Surgical Site Infections

Publication ID: 302418314
Published on: November 2023
Major Revision: November 9, 2023


Symptoms of surgical site infections (SSI) include redness and pain around the surgical site area, drainage of cloudy fluid from the surgical wound, and/or fever. Nearly half of all adverse events in industrialized hospital care settings are attributable to surgical procedures, with SSIs occurring in up to 11% of patients undergoing surgical procedures. With more than 10 million patients undergoing an invasive procedure annually, it is essential to reduce SSI risks from both endogenous factors (the patient’s flora or seeding from a distant site of infection) and exogenous factors (surgical staff, physical environment, ventilation, tools, equipment, and materials in the operating room). This blueprint summarizes the available evidence-based practice protocols to reduce SSIs and outlines the actionable steps organizations should take to successfully improve surgical safety.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent Surgical Site Infections:

Symptoms of a surgical site infection (SSI) include redness and pain around the surgical site area, drainage of cloudy fluid from the surgical wound, and/or fever. Follow the steps identified below to prevent an SSI: 

  1. Preoperative measures:
    1. Consider all minimally invasive measures first to make sure surgery is necessary.
    2. Conduct MRSA screening.
    3. Assess the patient for any allergies or sensitivities to skin antiseptics that may be used during the surgery.
    4. Provide clear and understandable instructions of the procedure to the patient and their family prior to surgery.
    5. Confirm patient identity, incision site, and procedure type.
    6. Remove patient jewelry or any clothing that may be an obstruction during the surgery.
    7. Isolate highly contaminated areas near the surgical site (e.g., anus).
    8. Utilize precautions to avoid ingestion of antiseptic for surgical sites near the mouth of the patient.
    9. Administer antibiotics within one hour prior to any surgical incisions and re-dose as needed per specific surgical procedure and patient.
  2. Intraoperative measures:
    1. Closely monitor the patient’s vital signs during the procedure.
    2. When needed, utilize antibiotic-impregnated implants.
    3. Minimize blood transfusions.
    4. Minimize traffic inside the operating room.
    5. Maintain room humidity at 20%–60%.
    6. Keep the interior of the room at a positive pressure.
    7. Adhere to sterile precautions by enforcing strict hand scrub compliance and maintaining PPE for the entire procedure. Note: PPE is not to be taken or worn outside of the operating room.
    8. Maintain protection and cleanliness of the site during the entire operation and perform topical irrigation of the incision site.
    9. Maintain tight glucose and temperature control.
  3. Postoperative measures:
    1. Ensure that all sponges, instruments, and needles used during the procedure are counted.
    2. Check blood glucose levels, temperature, and vital signs.
    3. Perform chlorhexidine shower two hours after the procedure.
    4. Protect primary closure incisions with sterile dressing for 24–48 hours post-op.
    5. Stop using antibiotics within 24 hours after the surgery end time—48 hours for cardiac patients, unless signs of infection are present.
    6. Document wound care and maintain infection vigilance during the entire stay of the patient at the hospital.
    7. Maintain infection vigilance throughout full hospital stay.
    8. If an infection is identified, actively engage the care team in sepsis prevention.
    9. Communicate key concerns for patient recovery with the full care team, including the patient and family.

Surgical site infection processes to consider assessing:

  1. Use of the standard surgical safety checklist
  2. Antimicrobial prophylaxis
  3. Delivery of antibiotics
  4. Documentation of wound care
  5. Hair removal
  6. Determination of the process/protocol that will be used for decolonization
  7. Identification of surgical site infections
  8. Discharge coordination
  9. Use of blood transfusions
  10. Set up of operating room conditions
  11. Maintenance and sterilization of operating rooms
  12. Fire risk assessment
  13. Consideration of noninvasive alternatives
  14. Sterile technique adherence
  15. Procedural delays
  16. Adaptation of procedure due to equipment or staffing shortages
  17. Storage and disposal of antiseptics
  18. Glucose and temperature control techniques intraoperatively and postoperatively

Risk Factors

Any patient undergoing a surgical procedure is at risk for an SSI. However, patient-specific risk factors include:

  1. Pre-existing infection
  2. Low serum albumin concentration
  3. Old age
  4. Obesity/diabetes
  5. Smoking
  6. Ischemia
  7. Trauma
  8. Blood transfusions
  9. Hypothermia
  10. Hypoxia
  11. Hyperglycemia
  12. Abdominal surgery
Unit Managers

This guide outlines the steps that managers can follow to prevent Surgical Site Infections:

