Risk Prevention Surgical Site Infections

Surgical Site Infections

A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. SSI can sometimes be superficial infections involving the skin only. Other SSI are more serious and can involve tissues under the skin, organs, or implanted material. The World Health Organization WHO stated that SSI threaten the lives of millions of patients each year and contribute to the spread of antibiotic resistance. 


Did You Know?

Table with estimations of possible additional costs as a consequence of complications caused by sharps injury.
Fig. 8: Costs associated with NSIs. The costs are segregated into 5 levels and number of NSIs increases from level 1 to level 5. Compensation claims are not explicitly included and have to be added individually.
313 Million people undergo surgery every year. SSI are considered the most frequent complication in surgical patients, being responsible for 38 % of all infections. Costs of SSI are up to $10 Billion annually. SSI increase the length of hospital stays by 3-20 days. Most SSI are caused by Staphylococcus aureus. 1 in 2 surgical staff do not clean their hands at the right moment. SSI is associated with a mortality rate of 3%, and 75% of SSI-associated deaths are directly attributable to the SSI.

(1) WHO. (2016). Hand Hygiene and the Surgical Patient Journey. http://www.who.int/gpsc/5may/EN_PSP_GPSC1_5May_2016/en/ (acc. 02/2017).

(2) WHO. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide. WHO: Geneva.

(3) Wiseman JT. Predictors of Surgical Site Infection after Hospital Discharge in Patients Undergoing Major Vascular Surgery. J Vasc Surg. 2015 Oct; 62(4): 1023–1031.e5.

(4) CDC. (2009). Surgical Site Infection (SSI) Toolkit. http://www.cdc.gov/HAI/ssi/ssi.html (acc. 08/2016).

(5) Centers for Disease Control and Prevention (CDC). April 2015. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf (acc. 02/2017)

(6) http://www.who.int/gpsc/5may/hh_infographic_A3_EN.pdf?ua=1 (acc. 02/2017)

Causes

Bar-Chart showing distribution of monomicrobial and polymicrobial SSI cases.
Fig. 1: Distribution of monomicrobial and polymicrobial SSI cases [16]

SSI belong to the “procedure-related” or “medical device-related” infection types. They can be caused by the transmission of pathogenic microorganisms in the same environment, between patients and between patients and medical staff.

Due to the invasive procedures in surgery and exposure to blood, body fluids and tissue, there is a high risk of transmission of pathogens, closely related to conditions around the operation field and the patient, the surgical team and the type of surgical intervention.

SSI are considered to be the most frequent complication in surgical patients, being responsible for 38% of all infections. The patient’s risk to develop an SSI is particularly dependent on the status of the immune system and its response to microorganisms that contaminate the patient’s operated area.3

“SSI are considered to refl ect the quality of care, as they are potentially preventable complications directly linked to surgery.“Guidelines for prevention of surgical site infections have been presented already since 1999.7,8,9

Line-chart showing trends in key microorganisms reported as causing SSI.
Fig. 2: Trends in key microorganisms reported as causing SSI (inpatient), all surgical categories*, NHS hospitals in England [17], * excludes breast, cranial, cardiac (non-CABG) and cranial surgery

Trends of key microorganisms that cause SSI in patients reported by NHS between 2004 and 2014 show a strong decrease of Staphylococcus aureus in general, mainly due to the decrease of MRSA, while Enterobacteriaceae representing mostly multiresistant, gramnegative germs show a marked increase. The reasons for the described decrease of MRSA and its lower occurrence in 2013/14 is reflecting the impact of infection control initiatives directed at controlling MRSA.3

On the patient side, surgical site infections have been identified to depend on the type of surgery.17 In the cardiac field, for non-CABG (coronary artery bypass grafting) surgery the risk of SSI is highest in younger patients (age < 45 years) whereas in e.g. bile duct/liver/pancreatic, CABG, gastric or for spinal surgery the risk is being observed to be higher in older patients. In knee prosthesis the risk is comparable in all age categories. The risk causes of patient infection are classified by score-based classification-systems e.g. the ASA-score, wound class-score or the BMI of the patient.

