American Journal of Infection Control 50 (2022) 1049−1054

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major Article

Important interventions in the operating room to prevent bacterial

contamination and surgical site infections
Camilla Wistrand PhD a,*, Karin Falk-Brynhildsen PhD b, Ann-Sofie Sundqvist PhD a
a €
University Health Care Research Centre, Faculty of Medicine and Health, Orebro €
University, Orebro, Sweden
b €
Faculty of Health and Medicine, School of Health Sciences, Orebro €
University, Orebro, Sweden

Key Words: Background: The aim of this study was to explore interventions that Swedish operating room (OR) nurses
Infection control considered important for the prevention of bacterial contamination and surgical site infections (SSIs).
Perioperative Methods: A web-based cross-sectional survey with an open-ended question was answered by OR nurses and
Surgical preparation analyzed using summative content analysis and descriptive statistics.
Infection prevention
Results: The OR nurses (n = 890) worked within 11 surgical specialties and most of them worked at univer-
Cross-infection
sity hospitals (37%) or county hospitals (53%). The nurses described twelve important interventions to pre-
vent bacterial contamination and SSI: skin disinfection (25.9%), the OR environment (18.2%), aseptic
technique (16.4%), OR clothes (13.4%), draping (9.8%), preparation (6.1%), dressing (3.6%), basic hygiene
(3.4%), normothermia (2.1%), communication (0.7%), knowledge (0.3%), and work strategies (0.2%).
Discussion: Skin disinfection was considered the most important intervention in order to prevent bacterial
contamination and SSI. The responses indicated that many OR nurses believed the patients’ skin to be sterile
after the skin disinfection process. This is not a certainty, but skin disinfection does significantly decrease the
amount of bacterial growth.
Conclusions: This study shows that many OR nurses' interventions are in line with recommendations.
Although, knowledge regarding the effect of skin disinfection needs further research, and continued
education.
© 2021 The Author(s). Published by Elsevier Inc. on behalf of Association for Professionals in Infection
Control and Epidemiology, Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/)

BACKGROUND patients and high costs for society.2 In Sweden the healthcare system
is primary funded through general taxation and it holds an explicit
Patient safety and prevention of surgical site infections (SSIs) are public commitment to ensure the health of all citizens. The responsi-
of international concern.1,2 Swedish law (SFS:2017:30) states that bility for health and medical care lies within 21 regions. A great num-
patients should be given health care with good standards on equal ber of publicly and privately owned health and medical care facilities
terms.3 The clinical work in Swedish operating rooms (ORs) is are to be found, and the patients are free to contact specialists
designed to have high hygiene standards4 in order to prevent bacte- directly but the majority are referred to the specialized care by the
rial contamination. SSIs are a major problem in terms of suffering for healthcare centers.5 According to a review published in 2012 the hos-
pitals in Sweden are grouped into country hospitals (approximately
70 hospitals), and university hospitals (n = 7). The private healthcare
* Address correspondence to Camilla Wistrand, PhD, University Health Care
€
Research Centre, Faculty of Medicine and Health, Orebro

University, S-huset van. 2 sector is relatively small, consisting of 6 hospitals.6
€
Region Orebro €n 701 85 Sweden
la There are international differences concerning which profession is
E-mail address: camilla.wistrand@regionorebrolan.se (C. Wistrand). responsible for patient preparation in terms of skin disinfection and
Funding source: This study was funded by the Research Committee of Region
€ draping of the patient within the OR. In Sweden, the OR nurse is
Orebro County, Sweden. The funding body had no involvement in the design of the
study, data collection, analysis, interpretation of data, writing of the manuscript, or
responsible for hygiene procedures including the cleanliness of the
decision to submit the manuscript for publication. OR, ventilation, sterile materials and instruments, patient preparation
Conflict of interest: None declared. (skin disinfection and draping), and maintaining aseptic technique
Availability of data and materials: The datasets generated and/or analyzed during during surgery. OR nurses in Sweden have a minimum of 4 years of
the current study are not publicly available due to ethical considerations of participant
education, comprising a 3-year bachelor’s degree in nursing followed
integrity, but are available from the corresponding author on reasonable request.

