CDC nearing completion of new SSI guidelines
APIC hails draft; surgeons question provisions
The American College of Surgeons (ACS) is suggesting some revisions to the Centers for Disease Control and Prevention's draft guidelines on the prevention of surgical site infections (SSIs), but the recommendations have passed muster with infection control professionals and operating room nurses, Hospital Infection Control has learned.1
Updating 1986 CDC guidelines, the draft outlines current surveillance and prevention strategies for SSIs, the second most common type of nosocomial infection and a major contributor to increased hospital costs and patient morbidity and mortality.2 The draft version is closed for comment and is expected to be considered for revisions at a November 1998 meeting of the CDC's Hospital Infection Control Practices Advisory Committee (HICPAC).
Comments submitted by the Chicago-based ACS suggested several revisions, including downgrading some of the recommendations on surgical masks, gowns, and drapes from "strongly recommended" (IB) to "suggested for implementation" (Category II). (See definitions of rankings, p. 153.) The comments by the ACS Committee on Operating Room Environment (CORE) were submitted by CORE chairman Samuel A. Wells Jr., MD, FACS.
For example, the CDC draft guidelines recommend wearing a surgical mask that fully covers the mouth and nose when entering the operating room if sterile instruments are exposed or if an operation is about to begin or is in progress. The CDC recommends that clinicians wear the mask throughout the entire operation. The guidelines note that such masking is in accordance with requirements of the Occupational Safety and Health Administration bloodborne pathogen standard.
"The invocation of the OSHA standard on the use of a mask for personal protection should not be construed as a reason to use a mask for the prevention of SSI," the ACS stated in the comments from its CORE committee.
The recommendation does not take into account all of the available literature, the ACS noted, citing studies that have shown that the presence of unmasked personnel in the operating room but not at the operating table did not increase the rate of SSIs.3,4 Likewise, the ACS took issue with the CDC recommendation to use materials for surgical gowns and drapes that are effective barriers when wet, noting that the draft overview points out that most of these materials inhibit heat loss and evaporation of sweat from the body.
"Implementation of this recommendation not only may make the surgical team uncomfortable but also may pose a health threat to some health care workers," the ACS states. ". . . CDC should recognize that most surgical gowns are ineffective barriers when wet, particularly in the arms. CORE believes that this objective should be presented as a future goal, but should not have the weight of a regulation that is strongly recommended."
The ACS also recommended downgrading recommendations on wound closure and draining techniques to the "suggested practice" level, saying they were supported by too few references.
"CORE encourages the CDC to recognize that appropriate closure techniques in any given circumstance are highly individual and should be left up to the surgeon of record," the comments state. "If the CDC wishes to make recommendations on these issues, a review of evidence-based practices by specialty throughout the world is necessary. The current recommendation is too broad for ubiquitous application."
James T. Lee, MD, PhD, FACS, one of the principal HICPAC members who worked with the CDC in drafting the guidelines, declined to comment on the draft while it is still under discussion and revision. While the ACS suggested some revisions, groups representing infection control professionals and operating room nurses largely endorsed the draft as written.
Indeed, in response to an inquiry by HIC, Ramona Conner, RN, MSN, operative nurse specialist with the Association of Operating Room Nurses in Denver, clarified via fax that the group had not submitted any comments on the CDC draft guideline because it has no "substantive concerns regarding the document."
Likewise, the Association for Professionals in Infection Control and Epidemiology (APIC) in Washington, DC, suggested only one revision and made a point to commend the CDC and HICPAC for the quality of the draft version.
"This guideline is excellent," stated comments submitted by Martha DeCastro, RN, MS, CIC, chair of the APIC guidelines committee. "It provides a comprehensive review of pertinent literature and organizes recommendations in an easy to understand manner."
APIC did express concern that the draft calls for hand washing with an "antiseptic agent before and after dressing changes." DeCastro pointed out that the recommendation conflicts with APIC's hand washing guidelines, which recommend the use of non-antimicrobial soap for general patient care.
References
1. Centers for Disease Control and Prevention. Draft guideline for prevention of surgical site infections, 1998. 63 Fed Reg 167-133, 192 (June 17, 1998).
2. Garner JS. Guideline for prevention of surgical wound infections, 1985. Infect Control 1986; 7:193-200.
3. McCluskey F. Does wearing a mask reduce bacterial wound infection? A literature review. Br J Theatre Nurs 1996; 6:18-20.
4. Mitchell NJ, Hunt S. Surgical face masks in modern operating rooms - a costly and unnecessary ritual? J Hosp Infect 1991; 18:239-242.
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