Safe Care



Surgical site infections are the second most common type of adverse events occurring in hospitalized patients. A surgical wound infection occurs when micro -organisms from the skin or the environment enter the incision that the surgeon makes through the skin in order to carry out the operation.

These infections can develop at any time from two to three days after surgery until the wound has healed (usually two to three weeks after the operation).


Infections are more likely to occur after surgery on parts of the body that harbor lots of germs, such as the gut. Surgical site infections have been shown to increase mortality, readmission rate, length of stay, and cost for patients who incur them.

Surgical Site Infection

Educational Media

Learn how to receive safe care while in the hospital. These videos teach you how.

Preparing for Surgery, a free

tutorial courtesy of the National Institutes of Health.

Infections are more likely to occur after surgery on parts of the body that harbor lots of germs, such as the gut. Surgical site infections have been shown to increase mortality, readmission rate, length of stay, and cost for patients who incur them.


An estimated 40 to 60 percent of these infections are actually preventable. 38% of all nosocomial infections in surgical patients are surgical site infections. 4 to 16% of all nosocomial infections are SSIs. 2 to 5% of operated patients will develop SSI. SSI increases the patients length of stay in the hospital by an average of 7.5 days.


Wound site infections are a major source of postoperative illness, accounting for approximately a quarter of all nosocomial infections. National studies shave defined the patients at highest risk for infection in general and in many specific operative procedures.


Advances in risk assessment comparison may involve use of the standardized infection ratio, procedure-specific risk factor collection, and logistic regression models.


Adherence to recommendations in the 1999 Centers for Disease Control and Prevention guidelines should reduce the incidence of infection in surgical patients.


What You Need to Know


An informative downloadable pdf, courtesy of Agency for Healthcare Research and Quality.

See the SHEA FAQ poster on How to Prevent Surgical Site Infections. This poster is also downloadable in full size.

Postoperative surgical site infections remain a major source of illness and a less frequent cause of death in the surgical patient. These infections number approximately 500,000 per year, among an estimated 27 million surgical procedures and account for approximately one quarter of the estimated 2 million nosocomial infections in the United States each year. Infections result in longer hospitalization and higher costs.


The incidence of infection varies from surgeon to surgeon, from hospital to hospital, from one surgical procedure to another, and most importantly, from one patient to another.


During the mid 1970s, the average hospital stay doubled, and the cost of hospitalization was correspondingly increased when postoperative infection developed after six common operations. These costs and the length of hospital stay are undoubtedly lower today for most surgical procedures that are done on an outpatient basis, such as laparoscopic (minimally invasive) operations or those that require only a short postoperative stay. In these cases, most infections are diagnosed and treated in the outpatient clinic or the patient's home.


However, major complications such as deep sternal infections continue to have a grave impact, increasing the duration of hospitalization as much as 20-fold and the cost of hospitalization fivefold. Any surgical site infection after open heart surgery results in a substantial net loss of reimbursement to the hospital compared with uninfected cases, a factor that should motivate hospitals to minimize the incidence of postoperative infections.

The Centers for Disease Control and Prevention (CDC) term for infections associated with surgical procedures was changed from surgical wound infection to surgical site infection in 1992. These infections are classified into incisional, organ, or other organs and spaces manipulated during an operation; incisional infections are further divided into superficial (skin and subcutaneous tissue) and deep (deep soft tissue-muscle and fascia). Detailed criteria for these definitions have been described These definitions should be followed universally for surveillance, prevention, and control of surgical site infections.




The pathogens isolated from infections differ, primarily depending on the type of surgical procedure. In clean surgical procedures, in which the gastrointestinal, gynecologic, and respiratory tracts have not been entered, Staphylococcus aureus from the exogenous environment or the patient's skin flora is the usual cause of infection. In other categories of surgical procedures, including clean-contaminated, contaminated, and dirty, the polymicrobial aerobic and anaerobic flora closely resembling the normal endogenous microflora of the surgically resected organ are the most frequently isolated pathogens.

According to data from the National Nosocomial Infections Surveillance System (NNIS), there has been little change in the incidence and distribution of the pathogens isolated from infections during the last decade. However, more of these pathogens show antimicrobial-drug resistance, especially methicillin-resistant S. aureus. Postoperative infections, including surgical site infections, were caused by multiple organisms in a multi - center outbreak due to contamination of an intravenous anesthetic, propofol. In this outbreak, CDC identified 62 patients at seven hospitals who had postoperative infections, primarily of the bloodstream or surgical site, after exposure to propofol.


