joint Commission’s implementation guide for NPSG.07.05.01 on surgical site infections (SSIs). Retrieved from http://www.jointcommission.org/assets/1/18/Implementation_Guide_for_NPSG_SSI.pdf Klevens, R. M., Edwards, J. R., Richards, C. L., Horan, T. C., Gaynes, R. P., Pollock, D. A., & Cardo, D. M. (2007). Estimating health care-associated infections and deaths in US hospitals, 2002. Public Health Reports, 122(2), 160. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1820440/

14. References Lee, I., Agarwal, R. K., Lee, B. Y., Fishman, N. O., & Umscheid, C. A. (2010). Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 31(12). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3833867 Malpiedi P.J., Peterson K.D., Soe, M.M., Edwards, J.R., Scott, R.D., Wise, M.E.,…McDonald, L.C. (2011). National and State Healthcare-Associated Infection Standardized Infection Ratio Report. Retrieved from http://www.cdc.gov/hai/national- annual-sir/index.html. Reichman, D. E., & Greenberg, J. A. (2009). Reducing surgical site infections: A review. Reviews in Obstetrics & Gynecology, 2(4), 212-221. U.S. Department of Health and Human Services [HHS]. (2013). Implementation guide for surgical site infections. Retrieved from http://www.health.mil/~/media/MHS/Technical%20Document%20Files/SSI_Guide_Final.ashx

15. Questions