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Infection of surgical-sites, formerly called surgical wounds, is the third most frequently reported hospital-acquired infection. (1) The price in patient morbidity and mortality is high, as are the related costs of treatment Surgical-site infections (SSIs) have been estimated to result in $1 to $10 billion in direct and indirect medical costs each year. (2-4) A study by Kirkland et al found that "... patients who develop SSI [surgical-site infection] have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital." (5)

That doesn't mean that, if you go to the hospital for say a face-lift or even a colostomy, you should fear you won't ever be going home again. Certain factors have bearing on the likelihood, or not, of contracting an SSI, factors that include but are not limited to category of surgery, ie, some surgeries are "cleaner" than others, eg, eye surgery would be less likely to result in infection than bowel surgery; length of hospital stay and length of surgical procedure; age, particularly very young or very old; and health status of the individual, because underlying illnesses can reduce the ability of the immune system to do its job. It's a wonderful thing that advances in health care, including infection control, allow us to live longer now; unfortunately, with ripe old age can come chronic, debilitating, immunocompromising diseases that could render us more susceptible to infection. This particular population can really crank up those infection rates.

The good news is that means of caring for wounds due to surgery and combating potential infection of those wounds are constantly being sought or tweaked. For instance, we now know that preoperative prophylactics should be administered to nip bugs in the bud; clippers, not razors, should be used to remove hair from surgical sites prior to surgery, because shaving can leave tiny cuts on the skin, providing an open invitation to bacteria; monitoring patients' glucose, even if they're not diabetic, is important; and normothermia, keeping patients warm, improves results, as can supplemental oxygen. In a study from a surgeon's perspective, Nichols highlighted these and other important factors: "The most critical factor in the prevention of postoperative infection, although difficult to quantify, are the sound judgment and proper technique of the surgeon and the surgical team, as well as the general health and disease state of the patient. Other factors influence the development of postoperative wound infection, especially in clean surgical procedures, for which the infection rate (<3%) is generally low. Infections in these patients may be due solely to airborne exogenous microorganisms." (6)

The Centers for Disease Control and Prevention concluded, "Thus, to reduce the risk of SSI, a systematic but realistic approach must be applied with the awareness that this risk is influenced by characteristics of the patient, operation, personnel, and hospital." (1)

Products good for the patient and the pocketbook

Accompanying aseptic technique in the battle against infection are a myriad of products designed for the care of surgical wounds. Angela Box-Peterson, a wound-care nurse, is the special programs coordinator in a hospital in the Birmingham Alabama, area who spends most of her time with patients who have wounds and ostomies. "Most of my time is spent with complicated post-op wounds," explained Box-Peterson. "My input into post-op care would usually involve application of the wound vac in the operating room, recovery room, or during the post-op recovery period in the hospital room. I work closely with our surgeons and doctors to develop a plan of care that is simple, effective, and cost-effective in meeting the goal of healing the wounds with as much patient independence and participation as possible. The typical patient I may see has a wound in an area of their body with a high risk of contamination. The patient is usually nutritionally compromised with limited mobility. Fecal incontinence only adds concern to our plan of treatment This may be further complicated by infection with Clostridium difficile, resulting in frequent liquid stools. Many patients and their family members dc not want temporary diverting colostomies, which would provide better opportunities for a dean wound environment in certain areas of the body. There are several products in use at our facility, in accordance with purchasing contracts, to help us reach our goals in providing care to these patients and their wounds." Box-Peterson described some of the products that have benefited their patients' healing process, the hospital's pocketbook, and the nurses by saving them time and labor.

The V.A.C. Therapy System (Vacuum Assisted Closure), by KCI, can be used to close wounds quickly, using negative-pressure wound therapy (NPWT), and therefore often reduces length of stay. It can help reduce contamination of a wound environment due to the occlusive nature of the dressing. Labor costs can also be reduced, as the dressings are generally changed 3 to 4 times a week, and not daily or twice daily, etc."

The Comfort Shield, by Sage, is a wipe that provides easy and quick clean up of urinary or fecal incontinence while placing a skin barrier at the same lime. This item can save labor and linen costs, as the product is disposable, while increasing the skin's resistance to breakdown, which may lead to a decrease in length of stay. The patient and family member may be able to learn to use this product to make a better and easier transition to the home environment. We also have used the wipe in conjunction with the FMS. In the first 24 to 48 hours of use, the special rectal tube may leak some fecal matter, so we have placed the wipe in the area around the tube to keep the stool from leaking into the wound area. When the patient is more mobile, this wipe is especially helpful in keeping the wound environment dean, while being easy to use. My hospital has been using the Sage Comfort Shield for over 2 years, hospital-wide, for incontinence care. The ease of use, disposability of the product, and reduction of steps to ensure protection of the skin after cleansing are a few of the aspects of this product that make it well-liked by staff, therefore increasing the compliance of recommended skin care and protection. Recently, our corporate wound-care council met and decided to make this product available in all of our hospitals. It seems to be the best product available for the cost. In my hospital, we were able to eliminate another product that we had available, perineal cleansing foam, and this helped save money."

Speaking of saving money, products impregnated with ionic silver are on the rise, and wound dressings are no exception. Knowledge of the possibilities for ionic silver has been around some years but has only recently been brought to the forefront. The advantages of ionic silver are impressive: it's a natural broad-spectrum antibiotic; ifs activated by wound exudate; bacteria are attracted to it; and bacteria don't grow resistant to it. Anything that can kill harmful bacteria while not engendering resistance is "a good thing," as Martha would say.