Evidence Based Paper

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Evidence-Based Project

Complete:

1. Title of the article:

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Answer the following questions. Responses for each question should be at least 60 words, but no more than 200 words. Please type your responses using 12-point font and double-spaced.

1. What is the problem that the research is addressing?

1. Why is this problem significant to nursing practice?

1. Summarize the findings from this research article.

1. Describe the recommendation (s) for nursing practice.

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Special Article

Nursing Practices in the Prevention of Post-Operative Wound Infection in
Accordance with Evidence-Based Approach

Selda Mert Boga, PhD
Lecturer Kocaeli University, Kocaeli Vocational School of Kocaeli Health Services, Kocaeli, Turkey

Correspondence: Lecturer Dr. Selda Mert Boga, Kocaeli University, Kocaeli Vocational School of Kocaeli
Health Services, Kocaeli, Turkey E-mail: seldamertboga@gmail.com selda.mertboga@kocaeli.edu.tr

Abstract

Nurses, working around the clock, are in an ideal position to participate or play a leading role in taking initiatives that aimed
to ensure quality of care and thus to enhance patient safety which includes prevention of surgical site infections. Previous
research has used survey, chart audit and algorithm methods to describe wound care practices. However, little research has
been published using contemporaneous observations to describe the surgical wound management practices of nurses. The
aim of this study is to describe the postoperative wound care practices of surgical nurses and the evidence-based guideline
recommendation of wounds.

Keywords: Postoperative wound infection, prevention, nursing practice, nursing, evidence-based.

Introduction

Surgical site infections (SSIs) are one of the
important complications after surgery that can
cause undesired patient outcomes. SSIs is a type of
wound infection which occurs after a surgical
operation. SSIs have been shown to consist up to
20% of all of healthcare-related infections. At least
5% of patients undergoing a surgical procedure
develop a surgical site infection (Ding, Lin and
Gillespie, 2016). Although some surgical
complications are inevitable, the quality of surgical
care can be improved if the focus is on evidence-
based practice recommendations and decisions are
made (Gillespie et al., 2014). The most important
factor in preventing surgical site infections is the
full and absolute compliance of health
professionals with the recommendations in the
guidelines (Han and Choi-Kwon, 2011, Maurya
and Mendhe, 2012; Ding et al., 2017; Qasem and
Hweidi, 2017).

Surgical Site Infections

The infections that occur within first 30 days after a
surgical operation if no implant is placed or within
1 year after a surgical operation if an implant is
placed and the infections appears to be related to a
surgical operation, are called as surgical site
infections (Famakinwa et al., 2014; Harrington,
2014; Ding et al., 2017). Despite innovations in the
surgical techniques, technological advances in the
operating room, environmental improvements, and
the use of prophylactic antibiotics, surgical site

infections (SSI) remains an important source of
morbidity and mortality in patients after surgery
(Gillespie et al., 2014).SSIs have a significant
impact on the global health care system and are
associated with increased duration of stay in
hospital, extra health care costs, mortality, pain,
discomfort, and, in some cases, permanent
disability (Maurya and Mendhe, 2014; Ding, Lin,
Gillespie, 2016; Ding et al., 2017). In addition, in
some studies SSI has been shown to significantly
influence patients’ mobility, independent life, and
psychological health (Cahill et al., 2008; Andersson
et al., 2010; Harrington, 2014; Maurya and
Mendhe, 2014; Qasem and Hweidi, 2017). In the
UK, the National Institute for Health and Care
Excellence (NICE) estimated that 5% of all surgical
procedures resulted in SSI, accounting for up to
20% cases of health care associated infections
(Ding, Lin, Gillespie, 2016).SSI continues to be a
problem for postoperative care and wound
management because of the increased number of
surgeries performed each year, the increased cost to
patient and health care systems, and the increased
mortality rate (Ding et al., 2017). Notwithstanding
the imperative to implement preventative measures
to reduce the risk of SSI, their negative effects
remains an international concern for frontline
clinicians and hospital administrators alike
(Gillespie et al., 2014).

Prevention of Surgical Site Infections

SSI is a health care-related disease in which a
wound infection occurs after an invasive (surgical)

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procedure. Prevention of SSI is an important issue
in both high- and low-income countries (Maurya
and Mendhe, 2014). It was stated that although all
bacterial infections can not be prevented, a
significant number of infections may be avoided by
precautions to be taken in preoperative, operative
and postoperative periods, and evidence-based
infection control measures (Maurya and Mendhe,
2014; Gillespie et al., 2014; Ding, Lin, Gillespie,
2016).