  1. Obtain buy-in for use of a surgical safety checklist to help prevent surgical site infections (SSI):
    1. Ask team members to think about how the checklist intervention is connected to their values.
    2. Involve surgeons and all other clinicians in building these safety mechanisms to emphasize the “why.”
    3. Hold staff accountable for providing the standard of care and reward success.
    4. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
    5. Use patient stories to help teach and inspire change in your staff.
  1. Invest in team-building:
    1. Designate an individual responsible for the use of the surgical checklist and make sure their role is known among other team members.
    2. Activate all team members in efforts to build and improve the standardized protocol and share the responsibility.
  1. Standardize the expectations:
    1. Standardize a surgical site infection prevention checklist for all surgical procedures.
    2. Incorporate hard stop reminders to complete the checklist during routine preoperative processes.
    3. Standardize SSI definitions and criteria for institutional reporting.
    4. Ensure that surgical safety protocols are embedded into clinical workflows, whether electronic or paper.
  1. Use metrics to inform needed process changes:
    1. Measure and report SSI and compliance monthly.
    2. Note trends in areas with low compliance and high SSI incidence. Routinely reassess outcomes.
    3. Track root causes of failure to use/complete the pre-op checklist and for procedure delays.
    4. Consider calling patients postoperatively to assess for signs of infection.
    5. Ensure that leaders have a simple process to oversee surgical safety improvement work while also considering how it aligns with other initiatives across the organization.

Performance Improvement Plan:

If leadership has determined that a performance improvement project is necessary, you can use the following steps:

  1. Gather the right project team.
    1. Be sure to involve the right people on the team.
    2. Form two teams: an oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread. The actual project team consists of 5–7 representatives who are most impacted by the process. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.
  2. Understand what is currently happening and
    1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data and validating the sources, but the most important action here is to go to the point of care and
    2. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening
    3. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.

Recommended surgical site infection improvement team:

  1. Infection preventionists
  2. Operating room nurses
  3. Surgeons
  4. Anesthesiologists
  5. Nurse anesthetists
  6. Operating room technicians
  7. Floor nurses
  8. ICU nurses
  9. Social workers/care coordinators
  10. Clinical educators
  11. Blood bank personnel
  12. Quality improvement leaders
  13. Admitting and registration staff


Hospital Executives

This protocol outlines the steps that executives can follow to prevent Surgical Site Infections:

Nearly half of all adverse events in industrialized hospital care settings are attributable to surgical procedures, with surgical site infections (SSI) occurring in up to 11% of patients undergoing surgical procedures. SSI is the most expensive type of healthcare-associated infection, costing $3.3 billion annually, with over one million preventable patient days. Since more than 10 million patients undergo an invasive procedure annually, the risk for SSI is significant.

Common organizational barriers to safe surgery and SSI prevention include:

  1. Awareness: Current research suggests that up to 50% of nurses and healthcare staff are unaware of the evidence-based recommendations to prevent SSIs.
  2. Attitudes: It has been suggested that clinicians may not agree on the standardized protocols or may not feel confident in their abilities to execute these standards Providers may not agree that the presented evidence is applicable to their patient’s situation. Hospital leaders should evaluate the number of steps in SSI prevention standards to better understand the operational barriers that even the most well-intended clinicians may face.
  3. Detection: Detecting SSI is becoming increasingly challenging due to the lack of standardized methods for post-discharge and outpatient surveillance. This is in part due to an increased number of outpatient surgeries and shorter postoperative inpatient stays.
Patient & Families

This guide outlines the steps that patients can follow to prevent Surgical Site Infections:

  1. Patients and their families can ask the following questions from the surgical team to learn about their risk for a surgical site infection (SSI) and methods to prevent it:
    1. What are the specific risk factors for a surgical site infection?
    2. What methods are used throughout the organization to prevent surgical site infection?
    3. What actions can patients take to prevent a surgical site infection?
    4. Should wearing/using certain personal care products (makeup, lotions, powders, etc.) be avoided?
    5. Should shaving the area around the surgery site be avoided?
    6. Is showering just before the procedure recommended?
    7. Is taking antibiotics prior to the surgery recommended?
  2. Patients and their families need to share the following information with their surgical team to help prevent SSI:
    1. Medical history and other illnesses
    2. Allergies (food and drugs, such as antibiotics)
    3. Smoking, recreational drug use, and alcohol consumption history
    4. History of other surgeries
    5. History of SSI or sepsis
  3. Patients and their families need to make sure they fully understand the postoperative wound care and discharge instructions.

Anderson, D. J., et al. Overview of control measures for prevention of surgical site infection in adults. Up to Date. (2020) 

CDC. What You Should Know Before Your Surgery. (2020) 

Edministon Jr. Charles E, et al. Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review

Heinz et al., PRESS survey: PREvention of surgical site infection—a global pan-specialty survey of practice protocol. Frontiers in Surgery (2023) 

Lin, F., et al. Preventing Surgical Site Infections: Facilitators and Barriers to Nurses’ Adherence to Clinical Practice guidelines-A Qualitative Study. Journal of Clinical Nursing, 1643–1652. (2019) 

Ling, M. L., et al. APSIC guidelines for the prevention of surgical site infections. Antimicrobial Resistance and Infection Control. (2019) 

Liu, Z., et al. Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic. Nature Public Health Emergency Collection, 1–5. (2020) 

Seidelman L. Jessica, et al. Surgical Site Infection Prevention A Review.  Journal of the American Medical Association. (2023) 

Syed, Husain. Effective and Evidence-Based Intervention Guidelines for Surgical Site Infection Prevention. Journal of the American College of Surgeons. (2022)