https://doi.org/10.1016/j.ajic.2021.12.021
0196-6553/© 2021 The Author(s). Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. This is an open access article under
the CC BY license (http://creativecommons.org/licenses/by/4.0/)
1050 C. Wistrand et al. / American Journal of Infection Control 50 (2022) 1049−1054

by a 1-year OR nursing program which includes both theoretical Data analysis

courses and clinical rotation and results in a professional title and a
master's degree.7
OR departments use many strategies to prevent SSIs, such as com- Summative content analysis
pliance with national guidelines. Swedish OR nurses have a Hand- The answers to the open-ended question were analyzed using
book for Health Care which guides them in using and implementing summative content analysis. This type of analysis combines quantita-
the correct strategies and interventions.4 However, in clinical work tive and qualitative analysis, including a latent analysis, thus going
the guidelines and local regulations that are determined in order to beyond the mere word count of a strict quantitative content analy-
prevent bacterial contamination may sometimes be neglected. The sis.10 The text was hand searched for words or combinations of words
underlying reasons for not conforming to guidelines might lie within describing interventions that the nurses performed clinically and
the individuals’ opinions on what is important. SSIs have historically stated to be important in preventing bacterial contamination or SSI.
decreased, but despite enhancements, there is much to learn about The frequency of each identified word and/or combination of words
the different factors involved in decision making during clinical was calculated in order to determine how often they occurred. Each
work. intervention was counted as a single unit, meaning that even if a
The aim of this study was to explore which interventions Swedish nurse used several words or combinations of words associated with
OR nurses considered to be important for the prevention of bacterial the same intervention, they were all considered a single unit. Fre-
contamination and SSIs. quency counts by type of intervention were calculated and compared
to the total number of words coded for each category. By counting
the words in the data, patterns were identified and codes were con-
METHOD textualized. The codes were scrutinized for differences and similari-
ties, resulting in 12 subcategories representing a manifest pattern. A
Study design and participants continual comparison of the codes and the content of each subcate-
gory was conducted throughout the analysis.
This is the second part of a descriptive cross-sectional survey. In The codes and the 12 subcategories were also analyzed in a more
December 2015 and January 2016, information about the study along latent manner. During this phase, the subcategories were scrutinized
with a link to a web-based survey was distributed by e-mail to 2,264 in order to find relationships between them, resulting in 3 categories
of the approximately 4,000 OR nurses in Sweden. The e-mail each comprised of subcategories sharing a common meaning. All 3
addresses of the remaining nurses could not be found due to the hos- authors conducted an individual analysis of the text, and disagree-
pitals’ lack of response. The inclusion criterion was having a specialist ments between their analyses were discussed until consensus was
degree as an OR nurse, and the exclusion criterion was no longer reached.
working actively as an OR nurse. All participants are hereafter
referred to as nurses.
Statistical analysis
Data were analyzed manually or by using descriptive statistics
computed in version 22.0 of the SPSS software package (SPSS Statis-
Questionnaire
tics; IBM, Armonk, NY, USA). Descriptive statistics were calculated for
all variables in terms of mean, number, percentage, and standard
Results from the first part of the survey, which contained 38
deviation.
closed-ended questions, were published in 2018.26 This second part
had one open-ended question. The questionnaire as a whole
addressed the daily activities nurses performed to prevent bacterial RESULTS
growth, such as preparing the patient’s skin (n = 12 items), maintain-
ing the patient’s temperature (n = 10 items), and preparing OR mate- Participants
rials (n = 10 items). The questionnaire also included 6
sociodemographic questions covering age, type of hospital, work In total, 967 of 2,264 nurses answered the questionnaire
experience, educational level, surgical specialty, and what region of (response rate: 43%). Of these 967 nurses, 77 were excluded due to
Sweden they worked in. The open-ended question which forms the not working as OR nurses but rather, for example, as chief of staff.
focus of the present analysis was “Which of the clinical interventions The nurses represented more than eleven different surgical special-
that you perform do you consider important in preventing surgical ties including orthopedic, thoracic, vascular, and general surgery
site infection?” (Table 1).