For this reason, a number of prevention strategies
are proposed for preoperative, operative,
postoperative periods to reduce surgical site
morbidity by Australian Wound Management
Association (AWMA, 2016), Canadian Association
of Wound Care (CAWC, 2018), Centers for
Disease Control and Prevention (CDC, 2017),
National Institute for Health and Care Excellence
(NICE, 2017), World Health Organization (WHO,
2016). In this study, some principles were included
for postoperative wound management in reducing
the SSI rate in the direction of current guidelines
These include the guidelines in Table 1.

However, prevention of surgical site infections is
complex and requires several precautions to be
taken before, during and after surgery. In addition,
the implementation of these measures has not been
standardized worldwide. There is no international
directive at the moment and there is often
inconsistency in the interpretation of the evidence
and recommendations between national guidelines
(Ozbayir, 2016).

Use of Evidence-Based Guidelines to Prevent
Surgical Site Infections

The highest level evidence is required for evidence-
based medicine and ultimately practice with focus
on wound care (Maurya and Mendhe, 2014). It has
been suggested that the use of evidence-based
guidelines in wound care has the potential to
improve patient outcomes and reduce hospital
wound care costs (Gillespie et al., 2014).
According to Maurya and Mendhe (2014), proof
based wound management was defined as the
combination of best scientific evidence with
clinical expertise and patient values by David
Sackett (2000) Maurya and Mendhe, 2014). In
relation to the subject, Gillespie et al. (2014)
carried out an audit in the United Kingdom; it
indicated that nursing time spent on dressing
changes was 88.5 full-time equivalents over 1 year,
while wound-related costs of patients were found to
be between 19,000–31,000 bed days per year. In
the United Kingdom, economic estimations
demonstrate that wound-related costs consist
approximately 4% of all health costs and this ratio

is rising (Gillespie et al., 2014). According to Ding
et al. (2017), it was stated in the systematic
compilation of Umscheid et al. (2011) conducted
with hospitals in United States, 55% of the SSIs
can be avoided by existing evidence-based
guidelines (Umscheid et al., 2011; Ding et al.,
2017). In a study by Maurya and Mendhe (2014) on
the prevention of post-operative wound infection
according to evidence-based practice, educators
trained in wound care informed nurses about new
evidence-base practices of wound care. Knowledge,
attitudes and behaviors of nurses in the study were
evaluated before and after the training. It was found
that nurses’ knowledge, skills and attitude of
wound care was 58.57% while developed by 100%
and that patients were satisfied with this practice
(Maurya and Mendhe, 2014).

Role of Nurse in Surgical Site Infections
Prevention and Effective Wound Care

Nurses working all day are in an ideal position to
take part or to become the leader in interventions
aimed at ensuring the quality of care, thereby
increasing patient safety, including the prevention
of SSIs (Teshager, Engeda, Worku, 2015). Nurses
should have knowledge of high-quality nursing
care; and reasons, effects,
management and evidence – based
recommendations of SSI’s (Han and Choi-Kwon,
2011; Harrington, 2014; Qasem and Hweidi, 2017).
Nurses should be aware of surgical site infections,
classifications, risk factors and populations at risk,
signs and symptoms of surgical site infection,
antibiotic prophylactic use, preoperative skin
preparations, postoperative surgical field care,
infection control standards and surgical site
infection prevention strategies. Nurses should also
defend their patients in any case (Gould, 2012;
Yao, Bae, Yew, 2013; Qasem and Hweidi, 2017).
Nurses need evidence-based guidelines for
effective wound care. Evidence-based clinical
practice guidelines are an effective communication
tool for health care professionals and can help them
make decisions (Han and Choi-Kwon, 2011).

