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Sternal wound infections: What every nurse

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should know
Elizabeth Dunaway, RN, CIC, BSN, MA, and Barbara A. Goldrick, RN, CIC, MPH, PhD

Surgical site infections (SSIs) are the third most frequent hospital-acquired infections among all hospitalized patients, causing substantial morbidity and mortality among surgical patients.1 In addition, the attributable costs of a SSI could reach $30,000 or more for patients undergoing cardiothoracic surgery.2 Proving as costly as they are deadly, SSIs are a significant threat and a widespread complication of patient care. The Centers for Disease Control and Prevention (CDC) published its Guideline for Prevention of Surgical Site Infection, established by the consensus of the Hospital Infection Control Practices Advisory Committee.1 The recommendations, which are evidence-based, are a major contribution to optimize the management of surgical patients to prevent SSIs. In 2004, the Joint Commission began participating in the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations, such as the Centers for Medicare and Medicaid and the CDC, which is dedicated to improving surgical care by reducing surgical complications nationally by 25% by the year 2010. Although the primary focus of the partnership is on hospitals, these measures are relevant for ambulatory surgery centers. SCIP, now known as the Surgical Infection Prevention (SIP) project, performance measures have been accepted by the Joint Commission, and hospitals face penalties in Medicare reimbursement for noncompliance with mandatory reporting.3 The Institute for Healthcare
OR Nurse2007 July/August

Improvement (IHI) has an ongoing campaign to significantly reduce surgical complications by reliably implementing the changes in care recommended by the SIP. The 2007 Joint Commission Requirement 7B reads: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health careassociated infection.4 SSIs that result in unanticipated death or major permanent loss of function are considered sentinel events that are reportable to the Joint Commission. Modifiable risk factors Sternal wound infections after cardiac surgical intervention are reported by the CDC's National Nosocomial Infections Surveillance (NNIS) system to be between 1.28 and 5.62 per 100 operations and are a major cause of postoperative morbidity.5 While a number of nonmodifiable risk factors, such as diabetes, chronic obstructive pulmonary disease, and advanced age have been identified, identification of modifiable risk factors is crucial for the implementation of practices that decrease the incidence of such infections. Preoperative risk factors for deep sternal infections/mediastinitis include obesity, diabetes, and smoking. Risk factors for superficial sternal infections include obesity, female gender, increased age, and smoking. Intraoperative risk factors include bilateral use of internal mammary arteries and transfusion of 4 units or more of packed red blood cells. Postoperative

Sternal wound infections

risk factors include prolonged ventilator support, intensive care for more than 5 days, and transfusions of 2 units or more of platelets postoperatively.6-8 Studies suggest that modifiable risk factors, such as cessation of smoking, strict glycemic control, preoperative weight loss, discriminate use of bilateral internal mammary arteries, and avoidance of staple use in patients with a normal body mass index (BMI) may decrease the incidence of postoperative sternal wound infection following coronary artery bypass graft (CABG) operations.6-8 Antimicrobial prophylaxis administered 2 hours or more before incision is also an independent risk factor for deep sternal site infection.8 Antibiotic prophylaxis protocols Antimicrobial prophylaxis is one of the most widely accepted practices to prevent SSIs. However, despite evidence of effectiveness, studies have demonstrated problems with inappropriate timing, selection, and excess duration of administration of antibiotics.

Surgical wound classifications1

Class I/Clean: An uninfected operative wound, with no inflammation observed and the respiratory, alimentary, genital, or uninfected urinary tract werent entered. Also, clean wounds are primarily closed and, if necessary, drained with closed drainage. Note: Incisions that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. Class II/Clean-contaminated: An operative wound in which the respiratory, alimentary, genital, or urinary tracts were entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique was encountered. Class III/Contaminated: Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (for example, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation occurs are included in this category. Class IV/Dirty-infected: Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. Definition suggests that the microorganisms causing the SSI were present in the operative field before surgery.