Ethical conduct of research FINDINGS

The study was performed in accordance with the Helsinki Dec- The latent analysis resulted in 3 categories covering the manifest
laration.8 Ethical approval was not required according to Swedish content included in the 12 subcategories and 3,522 codes (Table 2):
law concerning ethical review of research involving humans, infection control, preventing indirect contamination, and the surgical
since the study did not involve patients, and no sensitive data team. Since the category infection control included 57.7% of the total
were elicited.9 That is, no information was obtained regarding number of codes (n = 2033), it was considered the most important
political opinions, ethnicity, religion, union membership, philoso- way for the nurses to prevent bacterial contamination and SSI. This
phy, health, or sexual preferences. An introduction letter was was followed by 41.1% preventing indirect contamination (n = 1,448
included to outline the survey objective and inform respondents codes), and finally 1.2% the surgical team (n = 41 codes).
that participation was voluntary. By answering the questionnaire, A few nurses (n = 19) said it was difficult to rank anything as more
the nurses agreed to participate. The data were stored in data important than anything else when it came to bacterial contamina-
files in depersonalized form, and the results are presented at tion and SSI. These nurses believed that everything was equally
group level with no possibility of individual identification. important. One of them described:
 C. Wistrand et al. / American Journal of Infection Control 50 (2022) 1049−1054 1051

Table 1 Skin disinfection

Characteristics of the responding operating room nurses in Sweden (n = 890) Skin disinfection was the intervention that was described the
Mean (SD) most frequently, with almost 26% of all codes belonging to this
subcategory. It was therefore interpreted as the intervention that
Age 47 (9.8)
the nurses considered most important for preventing bacterial
Y of experience 16 (12.0)
n (%) contamination and SSI. The nurses described disinfecting the skin
OR nurses, male 57 (6.4) using different types of skin disinfectant not only preoperatively
OR nurses, female 833 (93.6) but also postoperatively, just before the dressing was applied.
Level of education
Licensed OR nurse 455 (51.0) “Skin disinfection with alcohol, on a large enough area, with prede-
Licensed OR nurse BSc 196 (22.0) termined strokes and appropriate pressure and time. Let the skin air
Licensed OR nurse MSc or higher 239 (27.0)
dry.” (nurse no. 56)
Type of hospital
University hospital 332 (37.2)
County hospital 475 (53.4)
Private hospital 22 (2.5) The performance of the skin disinfection was described using
Other* 61 (6.9) terms such as “thorough,” “adequate,” “careful,” “correctly,”
Surgical Specialty “mechanical,” “according to guidelines,” “methodically,” and “effec-
Orthopaedic surgery 285 (32.0) tive.” Other actions undertaken by the nurses interpreted as being
General surgery 283 (31.8)
Thoracic surgery 70 (7.9)
connected to skin disinfection were preoperative cutting of hair and
Gynaecologic surgery 61 (6.9) the inspection of the patient’s skin, checking for example that there
Ear, nose, and, throat surgery 50 (5.6) were no open wounds or eczema lesions in the surgical area.
Urologic surgery 31 (3.5)
Neurologic surgery 30 (3.4)
Hand surgery 23 (2.6) Aseptic technique
Vascular surgery 16 (1.8) The nurses described using an aseptic technique in order to pre-
Plastic surgery 15 (1.7)
vent bacterial contamination and SSI; 578 of the 2,033 codes related
Eye surgery 14 (1.5)
Other* 12 (1.3) to this subcategory. Aseptic technique was maintained during sur-
gery by keeping the sterile goods sterile, removing the draping after
OR, operating room; SD, standard deviation.
*Missing information the dressing was applied, supervising other persons in the surgical
team to ensure that they did not contaminate anything in the sterile
“All actions together are very important. If you deviate from your field, and quickly replacing any contaminated item with a new, sterile
routine, the risk of a postoperative surgical site infection is greater.” one. One of the nurses described this as follows:
(nurse no. 608) “Vigilant supervision during surgery so that nothing becomes unster-
ile, and if so ensure that it [the unsterile item] is replaced and any
unsterile areas are disinfected and draped over.” (nurse no. 78)
Infection control