Only exposure to this anesthetic was substantially associated with these postoperative infections. In six of the seven hospitals, the same pathogen was isolated from several infected patients. The infections were due to extrinsic contamination of the propofol by the anesthesia personnel, who frequently carried the pathogens in lesions on their hands or scalp or in their nares. Lapses in aseptic technique and reuse of single-use vials for several patients were important factors in these outbreaks. This report stresses the importance of conducting a formal epidemiological investigation when a cluster of infections involves an unusual organism such as Moraxella osloensis or Serratia marcescens.


Symptoms of a surgical site infection include:


A delay in healing of the surgical site


The tissue around the surgical site may be discolored


A foul odor coming from the incision site


Pain or sever tenderness in the area of the incision


Severe swelling of the incision


Incision is hot to the touch


Doctor should be notified at the earliest sign of symptoms


More technical information regarding serious and important life - saving intervention practices is provided below.  Discuss these recommended preventions with your medical team prior to surgery if possible.


1. Appropriate Use of Prophylactic Antibiotics


Administer antibiotics within 1 hour before surgical incision*.


Prophylactic antibiotic consistent with national guidelines.


Discontinuation of prophylactic antibiotics within 24 hours after surgery. (Due to the longer infusion time required for vancomycin, it is acceptable to start this antibiotic (e.g., when indicated because of beta-lactam allergy or high prevalence of MRSA) within 2  hours prior to incision.)

2. Use Clippers


The use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all. Clippers are suggested over razors.


3. Maintenance of Postoperative Glucose Control


Stringent glucose control in surgical intensive care unit patients reduces mortality.


4. Maintenance of Postoperative Normothermia


Studies indicate that patients undergoing certain surgeries have a decreased risk of surgical site infection if they are not allowed to become hypothermic during the peri-operative period. Anesthesia, anxiety, wet skin preparations, and skin exposure in cold operating rooms can cause patients to become clinically hypothermic during surgery. There is evidence to show that preventing hypothermia is beneficial in reducing other complications, and it clearly is more comfortable for patients.



Surgical care has been an essential component of health care worldwide

for over a century. As the incidences of traumatic injuries, cancers and

cardiovascular disease continue to rise, the impact of surgical intervention

on public health systems will grow.


WHO has undertaken a number of global and regional initiatives to

address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focused on access and quality.


The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care. The World Alliance for Patient Safety initiated work on the Challenge in January 2007.


The focus of the Challenge is the WHO Safe Surgery Checklist. The

checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.

The manual provides suggestions for implementing the checklist, understanding that different practice settings will adapt it to their own circumstances.


The implementation manual is designed to help ensure that surgical teams are able to implement the checklist consistently. By following a few critical steps, health care professionals can minimize the most common and avoidable risks endangering the lives and well-being of surgical patients.


Doctors and hospitals are reducing errors and saving lives with an  occupational concept fast - food restaurants have long used: checklists. Surgical teams started creating standardized lists of questions to use in operating theaters. In turn, patients and their families are now taking their own checklists to the hospital.


All these lists are significantly improving medical results. They can keep doctors from skipping steps and making careless and potentially fatal errors, such as operating on the wrong organ.


The most famous checklist advocate is Atul Gawande, a Boston surgeon and an assistant professor at Harvard. In 2008, he introduced a surgery checklist in eight hospitals. The practice resulted in 36 percent fewer major complications and 47 percent fewer deaths. The findings led to his bestselling book, "The Checklist Manifesto: How to Get Things Right."  Dr. Gawande said many doctors will reduce errors simply by acknowledging they can make errors and need to work as a team.


"The most important component [of the checklist] has turned out to be making sure that everybody in the room has been introduced by name and that people just take a minute to discuss the case in advance," he said in a Time magazine interview. "I introduced the checklist in my operating room, and I've not gotten through a week without it catching a problem. It has been really eye-opening. You just realize how fundamentally fallible we are."


He said the checklists have also been useful for X-rays and other simpler procedures outside the operating room. They also can save time in hospitals rather than creating time-wasting busy work, as some doctors fear.


