Development of Postoperative Infection in Women - Research Paper Example

Why so many Women between the ages of 30 to 50 Develop Postoperative Infection Nursing Research Introduction Postoperative wound infection is an important complication following surgery. The wound may be contaminated before surgery, during surgery, or following surgery being infected during healing. The skin is considered to be body's first line of defense, and surgery in itself is a mutilative procedure, where this defense may be violated. Even though the surgical procedure is performed in the best possible strict aseptic environment, there is a high probability of infection. There may be a variety of reasons of surgical wound infection in all the phases mentioned above, but the most probably the final common pathway for such infections is contamination of the surface of the skin by the natural commensal bacteria of the skin. Due to some violation of safety precautions before, during, and after surgery, these or other freshly colonized bacteria in the hospital environment may enter the wound and cause infection, where bacteria now easily penetrate the wounded skin. As mentioned earlier, injury and inflammation caused by surgical manipulation may also help the nosocomial bacteria enter into the wound after being transmitted from somewhere else from within the hospital environment. In effect such infections in the surgical wound would slow down the approximation of the wound edges, delay wound healing, lead to morbidity, and cause increased economic burden, increased hospital stay, and increased incidence of other infections. Usually the patients present with increased pain in the surgical wound as a result of inflammatory process early in the infection, redness at the wound margins that spreads unless treated, drainage from the wound margin, fever due to infection, and ultimately breakage of the wound (Pryor et al., 2004). Rationale Such cases are often encountered in clinical surgical nursing practice, and the nursing assessment usually yields the following diagnoses, risk for infection, impaired skin integrity, impaired tissue integrity, and delayed surgical recovery. Thus this is a recognised surgical nursing care problem the evidence-based knowledge about which would be helpful in clinical practice nursing. While the problem is evident and common one, in this author's clinical practice as a surgical nurse in the Jacobi Medical Center, despite an uniform age distribution in the surgical cases, it is a common finding that female patients develop postoperative infections more frequently, and as a result they on an average have a longer postoperative stay, and in some cases, following discharge from the hospital, they return to the hospital with wound discharge, breakdown, or infections. This leads to a focus question, why these female patients have an increased preponderance of wound infection. To find out the answers, this author has chosen the age group of 30 to 50-year-old female surgical patients, so the answers to this question in the context of these patients are found out from the literature. The findings may prove to serve as evidence base where change in practice in such cases may be mandated. Focus Question Why so many women between the ages of 30 to 50 develop postoperative infection Literature Review To this end, a literature search was conducted with key words postoperative infection, females, women, nursing care, surgical nursing, wound infection, and wound care. Out of the available literature which included studies, research articles, and reviews, including both quantitative and qualitative literature, six recent articles were selected for critical review in order to point out the evidence available. It is to be mentioned that although the assignment requirement only mentions nursing literature, it would not be prudent to include only nursing literature since the cause of surgical site infection may also lie in the operating room management and handling of the skin, the magnitude of the operative procedure, the technical dexterity of the surgical team, and safety protocol of the institute where the surgery is being performed. Nurses usually are involved in perioperative phase of the surgical care of the patient and hence they manage pre and postoperative states. Therefore to have a total idea of the causes, all sorts of literature are needed to be included. Moreover, out of about 19,161 literatures scanned, none of them were specific for females of age 30 to 50, indicating paucity of literature on specifically this group of patients. Therefore, it was decided that review will be made of the articles in general, and findings will be extrapolated to this age group. Reilly (2002) performed a 3-year prospective cohort study of 2202 surgical patients who were treated in seven surgical wards across two hospitals using the methodology of gold standard surveillance. An independent observer followed the surgical patients as inpatients and post discharge for 30 days. The data were collected, and the single best quality indicator of surgical care that prevents wound infection