The 5 subcategories skin disinfection, aseptic technique, draping, Along with this, the nurses described additional interventions that
dressing, and normothermia were all interpreted as interventions they performed in order to uphold an aseptic technique: the use of
undertaken by the nurses in order to uphold infection control and antibacterial sutures, avoiding touching implants, a thorough preop-
thus prevent bacterial contamination and the emergence of SSI. erative hand disinfection of their own hands including the checking

Table 2
An overview of the categories, subcategories, exact number, and percentage of codes including examples of codes showing interventions performed clinically by operating room
(OR) nurses in order to prevent bacterial contamination and surgical site infection (SSI)

Category Subcategory Number of Percentage of Examples of codes

codes (n) all codes (%)

Infection control Skin disinfection 911 25.9 Descutan, preoperative skin disinfection and done in an appropriate manner, letting the disinfec-
tant air dry, soaked cotton swabs, no infected wounds preoperatively
Aseptic technique 578 16.4 Maintaining sterility, replacing unsterile material, correct implant handling, wiping off blood from
the sterile goods
Draping 345 9.8 Thorough sterile draping with no gaps, leaving as little skin uncovered as possible, using double
layers of draping
Dressing 126 3.6 a dressing that is tight and adapted to the nature of the wound, adhere draping as soon as possible,
dense, and functional draping
Normothermia 73 2.1 maintaining the body temperature, warm blankets, minimizing temperature loss, keeping the
patient warm
Total 2,033 57.7
Preventing indirect OR environment 642 18.2 Minimizing the number of door openings, using as few personnel as possible, no running around,
contamination optimized ventilation
OR clothes 473 13.4 Proper dressing, mask, helmet, surgical gown, sterile gloves, changing gloves
Preparation 214 6.1 Covering the sterile goods, checking the instruments, ensuring undamaged packaging
Basic hygiene 119 3.4 Hand disinfection, following basic hygiene routines
Total 1,448 41.1
The surgical team Communication 24 0.7 Both written and verbal information, informing the team, good communication with colleagues
Knowledge 9 0.3 Knowledge of postoperative infections, keeping yourself updated, informed about the procedure
Work strategies 8 0.2 Optimizing the surgical time, working effectively, working without stress
41 1.2
Total 3,522 100
1052 C. Wistrand et al. / American Journal of Infection Control 50 (2022) 1049−1054