Optimal prophylaxis requires application in appropriate types of operations, selection of safe and effective antimicrobials, initial administration, redosing to maintain effective serum and tissue levels throughout the operation, and discontinuation of the antibiotic when its no longer beneficial.8-10 Current recommendations for cardiothoracic surgical prophylaxis in adults include the administration of an antibiotic at induction of anesthesia or 1 hour or less preoperatively (120 minutes for vancomycin), and prophylaxis for 24 hours following surgery.11,12 The optimal duration of prophylaxis is controversial for cardiothoracic surgery, where many surgeons prefer to continue prophylaxis for 48 hours or until all drains and tubes have been removed. Still, additional studies are necessary before confirming the effectiveness of prophylaxis lasting less than 48 hours. There is no evidence that prophylaxis administered for longer than 48 hours is more effective than a 48-hour regimen or to support the continuation of antibiotics until chest or mediastinal tubes are removed.10 Prolonged antimicrobial administration can be harmful to patients by promoting antimicrobial-resistant bacteria and increasing the incidence of antibiotic-associated complications.12,13 Research has found that only 70% of cardiac surgery patients received cefazolin (Ancef), and only 60% received antibiotics 1 hour or less prior to surgical incision.2 About a third (34%) of patients undergoing cardiac surgery had their antimicrobial prophylaxis discontinued within 24 hours of completion of surgery. Additional concerns regarding antimicrobial resistance were found. Vancomycin prophylaxis was used in 23% of cardiac surgery patients. The primary indication for use of prophylactic vancomycin is beta-lactam antimicrobial allergy. However, in nearly half of the cases where vancomycin was used, no beta-lactam allergy was documented.2 Data suggest that newer antimicrobials were frequently used when older agents proved effective. The use of newer broad-spectrum antibiotics is discouraged because of concern that widespread use of these drugs will promote the emergence and spread of bacterial strains resistant to these newer antibiotics.2,14 Prophylaxis using routine vancomycin resulted in fewer deep and superficial SSIs and fewer deaths compared with routine cefazolin for CABG surgery. Since most post-CABG SSIs are caused by staphylococci, studies on vancomycins impact on resistance are needed to quantify the trade-off between individual clinical outcomes, costs, and the future long-term consequences of antibiotic resistance.14
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Additionally, there are surgeons who prescribe mupirocin to be applied to the nares preoperatively. Despite the potential value of this practice, there are no studies to support this practice.1

Infections surveillance The NNIS system reports SSI rates by wound class, operative procedure, and patient risk index in U.S. hospitals.15 The NNISs basic SSI risk index is composed of the following criteria: American Society of Anesthesiologists (ASA) score of 3, 4, or 5; wound class and duration of surgery (see Surgical wound classi- Postdischarge SSI surveillance fications) and risk values of 0, 1, 2, or 3.15 The NNIS Studies have shown that most SSIs become evident risk index is operation-specific and applied to prospec- within 21 days after surgery. As a result, between 12% tively collected surveillance data. The index values and 84% of SSIs are detected after patients are disrange from 0 to 3 points, which are defined by three charged from the hospital.1 One study revealed that two-thirds of 291 sternal wound SSIs were identified independent and equally weighted variables, with 1 after discharge. Of these, 3% had deep sternal point scored for each of the variables when present infections/mediastinitis, and 6.4% had superficial (see NNIS risk index and NNIS SSI rates for cardiothoracic surgical patients).1 In January 1992, NNIS modified its NNIS risk index1 definitions of SSIs, and patients undergoScore/Points Independent and equally weighted variables ing CABG procedures were categorized 1 ASA physical status classification of >2 into those with two incisions (chest and 1 Either contaminated or dirty/infected wound donor vessel site) and those with only a classification chest incision.16 The latest NNIS data for 1 Length of operation in hours, which is the cardiothoracic surgery indicate that approximate 75th percentile of the duration CABG with chest and donor site inciof the specific operation being performed. sions from the femoral or radial artery Note: One point is scored for each of the variables when present, with a harvested as donor vessel for bypass maximum of 3. graft had a 70% higher median SSI rate

for high-risk patients than those undergoing CABG with only a chest incision.5 The use of standardized, valid, and reliable definitions is fundamental to the accurate measurement and monitoring of surgical adverse events. To compare its SSI rates with the NNIS benchmark data, a hospitals SSI rates should be stratified by surgical wound class plus ASA classification and duration of surgery. Surgeon-specific SSI rates should be calculated and reported to individual surgeons.17,18