The training of healthcare professionals can
improve the level of knowledge, thus it promotes
the implementation of anti-infection guidelines that
directly contribute to the reduction of health-related
infections (Belowska, Panczyk, Gotlib, 2014).
However, a significant number of studies have
shown that health professionals do not have
sufficient knowledge to prevent surgical site
infections, evidence-based guidelines and
recommendations are not being applied correctly,
and health professionals need information (Meeks
et al., 2011; Awad, 2012; Belowska, Panczyk,
Gotlib, 2014; Brisibe, Ordinioha, Gbeneolol, 2014;

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Famakinwa et al., 2014; Mitchell et al., 2014;
Surme, 2014; El-Sayed, Gomaa, Abdel-Aziz, 2015;
Teshager, Engeda, Worku, 2015; Qasem and
Hweidi, 2017). Labeau et al. (2010) conducted a
study in Belgium, to evaluate nurses’ knowledge
levels about evidence based guidelines for the
prevention of SSIs for identifying their specific
educational needs. They found that male nurses
were more knowledgeable than their female
colleagues on the implementation of the SSIs
prevention guidelines (Labeau et al., 2010). Awad
(2012) found that the compliance with SSI
prevention guidelines was poor at two different
county hospitals. Clinicians’ adherence to surgical
care bundle tactics such as the ‘Surgical Care
Improvement Project’ for the prevention SSIs was
insufficient (Awad, 2012). Another study which
was conducted in Australia found that there was a
positive relationship between the number of years
of occupational experience and nurses’ level of
knowledge on the prevention of SSIs (Qasem and
Hweidi, 2017). In a descriptive study conducted by
Surme (2014) with 311 nurses working in the
surgical services to determine the knowledge and
practice levels of the nurses on wound healing at
the incision site, it was found that half of the nurses
do not perform practices for wound healing, and
more than half of them do not regularly perform
discharge trainings related to wound care and that
nurses need training (Surme, 2014).

Another important issue about effective wound care
is the education of the patient, family and relatives
of the patient. Nursing who give care in the
preoperative perioperative and postoperative
periods have an important role in counseling about
the risks associated with SSIs and how the infection
should be managed (Harrington 2014).

The guidelines of NICE (2017) and AWMA (2010)
contains consideration of patient training, which
state that nurses should provide information and
advice to patients and caregivers thrugh all care
stages. Information should contain the risks of
developing SSIs, how to reduce the risks and how
to manage SSIs (AWMA, 2010; NICE, 2017).

The guidelines recommend that clinicians inform
the patient and/or their caregivers with evaluation
outcomes and education that is suitable for their
age and cognitive status (Ding et al., 2017). Study
of Ding et al. (2017) which examined nursing
practices to prevent postoperative wound
infections, reported that more than one-third of the
surgical nurses did not use clean gloves properly,
one-fifth of nurses did not use sterile gloves
properly, more than half of them did not train
patients on postoperative wound management, and

the recommended and applied practices in wound
care show difference (Ding et al., 2017).

Nurses have the responsibility to ensure that all SSI
standards are met and that evidence-based
guideline principles are applied to ensure optimal
patient outcomes (Harrington, 2014). The
successful application of infection control
measures, especially SSI prevention measures, and
well-structured continuing education programs are
considered as a substantial element that would
improve nurses’ knowledge about evidence based
guidelines to prevent SSIs and ultimately leads to
positive impacts on surgical patients who admitted
to the acute care settings in the context of patients’
quality of care, and patient safety.

Thus, hospital administrators and all other related
parties should continue to emphasize more on
nurses’ educational needs, particularly nurses
working in acute care settings in order not to
compensate quality of care delivered in acute care
settings (Qasem and Hweidi, 2017). A infection
control policy and procedures for guiding surgical
unit nurses should be established.

Wound Care Assessment and Documentation

Accurate assessment and documentation of wounds
by staff is essential for effective wound care and
best practice (Gartlan et al., 2010; Kinnunen et al.,
2012; Gillespie et al., 2014). Comprehensive
wound assessment and documentation has the
potential to reduce the incidence of SSI, morbidity
and mortality, and the economic burden on patients,
hospitals, and the health care system (Kinnunen et
al., 2012; Ding, Lin, Gillespie, 2016).

The management of SSIs and the protection of
surgical patients from SSIs are determined by
accurate wound assessment and documentation
practice, updated knowledge of proof-based wound
care clinical practice guidelines. Experts have
recommended that the prevention of SSIs should
concentrate on preoperative, intraoperative and
postoperative assessment and management.
According to the AWMA, the documentation of
wounds provides a legal and complete record of the
patients’ history of health, wound assessment
outcomes, diagnostic investigations, the plans of
prevention and treatment (Ding, Lin, Gillespie,
2016).