of other team members’ hand disinfection, and cleaning the sterile should use the phone to ask someone outside the OR to bring the
goods during surgery in order to avoid bacterial growth. missing instrument instead of opening the doors and fetching it
themselves.
Draping “Use the phone in the OR as your means of communication [with staff
The draping subcategory included several interventions outside of the OR], do not run in and out. Plan your work and make
(n = 345) that the nurses described undertaking to prevent bacte- sure that the equipment you might need is in the OR, use reach-
rial contamination and SSI. The use of incision drapes to protect through cabinets as much as possible.” (nurse no. 629)
the surgical area and transparent plastic film to cover open
wounds was considered important, as was fastening the sterile
draping close to the surgical area in order to leave as little as Interventions aimed at minimizing bacterial shedding included
possible of the patient’s skin uncovered. The nurses believed that minimizing the number of staff members and the equipment in the
it was important that the draping was employed correctly, and OR, as well as optimizing the ventilation and moving around slowly
that it should stay in place throughout the procedure. They in the OR.
described this with statements such as “the draping of the surgical
area is tight and lasts throughout the surgery” (nurse no. 956),
OR clothes
“constantly checking the draping throughout the surgery and rein-
The subcategory of OR clothes contained 473 codes (13.4%) and
forcing it if needed” (nurse no. 780), and “that it (the draping) fits
described interventions connected to the clothes that were worn in
correctly and tightly” (nurse no. 885).
the OR. The nurses believed that it was important for all personnel
working in the OR to be dressed appropriately in tightly woven
Dressing clothes or clean air suits, including using a mask and helmet, with
A properly attached dressing was the subject of 3.6% of the codes. sterile gowns and gloves for the personnel actively working with or
According to the nurses, important aspects included choosing a around the surgical area, such as the surgeons, assistants, or nurses.
dressing suitable for that specific surgery, applying the dressing in a Some of them stated that the work suits they used should be made
sterile manner, and applying the dressing closely and tightly against from a tightly woven fabric or made from disposable materials for 1-
the skin with no creases that could allow bacteria to contaminate the time use, in order to minimize bacterial shedding and thereby pre-
surgical wound. vent bacterial contamination and SSI.
“A dressing that fits well and does not need to be changed in the first Other strategies included wearing a sterile surgical gown and
place, and not starting to loosen the draping until the dressing is gloves, and using double sterile gloves in order to prevent bacterial
applied” (nurse no. 208) cross contamination if one of the gloves was punctured or torn. It
was important that the sterile gloves were changed not only if they
were punctured or torn, but also if the surgery continued for a long
Some of the nurses also stressed the importance of choosing a period of time (ie several hours), or before handling implants or
dressing that was gentle and appropriate for sensitive skin, and that attaching the dressing.
would not cause blisters or eczema. They also believed that it was
“You should change the gloves after cementation, contact with
important for the dressing to be left in place for a long period of time
infected material, and if they are heavily soiled.” (nurse no. 54)
postoperatively, and that it was better to reinforce the dressing than
to change it.

OR preparation
Normothermia
The nurses described several interventions (n = 214 codes) con-
The subcategory of maintaining the patient’s body temperature
nected to preparation, such as checking that the instruments were
during surgery contained only 2.1% of the codes, and so was the
sterilized before taking them out of their packaging, and ensuring
least mentioned intervention interpreted as belonging to infection
that the packaging was undamaged. This was done by “checking the
control. The interventions described by the nurses included heating
date marking, packaging, and sterilization indicators on sterile material”
blankets, blankets that were run through with a warm airflow, pre-
(nurse no. 374). The nurses stated that they felt it best to set up and
heated skin disinfectant, covering the patient’s body with duvets,
cover the sterile goods before the patient arrived at the OR if possible,
and warm fluids. This was described as a shared responsibility, per-
and that it was important for the preparation to be done in a sterile
formed in collaboration with the registered nurse anesthetist in the
manner.
surgical team.

Preventing indirect contamination Basic hygiene

Adhering to basic hygiene routines was mentioned 119 times, giv-
Preventing indirect contamination involved the nurses in control- ing a total of 3.4% of all codes. This included following local routines
ling interventions in order to decrease the risk of bacterial contami- as well as written guidelines. The nurses stated that it was important
nation and SSI. These were subcategorized as OR environment, OR for basic hygiene to be upheld by all members of the OR staff: “The
clothes, OR preparation, and basic hygiene. importance of sterility throughout the surgery, and being responsible for
ensuring that everyone in the OR follows the hygiene regulations” (nurse
no. 650). Basic hygiene also included thorough hand disinfection.
OR environment
Regarding the OR environment, the nurses considered it impor-
tant for the hygiene level in the OR to be satisfactory and the doors of The surgical team
the OR to be kept closed; or, at least, opened only when absolutely
necessary during preparation for surgery and the surgery itself. This Having a well-functioning surgical team was the smallest cate-
subcategory was the second largest of all, consisting of 642 codes gory, comprising only 41 codes (1.2%). Nevertheless, it contained
(18.2%). One example given of appropriate practice was that when important interventions described by the nurses in the form of com-
there was a lack of an instrument in the OR, the personnel in the OR munication, knowledge, and work strategies.
 C. Wistrand et al. / American Journal of Infection Control 50 (2022) 1049−1054 1053