NNIS SSI rates for cardiothoracic surgical patients5

Operative procedure category CARD Cardiac CABG chest and donor site CABG chest only Duration Risk cut point index (hours) category 5 0 N Rate Risk index category 1 N Rate Risk index category 2,3 N Rate

1,866

0.64

37,452

1.54

11,315

2.25

CBGB

2,196

1.28

301,715 3.51

2,3

62,625

5.62

CBGC

0,1

13,169

2.19

2,3

5,288

3.93

CARD: Cardiac; CBGB: Coronary artery bypass graft with chest and donor site incisions (for example, femoral or radial artery harvested as donor vessel for bypass graft); CBGC: coronary artery bypass graft with chest incision only (for example, use of internal mammary artery for bypass graft); CABG: Coronary artery bypass graft.

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Sternal wound infections

sternal wound infections.7 Hospitals with comprehensive postdischarge surveillance after CABG procedures are likely to record higher SSI rates than those that dont perform such surveillance. Only 28% of the CABG SSIs would have been detected if surveillance had been limited to hospital stay. Postdischarge surveillance identified more SSIs among risk-index 1 patients.19 The average length of postoperative hospitalization continues to decrease; therefore, many SSIs may not be detected for several weeks after discharge. Dependence solely on inpatient case-finding will result in underestimates of SSI rates for some surgeries, such as CABG procedures.1 For any comparisons of SSI rates to be valid, even in the same institution over time, case-findings should include SSIs detected after discharge using the same postdischarge surveillance methods. However, no consensus exists on which postdischarge surveillance methods are the most reliable and practical. Postdischarge surveillance methods must reflect a hospitals unique mix of operations, personnel resources, and data needs.1 Prevention recommendations Recommendations for the prevention of deep and superficial sternal wound SSIs following CABG surgery are based on the following categories: Category IA, Category IB, and Category II. Category IA and IB are recommendations viewed as effective by the CDC and experts in the fields of surgery, infectious diseases, and infection control. They differ only in the strength of the supporting scientific evidence; however, both are applicable to and should be adopted by all healthcare facilities. Category II recommendations are supported by less scientific data than Category I recommendations. Such recommendations may be appropriate for addressing specific patient populations or specific infections.1 These recommendations include: 1. Preoperative preparation of the patient in a surgical unit. u Identify modifiable risk factors for sternal wound infection, such as obesity, diabetes, and smoking. u When possible, identify and treat all infections remote to the surgical site before surgery. Postpone elective operations on patients with remote site infections until the infection has resolved (Category IA). u Dont remove hair preoperatively unless the hair at or around the incision site will interfere with the operation (Category IA).