The importance of surgical wound assessment and
documentation to decrease SSI complications is
increasingly known. Wound assessment, including
direct observation of surgical wounds, is reported
to be the most accurate technique for identifying
SSIs (Ding, Lin, Gillespie, 2016). Evidence-based
clinical practice guidelines (EBCPRs) have been

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published worldwide to emphasize recommended
practices for wound assessment and documentation.
EBCPRs recommend that acute wounds should be
evaluated daily or upon every dressing change.
Wounds should be reassessed after receiving
patients from the operating room or a different
facility, or if the wound markedly deteriorates, and
develops an odour or purulent exudates (Ding, Lin,
Gillespie, 2016). From these guidelines, NICE
recommends correct wound assessment since it
directs medical treatment, and identifies problems
during the recovery process (NICE, 2017).
According to AWMA, a comprehensive wound
assessment is the best way to determine if the
wound is progressing and whether the wound has
reached its desired recovery goal. The
comprehensive and continuous evaluation include
wound type, wounding aetiology and wounding
mechanism, wounding duration, anatomical
location of the wound, wound dimensions should
be conducted.

Clinical characteristics of wound bed and wound
edge, peri-wound and surrounding skin
characteristics, exudate, wound healing stage, the
signs and symptoms of inflammation or infection
should be documented by digital photography or
technologie (AWMA, 2010). According to Ding et
al. (2016), The World Union of Wound Healing
Societies (WUWHS) has recommended that the
assessment of wound infections’ synptoms should
include an increase in wound dimensions, offensive
odour, pyrexia, wound dehiscence or breakdown
(WUWHS, 2008). These recommendations provide
broad guidance only on wound assessment.
However, it was noted that there are shortcomings
as to which instruments can be used to evaluate
surgical wounds and how the obtained information
will be documented (Gartlan et al., 2010; Ding,
Lin, Gillespie, 2016).

Wound care is a worldwide concern, and
appropriate documentation process of wound
evaluation, interventions, and patient outcomes is a
substantial challenge for all health care system
(Kinnunen et al., 2012). Wound documentation
process is also required for legal aims because it
provides a legal record of the care provided and
enables to evaluate wound treatment or the
standards of wound care retrospectively (Gartlan et
al., 2010). Accurate documentation of wound
assessment and management is valuable for early
identification and early intervention of SSIs
(Gillespie et al., 2014; Ding, Lin, Gillespie, 2016),
it has also been shown to facilitate effective
communication in the multidisciplinary health care
team (Gartlan et al., 2010).

However, the limited number of studies (Gartlan et
al., 2010; Han and Choi-Kwon, 2011; Kinnunen et
al., 2012; Ding, Lin, Gillespie, 2016) reported that
acute wound assessment and documentation do not
meet the needs of the country. It has been reported
that nurses meet various problems with
documentation of wound care, and that lack of
time, limited number of nurses, non-mentoring of
experienced nurses, nursing culture which
sabotages orders constitute reasons of bad nursing
documents (Gartlan et al., 2010).

It was stated standardized systems in the
documentation of the wound status and wound care
interventions that provide evidence to nurses and
prospective observational studies to measure these
systems are needed (Gartlan et al., 2010; Kinnunen
et al., 2012; Gillespie et al., 2016; Ding, Lin,
Gillespie, 2016; Ding et al., 2017; Timmins et al.,
2018).

Multidisciplinary Approach in Wound Care

Wound care is a common concern for different
disciplines, even though it is generally accept as a
responsibility of nurses (Gartlan et al., 2010). A
multidisciplinary team work based on supervision
and surveillance is needed to early identification of
symptoms and indications, the implementation of
evidence-based guidelines, reduction and
prevention of SSI. Multidisciplinary team should
include surgeons, anesthetists, operating room
managers, microbiologists, infection control nurses,
administrative staff, surveillance and supervisory
staff. A coherent multidisciplinary team analyzes
reports on SSIs and communicates results to all
team members and monitors local policies and
procedures to avoid risking patient safety
(Harrington, 2014). In Australia, quality
improvement unit has created a team of clinic
services director, orthopedic surgeon, infection
control nurse, managers of operating room and
nurse surgical unit, general surgeon and university
professors to prevent SSI, and employees and
patients were trained. As a result, it was noted that
postoperative infection rates were reduced with
team effort (Maurya and Mendhe, 2014).