Communication is no evidence in the literature that the use of incision adhesive

Only 24 of the 3,522 codes belonged to the communication sub- drape reduces the number of SSIs,22 and one study even found
category. Communication included both communicating with other that it may increase bacterial contamination.16 Identifying areas
members in the surgical team while in the OR, and communicating of clinical practice with insufficient evidence is paramount for
with staff from the surgical ward or the patient. Examples of commu- patient safety. However, it is challenging to implement processes
nicating within the OR included the nurses taking on a teaching role to remove non−cost-effective or ineffective practices based on
in relation to all staff categories, or raising awareness of the impor- tradition, as well as to implement a new intervention or
tance of the World Health Organization’s surgical safety checklist. strategy.23
One of the nurses stated that:
“I encourage the surgeon to inject the local anesthetics subcutane- METHODOLOGICAL CONSIDERATIONS
ously while the wound is open in order to avoid several small punc-
tures next to the wound.” (nurse no. 605) The retrieval of OR nurses’ e-mail addresses depended on the
ability of the different counties and regions to disclose e-mail lists,
which limited the sample size. However, the survey had respond-
Communication with staff from the surgical ward or the patient ents from all counties and regions in Sweden, dispersed over 64 dif-
involved the provision of information regarding how the surgical site ferent hospitals.
and dressing should be cared for in order to maintain good hygiene The combination of qualitative content analysis together with
and thereby reduce the risk of SSIs. Information could be given to the quantification of the codes that appeared in the text strengthens
patient both verbally and in writing. the results, as the qualitative and quantitative approaches sup-
ported each other10 and provided a broadened perspective.24
Knowledge Representative quotations and examples of codes have been pro-
Logical thinking, long work experience, keeping oneself updated vided in order to help the reader to judge whether the analysis is
on new routines, and being well informed regarding the patient by reasonable in relation to the raw data.25 A standardized open-
reading their medical chart comprised 9 of the 3,522 codes. One ended question was asked of all participants, thus giving consis-
nurse stated that it was important to have “knowledge of postopera- tency in the data collection, and increasing the dependability of
tive wound infections in order to be able to prepare oneself properly” the results.25
(nurse no. 865).
CONCLUSIONS
Work strategies
Work strategies was the smallest of all the subcategories, contain- By providing quotations in addition to the numbers the under-
ing only 8 codes (0.2% of all codes). Of these 8 codes, 6 described the standing regarding which interventions Swedish OR nurses consider
strategy of “keeping the total surgical time as short as possible.” Two of as most important in order to prevent bacterial contamination and
the nurses stated that they needed to be given the proper amount of SSIs have deepened. Although most of their interventions were in
time to prepare the skin disinfection of the surgical area, in order to line with published data and recommendations, some others were
allow them to perform their work well, and without stress. not. The results may therefore be useful in identifying areas where
evidence and knowledge is lacking in clinical practice, indicating
DISCUSSION where continued education and scientific efforts is needed to fill
these gaps.
The 3 categories of interventions mentioned most frequently
when the nurses described what they considered important to pre- ACKNOWLEDGMENTS
vent bacterial contamination and SSI were skin disinfection (25.9%),
the OR environment (18.2%), and aseptic technique (16.4%). The authors would like to acknowledge the Swedish hospitals that
The responses indicated that many nurses believed the patients’ provided us with their OR nurses’ e-mail addresses. Without their
skin to be sterile after the skin disinfection process. This is not a cer- cooperation, we would not have been able to carry out the study. We
tainty, but skin disinfection does significantly decrease the amount would also like to express our gratitude to all the OR nurses who
of bacterial growth.11-16 Awareness of the importance of the OR took the time to answer the survey.
environment for reduction of bacterial air contamination was one of
the most frequently described interventions to be controlled by the
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