u If necessary, remove hair immediately before the operation, using electric clippers not razors (Category IA). u Control serum blood glucose levels in all patients with diabetes to avoid hyperglycemia perioperatively (Category IB). u Encourage tobacco cessation. At minimum, instruct patients to stop using any form of tobacco for at least 30 days before elective operation (Category IB). u Dont withhold necessary blood products from surgical patients as a means to prevent SSIs (Category IB). u Have patients shower or bathe with an antiseptic agent at least the night before the operative day (Category IB). u Use an appropriate antiseptic agent for skin preparation (Category IB). The general practice is to apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. Manufacturer's recommendations should be followed for each product. (Category II). u Keep preoperative hospital stays as short as possible while allowing for adequate care of the patient (Category II). u Administer prophylactic antibiotics only when indicated, and based on its efficacy against the most common pathogens causing SSIs for a specific operation and published guidelines (Category IA). u Administer the initial dose of prophylactic antibiotic I.V. Time this so that its bactericidal concentration is established in serum and tissues when the incision is made. Maintain the therapeutic serum and tissue levels of the antibiotic throughout the operation and until, at most, a few hours after the incision is closed (Category IA). u Dont use vancomycin routinely for antimicrobial prophylaxis (Category IB). u Preoperatively applying mupirocin to nares to prevent SSIs isnt recommended (Unresolved issue).1 2. Intraoperative procedures. u Check for the integrity of the packaging of all sterile supplies. u Check the indicator tape outside and the indicator inside of the instrument packs sterilized through the central service area. Sterility and integrity of packaging are the two attributes that must be monitored at the critical point of intraoperative procedures. If missed, it can lead to increased SSIs. u Sterilize surgical instruments according to published guidelines (Category IB).
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u Only use flash sterilization for patient care items thatll be used immediately (for example, to reprocess an inadvertently dropped instrument), and not for the convenience of avoiding the purchase of additional instruments, or to save time (Category IB). u Assemble sterile equipment and solutions immediately prior to use (Category II). u Keep OR doors closed except as needed for passage of equipment, personnel, and patients (Category IB). u Limit the number of personnel entering the OR to necessary personnel (Category II). u Avoid the use of tacky mats at the entrance to the OR suite or individual operating rooms for infection control (Category IB). u Shoe covers shouldnt be worn for the prevention of SSIs (Category IB). u Perform surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with lasting activity before donning sterile gloves when performing surgical procedures. A preoperative surgical scrub with antimicrobial soap should last at least 2 to 6 minutes using an appropriate antiseptic. (Category IB). u Wear surgical gowns and drapes that are effective barriers when wet, for example, any materials that resist liquid penetration (Category IB). u Change scrub suits that are visibly soiled, contaminated, or penetrated by blood or other potentially infectious materials (Category IB). u Apply principles of asepsis when placing intravascular devices (such as central venous catheters), spinal or epidural anesthesia catheters, or when dispensing and administering I.V. drugs (Category IA). u Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies (for example, sutures, charred tissues, and necrotic debris), and eradicate dead space at the surgical site (Category IB). u If drainage is necessary, use a closed suction drain. Place a drain through a separate incision, distant from the operative incision. Remove the drain as soon as possible (Category IB). u Assign surgical wound classification by a surgical team member upon completion of an operation (Category II). u For each patient undergoing an operation chosen for surveillance, a surgical team member should record variables shown to be associated with increased SSI risk (Category IB). u Establish well-defined procedures regarding responsibilities when personnel have potentially transmissible infectious conditions. These should identify personnel
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responsibility in reporting illness, work restrictions, clearance to resume work after a work restriction, and who has the authority to remove personnel from duty (Category IB). u The routine exclusion of surgical personnel who are colonized with organisms such as Staphylococcus aureus (nose, hands, or other body site) or group A Streptococcus isnt necessary, unless such personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting (Category IB).1 3. Postoperative incision care. u Protect primarily closed incisions with a sterile dressing for 24 to 48 hours postoperatively (Category IB). u Wash hands before and after dressing changes and any contact with the surgical site (Category IB). u When an incision dressing must be changed, use sterile techniques (Category II). u Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms (Category II). u There are currently no recommendations to cover an incision closed primarily beyond 48 hours, nor on the appropriate time to shower or bathe with an uncovered incision.1 4. Surveillance. u The infection control professional (ICP) uses CDC definitions of SSIs2 without modification for identifying SSIs among surgical inpatients and outpatients (Category IB). u For inpatient case-finding (including readmissions), the ICP uses prospective methods of observation for the duration of the patients hospitalization (Category IB). u When postdischarge surveillance is performed for detecting SSI following certain operations (such as CABG), the ICP uses a method that accommodates available resource and data needs (Category II). u For outpatient case-finding, a method that accommodates available resources and data needs is used (Category IB). u Periodically, ICPs will calculate operation-specific SSI rates stratified by variables shown to be associated with increased SSI risk (Category IB). u Operation-specific SSI rates should be reported to surgical team members. The healthcare facilitys infection control committee and the objectives of local, continuous quality improvement initiatives will determine the optimum frequency and format for such rate computations (Category IB).1
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Good management techniques Despite evidence detailing the validity of these recommendations, many of them are underutilized in practice. Nonetheless, modifiable risk factors and evidence-based protocols are major contributions to optimize the management of surgical patients and prevent SSIs. OR
REFERENCES 1. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-278. 2. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005;140(2):174-182. 3. The Joint Commission. When quality improvement meets surgery, complications will plummet. Available at: http://www.jcrinc.com/11265/ ?query=SCIP. Accessed May 9, 2007. 4. The Joint Commission. 2007 national patient safety goals. Available at: http://www.jcrinc.com/13469/. Accessed May 9, 2007. 5. Centers for Disease Control and Prevention. A Report from the NNIS system report, data summary from January 1992 to June 2002, issued August 2002. Am J Infect Control. 2002;30(8):458-475. 6. Crabtree TD, Codd JE, Fraser VJ, et al. Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center. Semin Thorac Cardiovasc Surg. 2004;16(1): 53-61. 7. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg. 2001;20(6):1168-1175. 8. Olsen M, Lock-Buckley P, Hopkins D, et al. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg. 2002;124:136-45. 9. Auerbach AD. Prevention of surgical site infections. In: Shojania KG, Duncan BW, McDonald KM, et al., eds. Making health care safer: A critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); July 2001:221-244. Evidence Report/Technology Assess-