Conclusions and recommendations

Nurses have an important role in the prevention of
surgical site infection and in providing wound
healing. Surgical nurses need to know and apply
the recommendations of the evidence-based clinical
practice guidelines to ensure optimal patient
outcomes in postoperative wound care
management. However, there is a need for an
internationally accepted standard checklist that can
be used with a multidisciplinary health team in the
prevention of postoperative wound infections and

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wound management. The standard checklist to be
used is thought to has an important effect in
preventing and reducing wound infections.

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Table 1. Recommendations of current guidelines on postoperative wound care management

Guidelines Recommendations References
Glycemic Control • Implement perioperative glycemic control and use blood glucose target levels less than 200 mg/dL in patients with and

without diabetes.

CDC 2017 (HQE)

Normothermia • Maintain perioperative normothermia CDC 2017 (H-M QE)
WHO 2016 (MQE)

Perioperative oxygenation • For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, administer
increased FIO2 during surgery and after extubation in the immediate postoperative period

CDC 2017 (MQE)
WHO 2016 (MQE)

Assessment of the surgical wound • Type of wound
• Duration of wound
• Location of wound
• Dimension of wound (length x width x depth)
• Clinical characteristics of wound bed (red, pink, yellow, black, undermined)
• Wound edge appearance (callus and scale, maceration, erythema, oedema)
• Periwound appearance
• Exudate type (serous, haemoserous, sanguineous, seropurulent, purulent) and colour
• Phase of wound healing (e.g. haemostasis, inflammation, reconstruction, maturation/remodelling).
• Wound pain
• Presence of foreign bodies
• Early signs and symptoms of infection (serous exudate with erythema, swelling with an increase in exudate volume,

edema, increase in local skin temperature and unexpected pain or tenderness)

• Prior wound treatments and their therapeutic outcome

AWMA 2010
WHO 2016

Wound assessment method: nursing
check list

• Direct observation
• Assessment tools used

CDC 2017
AWMA 2010

Dressing management • Use an aseptic non-touch technique for changing or removing surgical wound dressings
• Perform hand hygiene before and after dressing changes and any contact with the surgical site
• Protect an incision that has been closed primarily with a sterile dressing for 24–48 hours postoperatively
• Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions are not recommended on surgery wounds healing

by secondary intention.

• Use an appropriate interactive dressing to manage surgical wounds that are healing by secondary intention.
• Refer to a tissue viability nurse for advice on appropriate dressings healing by secondary intention.

NICE 2017

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Wound cleansing • Use sterile saline for wound cleansing up to 48 hours after surgery.
• Advise patients that they may shower safely 48 hours after surgery.
• Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to

drain pus.

NICE 2017
CAWC 2018

Topical antimicrobial agents • Topical antimicrobial agents are not recommended on surgery wounds healing by primary intension.

NICE 2017

Antibiotic treatment

• When a surgical site infection is suspected (eg. cellulite), the patient should be given antibiotics. Consider local resistance
patterns and the results of microbiological tests in choosing an antibiotic.

NICE 2017

• Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section
procedures.

• In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the
surgical incision is closed in the operating room, even in the presence of a drain.

CDC 2017 (HQE)

• Surgical antibiotic prophylaxis administration should not be prolonged after completion of the operation WHO 2016 (MQE)
Debridement • Avoid eusol and gauze, or dextranomer or enzymatic treatments yo manage wound infection. NICE 2017
Education of the patient, family, and
caregiver

• Advise the patients that they may shower safely 48 hours after surgery
• Inform about how to recognize an SSIs and who to contact if they are concerned.
• Inform the patients after their operation if they have been given antibiotics.
• Educate the patient on how to care for the wound after discharge and follow up wound care.

AWMA 2010
NICE 2017

CAWC 2018

Documentation of findings using a
standardized approach

• Initial and ongoing wound assessments
• Environmental assessment
• Documented care plan
• Integrated care pathway for the management of wound complications
• Collaborative multidisciplinary approach to patient care

AWMA 2010
NICE 2017

Team approach in wound healing • Effective communication AWMA 2010
CAWC 2018

HQE: High-Quality Evidence; MQE: Moderate-Qality Evidence

Note: We abstracted data from the following guidelines: the Australian Wound Management Association (AWMA), the Canadian Association of Wound Care (CAWC), the Centers

for Disease Control and Prevention (CDC), the National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO).

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