Moreover, SSIs in patients have been reported to correlate with individual risk factors, such as diabetes, cigarette smoking and its interference with wound healing, obesity (in association with diabetes), and coincident remote site infections or colonization.27,28

While SSI in patients are mostly of bacterial provenience, surgical staff infections are more often of viral origin. 26 different viruses have been described to be responsible for occupational pathogen transmission.18 The risk of bloodborne infections such as Hepatitis B (HBV), Hepatitis C (HCV) and the Human Immunodeficiency Virus (HIV) is highest in the operating room environment and is closely related to work practices. Compliance with standard precautions is crucial for prevention of percutaneous injuries.20 Surgeons and laboratory assistants have been identified with the highest risk of percutaneous injuries.20,21,22 Without post-exposition prophylaxis or adequate vaccination, the risk of HBV infection is estimated to reach up to 30% after percutaneous injuries in HCWs.23

The guideline for “Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus” of the Society for Healthcare Epidemiology of America SHEA categorizes the level of risk for bloodborne pathogen transmission in three risk categories, where open and extensive surgery are described to be at highest risk. SHEA argues for comprehensive education concerning bloodborne pathogens for all healthcare workers.25

Table showing glove perforation incidence rate in different surgical procedures by study.
Fig. 3: Glove perforation incidence in different surgical procedures.

The incidence of surgical cross infection is directly proportional to surgical gloves perforation and also directly related to the duration of the surgical procedure.29  The risk of acquiring glove perforations strongly depends on the type of surgery performed, and varies from 3.58% in total hip arthroplasty30 up to 91.1% in orthognatic surgery.31 According to a study by Partecke et al.32 cardio-thoracic surgeries show a risk of 32.3%, followed by vascular surgeries with 22.3%, abdominal surgeries (minor, moderate, major) with between 12.3% and 20.3% of punctuation and laparoscopic interventions with 15.3%. “Compared to other clinical fields, orthopedic surgery poses a higher risk of perforation due to the frequent manipulation of surgical instruments and the presence of sharp bones during operative treatment.”33

Table showing glove perforation incidence rate in surgical teams by study.
Fig. 4: Glove perforation incidence in surgical teams

Most studies investigating glove perforation show that within the surgical teams surgeons’ gloves are at highest risk for perforations. However, as shown in the table below there are also studies that identified (scrub) nurses at highest risk for glove perforation during surgical procedures.31,37

Depiction of average distribution of glove microperforations on the hands of glove wearers (in %)
Fig. 5: Average distribution of glove microperforations on the hands of glove wearers.

The perforated locations at both hands of the surgeons have been quantified in different studies, on average the highest frequency of perforation has been identified at the index finger of the non dominant hand – as shown in the table below and corresponding figure of gloved hands right and left with average puncture-frequency.30,31,32,34,39

Table showing overall distribution of glove microperforations on the hands of glove wearers (in %)
Fig. 6: Overall distribution of glove microperforations on the hands of glove wearers (in %).

Besides sharps puncture and mechanical stress, inadequate gloving procedures may be the cause of glove perforation. In a study investigating a total amount of 1,537 gloves after 113 operations 121 perforations were detected, and only 7 of them were noticed during the surgical procedure.11

When double gloving is performed, the relative risk of glove perforations from inner to outer glove has been shown to increase from 4.5% to 14.1%.38

In an investigation on glove perforation on a total of 3,863 gloves collected from 58 primary and 36 revision of total joint arthroplasty (TJA) cases, surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time.10According to the “Basel SSI Cohort study”12  glove perforation in the absence of surgical antimicrobial prophylaxis increased the risk of SSI significantly. 

 

Apart from standard gloving procedures and awareness regarding the detection of unnoticed glove perforations, main risk factors of occupational pathogen transmission are the experience of operators and surgical staff, their adherence and degree of compliance with standard procedures and to regular trainings as well as a feedback-culture between experienced seniors and e.g. students.