ment 43. AHRQ publication 01-E058. Available at: http://www.ahrq. gov/clinic/ptsafety/pdf/ptsafety.pdf. Accessed May 9, 2007. 10. Edwards FH, Engelman RM, Houck P, et al. Antibiotic prophylaxis in cardiac surgery, part 1: duration. Ann Thorac Surg. 2006;81(1):397-404. 11. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56(18):1839-1888. 12. Society of Thoracic Surgeons. Antibiotic prophylaxis in cardiac surgery: duration of prophylaxis. 2005. Available at: http://www.sts.org/sections/ aboutthesociety/practiceguidelines/antibioticguideline/. Accessed May 9, 2007. 13. Harbarth S, Samore MH, Lichtenberg D, et al. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. 2000;101(25):2916-2921. 14. Zanetti G, Goldie SJ, Platt R. Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis: example of coronary artery bypass surgery. Emerg Infect Dis. 2001;7(5):820-827. 15. Culver DH, Horan TC, Gaynes RP, and the NNIS System. Surgical wound infection rates by wound class, operative procedure, and patient risk index in U.S. hospitals, 1986-90. Am J Med. 1991;91(Suppl 3B): 152S-157S. 16. Gaynes RP, Culver DH, Horan TC, et al. Surgical site Infection (SSI) rates in the United States, 1992-1998: the national nosocomial infections surveillance system basic SSI risk index. Clin Infect Dis. 2001;33(suppl 2):S69-S77. 17. The Society for Hospital Epidemiology of America; the Association for Practitioners in Infection Control; the CDC; the Surgical Infection Society. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol. 1992.13(10):599-605. 18. Gaynes R, Richards S, Edwards J, et al. Feeding back surveillance data to prevent hospital-acquired infections. Emerg Infect Dis. 2001;7(2):295-298. 19. Avato JL, Lai KK. Impact of postdischarge surveillance on surgical-site infection rates for coronary artery bypass procedures. Infect Control Hosp Epidemiol. 2002;23(7):364-367.
Elizabeth Dunaway is a retired commander of the U.S. Navy Nurse Corps, and is a former OR supervisor. She is currently a certified infection control professional, and contractor of special projects at Kitsap County Health District, Bremerton, Wash. Barbara A. Goldrick is a certified epidemiology consultant in Chatham, Mass. The authors have disclosed that they have no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

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Sternal wound infections: What every nurse should know

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2.0
Sternal wound infections: What every nurse should know
ANCC/AACN CONTACT HOURS