technically turned out to be clean, elective surgical wound. Even with that if infection occurred the risks were indicated by smoking, higher body mass index which is common in women of 30-50 years of age, presence of malignancy as a diagnosis, technical failure leading to hematoma formation, increased number of people in the operating room, usage of adherent dressing, and higher times to suture removal related to increased subcutaneous fat. Although the care team needs to be vigilant about these factors and attempt to reduce these risks as much as possible, but if the team wanted to reduce the incidence of infections, surveillance in the above format may be the best way to collect data. The patient care practices were shown by this study to affect surgical wound infection rate, and this type of surveillance as evidenced in literature would reduce the risk from extrinsic risk factors mentioned above. Implementation of this evidence in practice significantly reduced the rates of surgical would infection (Reilly, 2002). Webster and Osborne (2006) did a meta-analysis of published researches from different databases to gather evidence regarding preoperative bathing of the surgical site with an antiseptic solution. All these studies compared antiseptic solution with a non-antiseptic washing agent with no bathing. From the reported data of surgical site infection, out of six trials involving 10,007 patients were treated with 4% chlorhexidine, but this meta-analysis showed bathing the operative area with chlorhexidine did not reduce surgical site infection. Similar result was obtained in the studies that used bar soap with chlorhexidine. The evidence did not support preoperative bathing with chlorhexidine as a means of surgical site infection (Webster and Osborne, 2006). Segal et al. (2002) report the nursing practice about the preoperative skin preparation of cardiac patients. This study highlights that nurses undertook initiative to optimize the process of the preoperative preparation of the skin open heart surgery patients. In order to do that they searched for evidence from literature and submitted a proposal to the surgeons along with the internal review board of the hospital. They accepted this proposal. Methodologically, it was a randomized controlled trial involving patients who were identified to be high risk prior to surgery. They were randomized into groups receiving any of one of four different prep solutions. The findings suggest that the incidence of infection was significantly lower in the groups who were prepped insoluble iodine containing prep. This also indicated that the type of surgical skin prep solution can predict surgical site infections, the prevention of which can be attained with insoluble iodine containing preps (Segal and Anderson, 2002). van Kasteren et al. (2007) analyzed the effects of parameters of antibiotic prophylaxis on the risk of surgical site infection (SSI) post total hip arthroplasty. The authors collected data about SSI. The information about potential prophylaxis, patient risk factors, and procedure-related risk factors were collected in a prospective design involving 1922 patients undergoing elective total hip arthroplasty in 11 hospitals under this study. The data were analyzed using multivariate logistic regression analysis for correction of random variation they might have existed among hospital protocols. The results demonstrated that superficial and deep surgical site infections occurred 2.6% of the patients with these occurring most frequently in patients receiving post incision prophylaxis, having an American Society of Anesthesiology score of >2, and having the duration of the surgery >75th percentile. Evidence indicated that prolonged prophylaxis over days post-surgery and antibiotic-impregnated cement could not cause reduction of SSIs. This study suggests that interventions to prevent SSI should be timely administration of antibiotic prophylaxis at the incision (van Kasteren et al., 2007). Fonseca et al. (2006) hypothesized that 1-dose antibiotic prophylaxis is sufficient to control SSI as opposed to a 24-hour regimen. They performed a before-after trial in a tertiary private general hospital in Brazil on a sample of 6140 consecutive patients on different indications across sub-specialities with an intervention of decreasing 24-hour regimen to a 1-hour regimen. The outcomes were measured by surgical site infections through in-hospital surveillance and post-discharge surveillance. This study demonstrated that one-dose antibiotic prophylaxis did not lead to an increase in rates of surgical site infection, which was promoted through education of staff (Fonseca et al. 2006). Pryor et al. (2004) did this randomized controlled trial to determine the justification of routine use of perioperative high FIO2 that was believed to reduce the incidence of surgical site infection in patients undergoing general surgery. This was a double-blind, randomized controlled trial done at a large hospital in New York City involving 165 patients who underwent major intra-abdominal surgery under general anesthesia. This methodologically sound