Health Consequences

Transmission of pathogens during surgery may lead to severe illness, both for patients and health care workers. In patients, surgical site infections are most frequently caused by bacteria, in less cases also by fungi. These microorganisms are leading to surgical wound infections which may develop severe and life-threatening complications. Multi-drug resistance may restrict options of therapies.

As a result, the hospital stay will be prolonged after surgery, depending on the severity of infection, therapies and additionally necessary surgical procedures.

Financial Consequences

Potential Risk Associated Cost

Depending on surgical procedures and patient risk factors, the estimated cost per SSI reflecting data of the 1990s may vary from less than $ 400 to more than $ 30,000.41 A more recent publication reviewing data of 14 studies between the years 2000 and 2009 is stating additional costs between $ 3,859 (mean) and $ 40,559 (median) per SSI.42

The Centers of Disease Control and Prevention CDC is estimating 300,000 SSIs per year in the US with 3% mortality, 7-10 additional postoperative hospital days and up to $ 10 billion annual costs.15 Detecting SSI is challenging due to an increasing number of out-patient surgeries and shorter inpatient stay. Total annual costs may therefore be even higher.

Table depicting direct and indirect costs associated with SSI.
Fig. 7: Costs associated with SSI [35].

Little information is available about SSI follow up after hospital discharge, including frequency of rehospitalization, outpatient treatments and longterm disabilities. Post discharge surveillance other than readmission surveillance is especially important for evaluation of short postoperative stay.

A study on SSI after hospital discharge using patient questionnaires reports an incidence of 1.9 % of 4,571 procedures. Average total cost during 8 weeks after discharge for patients with SSI was $ 5,155 compared to $ 1,773 for controls.43

Pie-chart depicting risk of percutaneous injury in surgery (in %).
Fig. 8: Risk of percutaneous injury in surgery [44].

In healthcare workers, pathogen transmission during surgery happens after sharps injuries. Safety campaigns have decreased sharps injuries in the US by 31.6 % during 2001-2006 but injuries in surgical settings increased in the same period by 6.5%. The highest risk of percutaneous injury in surgery is associated with the use of suture needles as shown in the figure to the right.44

Sharps injuries can cause a number of direct and indirect costs for the health care facility, including:

  • Loss of employee time 
  • Investigation related to the injury
  • Laboratory testing
  • Treatment for infected staff
  • Replacement of staff.

Affected workers and their families usually suffer of enormous anxiety during test periods and distress due to treatment and consequences of potential infection.

The Fig. 9 below shows an estimation of possible additional costs as a consequence of complications caused by sharps injury. 

Table with estimations of possible additional costs as a consequence of complications caused by sharps injury.

Fig. 9: Costs associated with NSIs. The costs are segregated into 5 levels and number of NSIs increases from level 1 to level 5. Compensation claims are not explicitly included and have to be added individually.

Preventive Strategies

Optimizing and standardizing gloving procedures together with protective wear are basic means in surgical risk prevention strategy.48,49

The “Basel SSI Cohort Study” states that SSI account for 14 - 16% of all nosocomial infections in hospitalized patients thereby representing the most frequent hospital-associated infection in surgery. SSI are considered to be preventable complications after surgery and may well reflect performance and quality of care in the clinical institutions. Introduction of double gloving procedures as well as surgical training are recommended to reduce the SSI incidence.12

During surgical procedures, microperforations have been shown to increase over time and remain mostly unnoticed. It is therefore advisable to implement glove changing standards according to risk evaluation with respect to different surgical interventions.  

Medical professional wearing  double gloving with B. Braun Vasco® OP Underglove and Vasco® OP Sensitive.

Fig. 10: Double gloving procedure.