As a patient, you are an important member of the team responsible for your health care. If you have been scheduled for surgery, here are some ways you can help prevent surgical infections.


Before you go to the hospital:


Stop smoking. If you smoke, consider stopping smoking a few weeks before your surgery. Smoking may increase your chance of developing a lung infection following a surgery and may inhibit healing.


Talk to your doctor about chronic medical conditions.  Some chronic medical conditions such as diabetes increase your risk of infections.


Ask your doctor about monitoring your glucose (sugar) levels during and after surgery, especially if you are having cardiac surgery.  Find out what you can do to keep your blood sugar levels in control before, during and after surgery. The stress of surgery can make glucose levels fluctuate. Controlled blood glucose levels help you to resist infection better.

Consider losing weight. If you are overweight, try to lose some of those extra pounds before your surgery is scheduled. Patients who are overweight are more likely to develop complications after surgery.


Eat healthier. Make sure your diet includes healthy food items that are rich in vitamins, minerals and proteins.


Ask about how your skin will be prepared before surgery. Your doctor may give you special instructions for cleaning the surgical site before your surgery. Some physicians use a special product, such as chlorhexidine, that helps reduce the risk of infection. Do not shave the surgical site. Shaving has been shown to cause skin irritation that increases the risk of infection. If hair must be removed before surgery, ask that clippers be used instead of a razor.


Ask your doctor about keeping you warm during surgery.  Operating rooms are often kept cold, but for many types of surgery, patients who are kept warm resist infection better.  This can be done with special blankets, hats and booties and warmed IV fluids.


Ask your doctor about being tested for MRSA prior to your surgical procedure. Many of us carry MRSA without even knowing it. MRSA, (pronounced Muhr-sah) is a type of Staph bacteria that can cause very serious bacterial infections. MRSA stands for Methicillin Resistant Staphylococcus aureus or MRSA. MRSA is caused by "Staph," that has acquired an immunity or resistance to the penicillin type of antibiotics and other currently used antibiotics.


MRSA statistics show that more people die each year from MRSA infections than the AIDS virus. This nasty bacteria is also responsible for the "flesh-eating" disease you've likely heard of. To conclusively know if you are “colonized” with MRSA, you'll need to have a doctor perform a quick and painless culture test to identify your infection-causing bacteria.


While you are in the hospital:


Clean your hands. Hand washing, using either soap and water or an alcohol-based hand sanitizer, remains our best defense against infections. In the hospital environment, hands are one of the primary ways that germs are transmitted. Germs cause infections. Hand washing is recommended when your hands are visibly soiled (dirty), before eating, and after using the restroom. You also should remind visitors and ALL HEALTH CARE WORKERS, including YOUR DOCTOR to wash their hands. If you don’t see a health care employee clean their hands, ask them to do so before touching you.

All  the time, EVERY TIME.


If you notice that a dressing has become loose or is wet, ask a nurse to change it for you. Bandages should stay clean and dry to help protect your skin. Also, tell your nurse if a drainage tube or catheter becomes loose.


You may need a urinary catheter following your surgery, but remind the doctors and nurses that you want it removed as soon as possible since this will reduce your risk of infection. It’s also important that you drink as many fluids as your doctor allows to help flush your urinary tract system.


Breathe and move. If your doctor prescribes breathing exercises following surgery, make sure you follow the instructions for frequency and duration of the exercises. These will help keep your lungs clear. You also should be as active as your doctor will allow. Even if it’s just a slow walk across the room, you are helping your body heal.


Avoid spreading germs. You should try not to touch your mouth or eyes with your hands.  Do not set food or utensils on furniture or bed sheets. Germs can live on surfaces for days and may cause infections if they get into your mouth.


When you get ready to go home:


Make sure you understand all your doctor’s instructions, including:


What medicines you should take and how often they should be taken.


Bathing instructions (sponge bath, shower or tub baths).


Incision care instructions such as how to change dressings and tips for keeping the area clean.


What activity levels are allowed, including whether you can drive or if there are limitations on lifting heavy objects.


When you should schedule follow-up appointments.


You also should know about warning signs that make it necessary to call your physician. These may include fever, increased pain, drainage, and redness or swelling around the incision site. At home, you should drink plenty of fluids, get regular exercise and follow good hygiene practices.