Wounds International Vol 2 Issue 1Practice Reducing surgical site infection in a hospital in Singapore

Reducing surgical site infection in a hospital in Singapore

01/02/11 | Infection, Service development and delivery | Kui-Hin L, Aung KT

Reducing surgical site infection in a hospital in SingaporeSurgical site infection (SSI) is preventable and achieving zero SSI rates for every clean operation should be the goal of all surgeons. This paper describes one hospital’s strategy for reducing SSIs, enhancing the care of patients and promoting a culture of patient safety. All clean and clean-contaminated elective gastrointestinal and hernia operations were managed using four specific interventions. SSI rates were compared to historical data.

The authors' hospital has 1,440 beds, making it the second largest public acute care hospital with specialty centres in Singapore. The clinicians' expertise is well-supported by state-of-the-art facilities and medical equipment. The surgical department is composed of upper gastrointestinal, hepatobiliary, colorectal, vascular, urology and trauma teams, each performing a wide range of surgical operations [Fig 1].

Although there is evidence on preventing surgical site infection (SSI) dating back to the 1970s, these practices were not standardised in the hospital.

In 2006, the authors implemented an SSI prevention project to improve the surgical infection rate on elective gastrointestinal and hernia operations in the hospital.

The Clinical Practice Improvement Program (CPIP) is a training programme for clinical leaders aimed at improving the quality of health care. It was developed by Wilson and Harrison and was first implemented in New South Wales, Australia, in 1999 [1].

The hospital adopted this programme and has used the CPIP to train clinicians since early 2000. During the planning stage of the CPIP project, the team brainstormed all the risk factors for SSI.

The risk factors were categorised and summarised in a fish-bone diagram [Fig 2]. All the staff involved in the project were given the opportunity to vote on the top risk factors. Staff participation in voting encourages a deeper sense of project ownership and improves motivation. A Pareto chart was then used to identify and prioritise the most important risk factors for intervention
planning [Fig 3]:

  • Skin preparation
  • Prophylactic antibiotic regimen
  • Routine glucose monitoring
  • Postoperative core temperature monitoring.

Before the SSI project, surgical site hair was removed with a razor by the operating room attendants soon after anaesthesia had been administered. However, this practice is associated with increased SSI rate due to the potential for micro-injuries to the skin, which can predispose the skin to contamination and infection [2, 3].

In addition, there was no standard prophylactic antibiotic guideline in the hospital. This meant that the choice of prophylactic antibiotic was guided by the preference of the surgeons. The timing of prophylactic antibiotic administration was also variable. As a way of combating these inconsistencies, the following new interventions were standardised and implemented.


Figure 1 – The authors' team performing surgery in the operating room.

Skin preparation
Firstly, razors were replaced by electric clippers when performing preoperative hair removal. This is because shaving by razors was a known risk factor for SSI [2,3]. Posters were used to remind staff to use clippers in the operating room, operating room attendants were trained to use clippers,and patients were instructed not to shave themselves preoperatively.

All razors were removed from operating rooms and the team worked with the purchasing department to provide a continuous supply of clippers. 

Page Points

  • Surgeons, pharmacists and the infection control team were all involved in developing a standardised prophylactic antibiotic guideline
  • Where surgery was scheduled to last for more than four hours or where the estimated blood loss was expected to exceed one litre, a repeat dose of antibiotics was administered