In general, glove changing after at least 90 minutes is recommended.9,32,36 

In a simulation model it was shown that when double gloving is used, only 17% of the blood is transferred through the gloves compared to single glove layers.53 An enzyme contamination assay proved double glove layers to be more puncture-resistant and able to remove more enzyme contaminant from a solid cutting suture needle compared with an equivalently thick single layer.54 During removal of protective wear after surgery, an experimental study reported a significantly lower virus transfer to hands after double gloving compared to single gloving.55

In a clinical study, in four out of five cases the inner glove remained intact when the outer glove was inadvertently perforated. “Surgical teams must balance the improved safety of double gloving with the possible discomfort and reduced sensitivity”.11

In contrast to this statement, various studies have shown, that double gloving does not have a substantial impact on manual dexterity or tactile sensitivity when compared to no gloves or single gloving.8,33,56

A double gloving indicator system of dark-colored undergloves and a white second pair of gloves helps detecting perforations of the outer gloves layer. In case of liquid entrance through the outer glove, a dark spot becomes immediately visible between the glove layers and the gloves can be changed instantly. The use of indicator glove systems reduces the frequency of unnoticed glove perforations and risk of intra operative cross-infection.37

It is significantly more effective than single gloving in reducing glove perforations and provides also more protection than standard double gloving.7 “Evidence supports the use of double gloving and double gloving with an indicator glove system to decrease the risk of percutaneous injury and therefore double gloving is an effective barrier to bloodborne pathogen exposure.”58

In a clinical study, in four out of five cases the inner glove remained intact when the outer glove was inadvertently perforated. “Surgical teams must balance the improved safety of double gloving with the possible discomfort and reduced sensitivity”.11

In contrast to this statement, various studies have shown, that double gloving does not have a substantial impact on manual dexterity or tactile sensitivity when compared to no gloves or single gloving.8,33,56

A double gloving indicator system of dark-colored undergloves and a white second pair of gloves helps detecting perforations of the outer gloves layer. In case of liquid entrance through the outer glove, a dark spot becomes immediately visible between the glove layers and the gloves can be changed instantly. The use of indicator glove systems reduces the frequency of unnoticed glove perforations and risk of intra operative cross-infection.37

It is significantly more effective than single gloving in reducing glove perforations and provides also more protection than standard double gloving.7 “Evidence supports the use of double gloving and double gloving with an indicator glove system to decrease the risk of percutaneous injury and therefore double gloving is an effective barrier to bloodborne pathogen exposure.”57

Comparative demonstration of perforation between double gloving with a green underglove (indicator system) and two white surgical gloves.

Fig. 11: Comparative demonstration between double gloving with a green underglove (indicator system) and two white surgical gloves.

Double gloving is not only recommended to be introduced as a routine practice for surgeons but has also been shown to be effective in protecting operating room nurses against bloodborne pathogen exposure.58 In laryngoscopy and intubation it was shown that when anesthesiologists wear 2 sets of gloves and remove the outer set immediately after intubation, the contamination of the intra-operative environment is significantly reduced.59

The recent literature review by the Cochrane Collaboration Group identified until June 2013 34 assessable studies covering altogether 6,890 surgical procedures and in particular 17 studies investigating double standard gloves. The authors conclude “There is moderate-quality evidence that double gloving compared to single gloving during surgery reduce perforations and blood stains on skin, indicating a decrease in percutaneous exposure incidents. (…) The preventive effect of double gloves on percutaneous incidents in surgery does not need further research.”

Today, double gloving is recommended by various professional organizations, including the Centers for Disease Control and Prevention (CDC), the Association of periOperative Registered Nurses (AORN), the American Academy of Orthopedic Surgeons (AAOS), the American College of Surgeons (ACS) and the WHO Patient Safety initiative to create a safer working environment. Checklists and tools have been developed to increase compliance and safety, such as SSI Toolkits by US Department of Health or by the CDC.15

In addition, recommendations of the German Association for the Control of Viral Diseases (DVV) e.V. and the Society for Virology (GfV) e.V. are given for HIV-positive Healthcare Workers (HCW): 

“With a permanent viral burden of less than or equal to 50 copies/mL, HIV-positive HCWs are allowed to perform any surgery and any invasive procedure, as long as the infected HCW uses double gloving, undergoes follow-up routinely by occupational medicine professionals, undergoes a quarterly examination of viral burden, and has a regular medical examination by a physician who has expertise in the management of HIV.“60

