CDC nearing completion of new SSI guidelines
CDC nearing completion of new SSI guidelines
Surgeons question some provisions
The American College of Surgeons (ACS) is suggesting revisions to the Centers for Disease Control and Prevention's (CDC's) draft guidelines on the prevention of surgical site infections (SSIs), but the recommendations have passed muster with OR nurses, Same-Day Surgery 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, patient morbidity, and mortality.2 The draft version is closed for comment and is expected to be considered for revisions at a November 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). (The def initions of rankings are explained on p. 129.) The comments by the ACS Committee on Operating Room Envir on ment (CORE) were submitted by CORE chairman Samuel A. Wells Jr., MD, FACS.
OSHA standard used
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 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 by the Occupational Safety and Health Administration (OSHA) 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 states in the comments from its CORE committee.
ACS cites studies on masks
The recommendation does not take into account all of the available literature, notes the ACS, citing studies that have shown that having unmasked personnel in operating room, but not at the operating table, did not increase the rate of SSIs.3,4
Likewise, the ACS takes issue with the CDC recommendation to use materials for surgical gowns and drapes that are effective barriers when wet. The group noted that the draft overview points out that most of these materials inhibit heat loss and evaporation of sweat from the wearer's 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."
Too few references, surgeons say
The ACS also recommends downgrading recommendations on wound closure and draining techniques to the "suggested practice" level and says 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 ACS states. "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. Although the ACS suggests some revisions, groups representing operating room nurses largely endorse the draft as written.
Indeed, in response to an inquiry by SDS, Ramona Conner, RN, MSN, operative nurse specialist with the Association of Operating Room Nurses in Denver, clarified via fax that the group has not submitted any comments on the CDC draft guidelines because it has no "substantive concerns regarding the document."
References
1. Centers for Disease Control and Prevention. Draft guideline for prevention of surgical site infections, 1998. Federal Register. June 17, 1998; 63:33,167-33,192.
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 Inf 1991; 18:239-242.
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