1. Bockman, Tammy RN, BSN, MHA
  2. Putney, Jeannette L. RN, CNOR, BSN

Article Content

Perioperative nurses have the responsibility to act as patient advocates, which includes implementing measures to promote patient safety and to decrease the risk of postoperative surgical site infections. The Institute for Healthcare Improvement (IHI) and the Centers for Medicare and Medicaid Services (CMS) offer simple, evidence-based practices that dramatically impact surgical site infection (SSI) rates.


The measures may seem simple, but as our institution took on this worthwhile adventure, it became evident that the entire perioperative team had to work together to meet the recommendations. The task was not easy, and required the team's leaders to remain diligent and keep pushing forward.


Four areas were monitored throughout the collaboration: appropriate hair removal, prophylactic antibiotics, patient temperature, and postoperative glucose control.1 The acronym CATS (Clippers, Antibiotics, Temperature and Sugar) is used to symbolize the measures and the interventions.



The appropriate method of hair removal includes clipping at the surgical site versus shaving. Shaving hair may cause microscopic abrasions that will harbor bacteria and can lead to an increased risk of infection. It's important to remember that the hair removal should take place as close to the time of incision as possible and it must be completed outside of the room where the procedure will be performed.2


In our experience, it was easy to motivate the surgeons and OR staff to discontinue the use of razors and convert solely to clippers. However, we did discover patients that were eager to assist in this process and completed their preoperative shave the night before. We implemented a more intense preoperative patient education process in the outpatient setting before the day of surgery. The patient was informed not to shave the surgical site. We also provided chlorhexidine gluconate soap for the patient to bathe with the night before and morning of surgery.



The antibiotics intervention includes appropriate selection and timing. The Surgical Care Improvement Project provides a list of recommended antibiotics categorized by surgical procedure.3 Our team worked closely with the hospital pharmacy department and also the surgeons to identify available formulary antibiotics.


The timing of the prophylactic antibiotic is also essential. There is evidence that the most benefit for infection prevention is between 30 to 60 minutes before incision.4 In addition, to gain the most prophylactic coverage in any procedure requiring a pneumatic tourniquet, the entire antibiotic must be administered prior to inflation of the tourniquet.5


It's important during the improvement process to identify and clarify each team member's role. In our experience, the preop nurse prepared the antibiotic and the anesthesia staff was responsible for starting the antibiotic and documenting the time on the anesthesia record. This improved compliance for documentation of the timing. The anesthesia record was also revised to include a space for the preop antibiotic dosing time.


As our team looked at the timing of the antibiotics, we noticed that none of our clocks showed the same time. Our times were usually within just a few minutes of meeting the requirement: approximately 60 minutes.


To address this, each quarter all clocks were synchronized with the preop room clock. The times still continued to vary, so atomic clocks were installed throughout the department. This change in practice made a positive impact on our timing measurement.


Focusing on antibiotics also included appropriate weight-based dosing. In our preliminary data collection, we noticed several patients weren't receiving the appropriate dose according to their weight. Our institution began to weigh all surgical patients the morning of surgery and identify those patients weighing more than 176 lbs (80 kg). The surgeon was notified if the dose wasn't adequate for the patient's weight.


Lastly, discontinuation was considered during the antibiotic focus. There is no evidence to continue prophylactic antibiotics beyond 24 hours of surgery and in fact, using antibiotics beyond 24 hours may lead to increased risk of resistance.3


We have incorporated educational opportunities for our physician staff and nursing staff but still have difficulty with this measure. We use a computerized ordering system and have changed the order sets several times. The latest revision includes writing the order for the postop antibiotic every 8 hours times two doses. This effort has made the biggest impact on adherence so far.



This measure begins with the first temperature upon arrival to the PACU. Maintaining a patient's normothermia in the perioperative period improves outcomes. This also impacts the healing process by improving perfusion to the surgical site. A patient should maintain a temperature between 96.8[degrees] F and 100.4[degrees] F (36[degrees] C and 38[degrees] C).6


There is also evidence that instituting preventative warming measures for 30 minutes prior to the start of surgery,6 along with intraoperative warming measures, will help the patient to maintain a normal temperature during the intraoperative period. There are many patient warming devices on the market; we chose a forced-air warming gown controlled by the patient. The gowns have given us great results and are well received by patients.



Sugar refers to blood glucose control. The measure states that cardiac surgery patients should have controlled 6 a.m. postoperative serum glucose levels (less than 200mg/dL) on postoperative day one and day two. One study identified that postoperative hyperglycemia has been associated with the development of SSIs among cardiothoracic surgery patients.7 Our facility doesn't perform cardiothoracic surgical procedures, but elected to adapt this measure by following all surgical patients admitted to ICU postoperatively. In addition to this postoperative monitoring, the perioperative nursing and anesthesia staff monitor and record serum levels on diabetic surgical patients and nondiabetic patients that will be admitted to ICU postoperatively. These patients are monitored throughout the surgical experience. Surgical outcomes are improved in patients with diabetes who have good metabolic control.8


Our facility committed to this journey over 2 years ago, and we have seen dramatic improvements in our overall clean SSI rate. Our starting point was an average of 3.8% and is now 1.8% of surgical clean care procedures per month. This is attributed to all members of the perioperative team who diligently worked to implement all of the strategies identified. The patients are the benefactors and our number one concern.




1. Health Service Advisory Group, Inc. (HSAG). The Medicare Quality Improvement Organization of Arizona. CATS decrease surgical site infections. Available at: Accessed February 26, 2008. [Context Link]


2. AORN. Recommended practices for skin preparation of patients. Standards, Recommended Practices, and Guidelines. Denver, Colo. AORN, Inc.; 2007:653. [Context Link]


3. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: National initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006; 43:322-30. [Context Link]


4. Classen DC, Evans RS, Pestotnik SK, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992; 326:281-286. [Context Link]


5. Antimicrobial prophylaxis for surgery. Treatment guideline. Med Lett. 2006 Dec; 4(52):83-88. [Context Link]


6. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med. 1996; 334:1209-1215. [Context Link]


7. Latham R, Lancaster Ad, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol. 2001; 22:607-612. [Context Link]


8. Marks J. Perioperative management of diabetes. Am Fam Phys. 2003; 67(1): 93-98. [Context Link]