A standardized preoperative decolonization treatment to prevent MDRO (Multi-Drug Resistant Organisms) colonization in the nose, on the skin and in the oropharynx prior to elective interventions can contribute to minimize the risk for infection.50,51,52

A number of patient-related factors do exist for which correlations to SSIs have been suggested, e.g. diabetes, cigarette smoking, obesity, coincident remote site infections or colonization.21 So, as to “preventive strategies”, the patients themselves would be able to contribute to a prevention – they should be enabled and encouraged to try to reduce theses risk factors and in parallel become aware of their own responsibility towards their health, nowadays called “patient empowerment”.

Surveillance is an important strategic tool to fight against infections like SSI, with feedback of appropriate data to surgeons to reduce or minimize the corresponding risk.26 A new CDC and Healthcare Infection Control Practices Advisory Committee guideline for the prevention of surgical site infection has been announced, based on the results of a successfully introduced surveillance program26 , replacing the previous “Guideline for Prevention of Surgical Site Infection” by Mangram et al. 1999.13

Highlight Safety Products

Scientific Evidence

1 WHO. (2016). Hand Hygiene and the Surgical Patient Journey. http://www.who.int/gpsc/5may/EN_PSP_GPSC1_5May_2016/en/ (accessed Aug. 2016).

2 WHO. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide. WHO: Geneva.

3 Wiseman JT. Predictors of Surgical Site Infection after Hospital Discharge in Patients Undergoing Major Vascular Surgery. J Vasc Surg. 2015 Oct; 62(4): 1023–1031.e5.

4 CDC. (2009). Surgical Site Infection (SSI) Toolkit. http://www.cdc.gov/HAI/ssi/ssi.html (accessed Aug. 2016).

5 Centers for Disease Control and Prevention. (CDC). April 2015. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf (accessed Nov. 5, 2015).

6 http://www.who.int/gpsc/5may/hh_infographic_A3_EN.pdf?ua=1 (accessed May 10, 2016).

7 Tanner J et Parkinson H. Double gloving to reduce surgical cross-infection (Review). The Cochrane Library 2009, Issue 4.

8 Mischke C, Verbeek JH, Saarto A, Lavoie M-C, Pahwa M & Ijaz S. Gloves, extra gloves or special types of gloves for preventing  percutaneous exposure injuries in healthcare personnel (Review). The Cochrane Database of Systematic Reviews 2014, Issue 3, Art. No.: CD009573. DOI: 10.1002/14651858.CD009573.pub2.

9 Harnoß J-C, Partecke LI, Heidecke C-D, Hübner N-O, Kramer A & Assadian O. Concentration of bacteria passing through puncture holes in surgical gloves. Am J Infect Control 2010;38:154-8.

10 Carter AH, Casper DS, Parvizi J, Austin MS. A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty. Journal of Arthroplasty (2012) 27:7 (1271-1275).

11 De Castro-Peraza ME, Garzon-Rodriguez E, Rodriguez-Perez V, Sosa-Alvarez I, Gutierrez-Hernandez J & Asiain-Ugarte C. Glove perforation in surgery and protective effect of double gloves. Enfermeria Clinica (2010) 20:2 (73-79).

12 Junker T, Mujagic E, Hoffmann H, Rosenthal R, Misteli H, Zwahlen M, Oertli D, Tschudin-Sutter S, Widmer AF, Marti WR & Weber WP. Prevention and control of surgical site infections: review of the Basel SSI Cohort Study. Swiss medical weekly (2012) 142 (w13616).

13Mangram AJ, Horan TC, Pearson ML, Silver LC & Jarvis WR. Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 1999;20:247-78.