study did a comparative intervention of "either 80% oxygen (FIO2 of 0.80) or 35% oxygen (FIO2 of 0.35) during surgery and for the first 2 hours after surgery." The outcomes were presence of significant site infection after 14 days postoperative. It was found that patients who developed infection indicated by clinical criteria, management change, or defined objective criteria had a prolonged stay in the hospital. This study concluded that use of high FIO2 in the surgical patients is not helpful to reduce SSI, and they may in fact be detrimental (Pryor et al., 2004). Summation The current practice in operative surgery has many elements that can be changed as indicated by evidence to foster reduced surgical site infections. As tabulated below, these studies indicate the following main findings. Smoking, higher body mass index which is common in women of 30-50 years of age, presence of malignancy as a diagnosis, technical failure leading to hematoma formation, increased number of people in the operating room, usage of adherent dressing, and higher times to suture removal related to increased subcutaneous fat, all lead to high rates of surgical site infections. In this category of patients, the nurses must initiate a surveillance procedure right from the perioperative period, which reduces incidence. Washing the surgical site with chlorhexidine 4% solution has no effect, where as in high risk patients, use of insoluble iodine prep can reduce infections. Immediately following incision 1 dose of antibiotic is superior to day-long or prolonged course of antibiotics in reducing surgical site infection. In general surgical patients, perioperative high FIO2 can be detrimental and is useless in reducing infection. Study Findings Reilly, 2002 Smoking, higher body mass index which is common in women of 30-50 years of age, presence of malignancy as a diagnosis, technical failure leading to hematoma formation, increased number of people in the operating room, usage of adherent dressing, and higher times to suture removal related to increased subcutaneous fat, all lead to high rates of surgical site infections. In this category of patients, the nurses must initiate a surveillance procedure right from the perioperative period, which reduces incidence. Webster and Osborne, 2006 The evidence did not support preoperative bathing with chlorhexidine as a means of surgical site infection Segal and Anderson, 2002 Incidence of infection was significantly lower in the groups who were prepped insoluble iodine containing prep. This also indicated that the type of surgical skin prep solution can predict surgical site infections, the prevention of which can be attained with insoluble iodine containing preps. van Kasteren et al., 2007 Interventions to prevent SSI should be timely administration of antibiotic prophylaxis at the incision. Fonseca et al. 2006 One-dose antibiotic prophylaxis did not lead to an increase in rates of surgical site infection, which was promoted through education of staff. Pryor et al., 2004 Use of high FIO2 in the surgical patients is not helpful to reduce SSI, and they may in fact be detrimental Table 1: Comparison of Evidence from Reviewed Articles Practice Implications and Conclusion This review clearly indicates that in the study group of patients, there are certain characteristics of the patients that indicate high risk for SSI. Nurses must be vigilant about Smoking, higher body mass index which is common in women of 30-50 years of age, presence of malignancy as a diagnosis, technical failure leading to hematoma formation, increased number of people in the operating room, usage of adherent dressing, and higher times to suture removal related to increased subcutaneous fat in such patients, and an adequate surveillance programme may reduce incidence of infection. Skin prep has important role, but as against conventional chlorhexidine, iodine preps are evidenced to reduce incidence of SSI. Timely administration of single dose antibiotic just after the incision as against day-long antibiotic must be initiated as evidence through staff education, and the conventional high perioperative FIO2 should be stopped. Reference List Fonseca, SNS., Kunzle, SRM., Junqueira, MJ., Nascimento, RT., de Andrade, JI., and Levin, AS., (2006). Implementing 1-Dose Antibiotic Prophylaxis for Prevention of Surgical Site Infection Arch Surg; 141: 1109 - 1113. Pryor, KO; Fahey, III, TJ.; Lien, CA., and Goldstein, PA., (2004). Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population: A Randomized Controlled Trial. JAMA.;291(1):79-87 Reilly, J., (2002). Evidence-based surgical wound care on surgical wound infection. Br J Nurs; 11(16 Suppl): S4, S6, S8, S10, S12. Segal, CG. and Anderson, JJ. (2002). Preoperative skin preparation of cardiac patients. AORN J; 76(5):821-8. van Kasteren ME, Mannin J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. (2007). Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis;44(7):928-30. Webster J and Osborne S. (2006). Meta-analysis of preoperative antiseptic bathing in the prevention of surgical site infection. Br J Surg;93(11):1335-41. Read More