GENERAL PURPOSE: To provide perioperative nurses with information about the prevention, identification, and treatment of sternal wound infections. LEARNING OBJECTIVES: 1. Delineate the incidence and risk factors for SSIs. 2. Discuss antibiotic prophylaxis protocols and prevention recommendations for SSIs. 1. Which statement about an SSI is correct? a. The risk factors for sternal wound infection are nonmodifiable. b. Its the third most frequent hospital-acquired infection among all hospitalized patients. c. The cost of an SSI following cardiothoracic surgery is usually less than $10,000. d. The sternal wound infection rate after cardiac surgery is about 15%. 2. The patient at greatest risk of developing a superficial sternal infection is a a. 45-year-old female with osteopenia and a family history of type 1 diabetes. b. 56-year-old African-American male with a history of uncontrolled hypertension. c. 65-year-old male with a BMI of 24 and taking atorvastatin (Lipitor). d. 72-year-old obese female who has a 50 year, pack-a-day history of smoking. 3. The incidence of sternal wound infections following CABG operations may be decreased by a. routine use of bilateral mammary arteries for grafting. b. maintaining a hemoglobin A1C level of 8.3% in patients with diabetes. c. avoiding the use of staples in patients with a normal BMI. d. shaving the sternum 24 hours before surgery. 4. Research has found that of those who had cardiac surgery a. 70% received cefazolin. b. 60% received vancomycin. c. 43% had their antimicrobial medication discontinued within 24 hours. d. 34% had their antimicrobial medication initiated at least 12 hours preoperatively. 5. The highest median SSI rate is found in highrisk patients undergoing CABG surgery with a. a chest incision only. b. chest and donor-site incisions with a femoral artery graft. c. a transthoracic incision. d. a single chest incision used with a mammary artery graft. 6. Most postoperative SSIs become evident within a. 3 days. c. 14 days. b. 7 days. d. 21 days. 7. Which of the following is a Category II recommendation for preoperative preparation? a. Apply antiseptic to skin in concentric circles moving toward the periphery. b. Dont remove hair unless the hair at or around the incision site will interfere with the operation. c. Control serum blood glucose levels in all patients with diabetes to avoid hyperglycemia perioperatively. d. Have patients shower or bathe with an antiseptic agent at least 12 hours preoperatively. 8. Which of the following statements about the administration of prophylactic antibiotics is correct? a. Prophylactic vancomycin is recommended for patients with a risk index greater than 2. b. Application of mupirocin to the nares is recommended for high-risk patients. c. The initial dose of an antibiotic should be administered I.V. d. Maintain therapeutic serum antibiotic levels for at least 48 hours after closure. 9. Intraoperative procedure recommendations include a. using flash sterilization for all patient care items. b. exiting closed suction drains from the operative site when possible. c. wearing shoe covers for the prevention of SSIs. d. avoiding use of tacky mats at the OR suite entrance. 10. Which of the following is a Category I recommendation for SSI prevention? a. Assign surgical wound classification upon completion of an operation. b. Assemble sterile equipment and solutions immediately prior to use. c. Apply principles of asepsis when placing intravascular devices. d. Keep preoperative hospital stay as short as possible. 11. Recommendations for postoperative incision care include a. covering a primarily closed incision with a sterile dressing for 24 to 48 hours. b. wearing a moisture-proof gown for dressing changes. c. covering closed incisions with a dry sterile dressing until the sutures or staples are removed. d. instructing the patient not to shower for at least 72 hours postoperatively. 12. When providing postoperative surveillance, its important to a. modify CDC definitions of SSI for the outpatient population. b. report all operation-specific SSI rates to the CDC. c. calculate operation-specific SSI rates weekly as required by the CDC. d. calculate and report operation-specific SSI rates to the surgical team. 13. Which patient is at greatest risk of developing a Class III surgical wound? a. a patient with type 2 diabetes undergoing a breast biopsy b. a patient who received open cardiac massage c. an obese patient undergoing a cystoscopy d. a patient who endured nonpenetrating blunt trauma 14. An SSI resulting from a preexisting clinical infection is classified as a. Class I. c. clean-contaminated. b. Class IV. d. contaminated.

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