14NICE, National Institute for Health and Care Excellence, UK. Surgical Site Infections: prevention and treatment. NICE guidelines [CG74]. Published date: October 2008. https://www.nice.org.uk/guidance/cg74 (Accessed Nov., 05, 2015)

15 Berrios-Torres SI. Surgical Site Infection (SSI) Toolkit. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Department of Health & Human Services USA, 2009. http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf (Accessed Nov., 05, 2015)

16 Public Health England, Dec. 2013. Surveillance of Surgical Site Infections in NHS Hospitals in England 2012/13. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/364319/SSI_annual_report_2012_to_13_final.pdf (Accessed: Nov., 11, 2015)

17 Public Health England, Dec. 2014. Surveillance of Surgical Site Infections in NHS Hospitals in England: 2013 to 2014. https://www.gov.uk/government/publications/surgical-site-infections-ssi-sur-veillance-nhs-hospitals-in-england (Accessed Nov., 05, 2015)

18 Tarantola A, Abiteboul D & Rachline A. Infection risks following accidental exposure to blood or body fluids in health care workers: a review of pathogens transmitted in published cases. Am J Infect Control 2006;34:367–75.

19 Deuffic-Burban S, Delarocque-Astagneau D, Abiteboul D, Bouvet E & Yazdanpanah Y. Blood-borne viruses in health care workers: Prevention and management. J. of Clinical Virology, Vol. 52, Issue 1, 4-10,  Sept. 2011.

20 FitzSimons D, Francois G, De Carli G, Shouval D, Pruss-Ustun A, Puro V et al. Hepatitis B virus, hepatitis C virus and other bloodborne infections in health-care workers: guidelines for prevention and management in industrialised countries. Occup Environ Med 2008;65:446–51.

21 Wicker S, Jung J, Allwinn R, Gottschalk R & Rabenau HF. Prevalence and prevention of needlestick injuries among health care workers in a German university hospital. Int Arch Occup Environ Health 2008;81:347–54.

22 Alamgir H, Cvitkovich Y, Astrakianakis G, Yu S & Yassi A. Needlestick and other potential blood and body fluid exposures among health care workers in British Columbia, Canada. Am J Infect Control 2008;36:12–21.

23 Hofmann F, Kralj N & Beie M. Needle stick injuries in healthcare—frequency, causes and preventive strategies. Gesundheitswesen 2002;64:259–66.

24 Deisenhammer S, Radon K, Nowak D & Reichert J. Needlestick injuries during medical training. J Hosp Infect 2006;63:263–7.

25 Henderson DK, Dembry L, Fishman NO, Grady C, Lundstrom T, Palmore TN, Sepkowitz KA, Weber DJ for the Society for Healthcare Epidemiology of America. SHEA Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus. Infect Control Hosp Epidemiol 2010, Vol. 31, No. 3:203-32.

26 Centers for Disease Control and Prevention (CDC), April 2015. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf (Accessed Nov., 05, 2015)

27 Reichman DE & Greenberg JA. Reducing surgical site infections: A Review. Rev Obstet Gynecol 2009; 2(4):212-221.

28 Rajvir Singh, Pooja Singla & Uma Chaudhary. Review Article - Surgical Site Infections: Classification, Risk factors, Pathogenesis and Preventive Management. International Journal of Pharma Research and Health Sciences Volume 2 (3), 2014, Page-203-214, e-ISSN: 2348-64652014.

29 Kabiling CS. Intraoperative glove perforation and incidence of surgical site infection. Colorectal Disease (2011) 13 SUPPL. 5 (59).

30 Beldame J, Lagrave B, Lievain L, Lefebvre B, Frebourg N & Dujardin F. Surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: When gloves should be changed. Orthopaedics and Traumatology: Surgery and Research (2012) 98:4 (432-440).

31 Kuroyanagi N, Nagao T, Sakuma H, Miyachi H, Ochiai S, Kimura Y, Fukano H & Shimozato K. Risk of surgical glove perforation in oral and maxillofacial surgery. International Journal of Oral and Maxillofacial Surgery (2012) 41:8 (1014-1019).

32 Partecke LI, Goerdt A-M, Langner I, Jaeger B, Assadian O, Heidecke C-D, Kramer A, Huebner N-O. Incidence of Microperforation for Surgical Gloves Depends on Duration of Wear. Infection Control and Hospital Epidemiology, Vol. 30, No. 5 (May 2009), pp. 409-414.

