INFECTION CONTROL POLICY AND PROCEDURE MANUAL SUBJET: Prevention of Surgical Site Infection DEPARTMENT: INFECTION CONTROL DIVISION: Hunt Regional Medical Center PAGE: 1 of 1 EFFECTIVE DATE: 1/93 PREPARED BY: Kristi Saenz, RN, CIC Infection Control Coordinator APPROVED BY/TITLE: Infection Control Committee REVIEWED: 6/08, 03/10, 03/12, 03/13, 01/14, 01/15, 01/16, 01/17, 01/19 REVISED: 6/95. 12/98, 1/00, 6/09, 01/11, 01/18, 09/19, 01/20 Purpose: Hunt Regional Healthcare utilizes best practices to decrease surgical site infections. Policy:  Hunt Regional Healthcare conducts an annual risk assessment for surgical site infections and selects surgical site infection measures using best practices or evidence-based guidelines.  The Infection Control Coordinator and the Surgical Services Director monitors compliance with best practices or evidence-based guidelines, and evaluates the effectiveness of prevention efforts.  Hunt Regional Healthcare utilizes the National Healthcare Safety Network (NHSN) Surgical Site Infection (SSI) definitions for infection surveillance. There are three categories, Superficial, Deep and Organ Space.  Measurement strategies follow evidence-based guidelines, and surgical site infection rates are measured for the first 30 days for superficial incisional SSI and 30 - 90 days for deep and/or organ/space SSI.  To provide data for the purpose of improved patient care outcomes, HRHC conducts surveillance of post surgical site infections (SSI). Post-discharge surveillance includes: a review of readmission data to identify potential surgical site infections and requesting surgical site infection data of discharged patients from the surgeon.  Data, as required by federal and/or state mandates, will be entered into the NHSN databank.  The Infection Control Coordinator provides surgical site infection rate data and prevention outcome measures to key stakeholders including the Infection Control Committee, Quality Counsel and the Governing Body.  Hunt Regional Healthcare has implemented the Institute for Healthcare Improvement Surgery Bundle for the prevention of surgical site infections. The best practice components include: IC26 - 1 Prevention of Surgical Site Infections Bundle  Antibiotics within 1 hour (two hours are allowed for the administration of vancomycin and fluoroquinolones).  Correct antibiotics (Infectious Diseases Society of America Recommendations)  Antibiotic discontinued within 24 hours  Glucose control  Appropriate hair removal- clippers (no razors)  Normothermia  Advise patients to shower or bathe (full body) with soap at least the night before the operative day. Chlorhexidine Gluconate (CHG) soap for pre-op bathing for all total joint surgeries. Reference: CDC, Guideline for the Prevention of Surgical Site Infection, 2017 CDC, Guidelines for the Prevention of Surgical Site Infections, 1999 Institute for Healthcare Improvement, Surgery Bundle, 2008 Infectious Diseases Society of America Recommendations, 2006 IC26 - 2

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