33 Han CD, Kim J, Moon SH, Lee BH, Kwon HM & Park KK. A Randomized Prospective Study of Glove Perforation in Orthopaedic Surgery: Is a Thick Glove More Effective? Journal of Arthroplasty (2013) 28:10 (1878-1881).

34Demircay E, Unay K, Bilgili MG & Alataca G. Glove perforation in hip and knee arthroplasty. Journal of Orthopaedic Science (2010) 15:6 (790-794).

35 Feng T, Yohannan J, Gupta A, Hyndman ME & Allaf M. Microperforations of surgical gloves in urology: minimally invasive versus open surgeries. The Canadian Journal of Urology (2011) 18:2 (5615-5618). 

36 Dhar D. Occult glove perforation during adult elective orthopaedic surgery. Macedonian Journal of Medical Sciences (2011) 4:4 (399-402).

37 Witzke HJ, Fuchs S, Schmitz E, Wittmann A, Kralj N, Vetter HO. Surgical glove perforation-Raising the bar for safety during cardiac surgery.  Thoracic and Cardiovascular Surgeon (2012) 60 SUPPL. 1.

38 Shimantani M, Matsui Y, Sakakibara K, Iwase T & Yano K. Investigation of the rate of glove perforations in orthopedic procedures with an indicator underglove system (IUS) in a Japanese hospital. American Journal of Infection Control (2009) 37:5 (E117-E118).

39 Timler D, Bończak O, Jończyk J, Iltchev P, Śliwczyński A & Marczak M. Risk assessment of accidental exposure of surgeons to blood during orthopedic surgery. Are we safe in surgical gloves? Annals of Agricultural and Environmental Medicine 2014, Vol 21, No 1, 212–216.

40 Centers for Disease Control and Prevention (CDC), 2015.Healthcare-associated Infections (HAI) Progress Report. http://www.cdc.gov/hai/progress-report/index.html (Accessed Nov., 05, 2015)

41 Urban JA. Cost Analysis of Surgical Site Infections. Surgical Infections, Vol. 7, Suppl. 1, S19-S22, 2006.

42 Graf K, Ott E, Vonberg R-P, Kuehn C, Schilling T, Haverich A & Chaberny, IF. Surgical site infections – economic consequences for the health care system. Langenbecks Arch Surg (2011), 396: 453-459.

43 Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E & Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis. 2003 Feb; 9(2):196-203.

44 Centers for Disease Control and Prevention (CDC), June 2013. The National Institute for Occupational Safety and Health (NIOSH). STOP STICKS CAMPAIGN. http://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html (Accessed Nov., 05, 2015)

45 Hatcher IB. Reducing Sharps Injuries Among Health Care Workers: A Sharps Container Quality Improvement Project. Jt Comm J Qual Improv 2002;28(7):410-414.

46 National Health Service for Scotland (NHS Scotland). Needlestick Injuries: Sharpen Your Awareness. Report of the Short Life Working Group on Needlestick Injuries in the NHS Scotland. Edinburgh: National Health Services for Scotland:2001.

47 Tan L, Hawk JC, Sterling ML. Report of the Council Scientific Affairs: Preventing Needlestick Injuries in Health Care Settings. Arch Intern Med 2001;161(7):929-936.

48 Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky DS, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ & Roselle GA. Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections. N Engl J Med 2011; 364:1419-30.

49 Harris AD, Pineles L, Belton B, Johnson K, Shardell M, Loeb M, Newhouse R, Dembry, L, Braun B, Perencevich EN, Hall KK, Morgan DJ and the Benefi ts of Universal Glove and Gown (BUGG) investigators. Universal Glove and Gown Use and Acquisition of Antibiotic resistant bacteria in the ICU: A Randomized Trial. JAMA. 2013 October 16; 310(15): 1571–1580. doi:10.1001/jama.2013.277815.

50 Schweizer M, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. The “STOP SSI”-Study. JAMA. 2015;313:2162-71.

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