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Inadvertent perioperative hypothermia

About

What is covered

This interactive flowchart covers preventing and managing inadvertent hypothermia in people over 18 having surgery. It does not cover deliberate induction of hypothermia for medical reasons.

Updates

Updates to this interactive flowchart

7 February 2017 HumiGard for preventing inadvertent perioperative hypothermia (NICE medical technologies guidance 31) added to temperature recording and warming devices.
13 December 2016 Structure revised and summarised recommendations replaced with full recommendations. Recommendations amended in line with the update of NICE guideline CG65 on hypothermia: prevention and management in adults having surgery.
30 October 2013 Surgical site infection (NICE quality standard 49) added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on preventing and managing inadvertent perioperative hypothermia in adults having surgery in an interactive flowchart

What is covered

This interactive flowchart covers preventing and managing inadvertent hypothermia in people over 18 having surgery. It does not cover deliberate induction of hypothermia for medical reasons.

Updates

Updates to this interactive flowchart

7 February 2017 HumiGard for preventing inadvertent perioperative hypothermia (NICE medical technologies guidance 31) added to temperature recording and warming devices.
13 December 2016 Structure revised and summarised recommendations replaced with full recommendations. Recommendations amended in line with the update of NICE guideline CG65 on hypothermia: prevention and management in adults having surgery.
30 October 2013 Surgical site infection (NICE quality standard 49) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
HumiGard for preventing inadvertent perioperative hypothermia (2017) NICE medical technologies guidance 31
Surgical site infection (2013) NICE quality standard 49

Quality standards

Surgical site infection

These quality statements are taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statements

Personal preparation for surgery

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

People having surgery are advised not to remove hair from the surgical site and are advised to have (or are helped to have) a shower, bath or bed bath the day before or on the day of surgery.

Rationale

It is not necessary to remove hair routinely to reduce the risk of surgical site infection, and the use of razors for hair removal may increase the risk of infection. If hair needs to be removed, this should be done by healthcare staff using electric clippers with a single-use head on the day of surgery. Pre-operative showering is likely to reduce the number of microorganisms on the skin surrounding the incision and may therefore reduce the risk of infection. Pre-operative advice (and assistance if needed) on personal preparation for surgery will help to ensure that people having surgery have clean skin without unnecessary micro-abrasions (from shaving), which will reduce the risk of surgical site infection.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people having surgery are advised not to remove hair from the surgical site.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people having surgery are advised to have (or are helped to have) a shower, bath or bed bath the day before or on the day of surgery.
Data source: Local data collection.
Process
a) Proportion of surgical procedures for which the person having surgery is advised not to remove hair from the surgical site.
Numerator – the number in the denominator for which the person having surgery is advised not to remove hair from the surgical site.
Denominator – the number of surgical procedures.
Data source: Local data collection.
b) Proportion of surgical procedures for which the person having surgery is advised to have (or is helped to have) a shower, bath or bed bath the day before or on the day of surgery.
Numerator – the number in the denominator for which the person having surgery is advised to have (or is helped to have) a shower, bath or bed bath the day before or on the day of surgery.
Denominator – the number of surgical procedures.
Data source: Local data collection.
Outcome
Feedback from people having surgery on whether they received the help they needed to have a shower, bath or bed bath the day before or on the day of surgery.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, social care practitioners and commissioners

Service providers ensure that systems are in place for their staff to understand and act on the need to advise people having surgery not to remove hair from the surgical site and to advise them to have (or help them to have) a shower, bath or bed bath the day before or on the day of surgery.
Healthcare professionals advise people having surgery not to remove hair from the surgical site and advise them to have (or help them to have) a shower, bath or bed bath the day before or on the day of surgery.
Social care practitioners help people to have a shower, bath or bed bath the day before or on the day of surgery.
Commissioners ensure that they commission services from service providers that can demonstrate arrangements to ensure that people having surgery are advised not to remove hair from the surgical site and advised to have (or helped to have) a shower, bath or bed bath the day before or on the day of surgery.

What the quality statement means for patients, service users and carers

People having an operation are advised not to remove hair from the area of the body where they are having the operation and are advised to have a shower or bath either the day before or on the day of the operation. If they are not able to wash themselves, they should be helped by health or social care staff.

Source guidance

  • Surgical site infection (NICE clinical guideline 74) recommendations 1.2.2, 1.2.3 (key priorities for implementation) and 1.2.1.

Equality and diversity considerations

This quality statement applies to all people preparing for surgery, regardless of their ability to carry out personal preparations themselves. If people need help with washing before surgery or if hair removal is necessary, they should be treated with dignity at all times.
Advice should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People having surgery and their carers or parents should have access to an interpreter or advocate if needed.

Antibiotic prophylaxis

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

People having surgery for which antibiotic prophylaxis is indicated receive this in accordance with the local antibiotic formulary.

Rationale

Antibiotic prophylaxis is effective for preventing surgical site infections in certain procedures. However, the use of antibiotics for prophylaxis carries a risk of adverse effects (including Clostridium difficile-associated disease) and increased prevalence of antibiotic-resistant bacteria. The choice of antibiotic prophylaxis should cover the organisms most likely to cause infection and be influenced by the strength of the association between the antibiotic used and these adverse effects. Using a local antibiotic formulary should ensure that the most appropriate antibiotic, dose, timing of administration and duration are used for effective prophylaxis.

Quality measures

Structure
Evidence of local arrangements to ensure that people having surgery for which antibiotic prophylaxis is indicated receive this in accordance with the local antibiotic formulary and that this is recorded.
Data source: Local data collection.
Process
Proportion of surgical procedures for which antibiotic prophylaxis is indicated for which the person having surgery receives antibiotic prophylaxis in accordance with the local antibiotic formulary and that this is recorded.
Numerator – the number in the denominator for which the person having surgery receives antibiotic prophylaxis in accordance with the local antibiotic formulary and that this is recorded.
Denominator – the number of surgical procedures for which antibiotic prophylaxis is indicated.
Data source: Local data collection. Also contained within NICE clinical guideline 74 audit support, criteria 4a and 4b.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that they develop or have access to a local antibiotic formulary and that their staff understand and act on the need to prescribe and administer antibiotic prophylaxis in accordance with this to people having surgery for which antibiotic prophylaxis is indicated. This includes having systems in place to record when antibiotic prophylaxis has been given.
Healthcare professionals offer antibiotic prophylaxis to people having surgery for which antibiotic prophylaxis is indicated, in accordance with the local antibiotic formulary and record when this has been given.
Commissioners ensure development of, or access to, a local antibiotic formulary and commission services from service providers that can demonstrate arrangements to prescribe and administer antibiotic prophylaxis to people having surgery for which antibiotic prophylaxis is indicated in accordance with the local antibiotic formulary.

What the quality statement means for patients, service users and carers

People having certain types of operation for which there is a higher risk of infection are given antibiotics before surgery to help prevent infection.

Source guidance

  • Surgical site infection (NICE clinical guideline 74) recommendation 1.2.13 (key priority for implementation).

Definitions of terms used in this quality statement

Antibiotic formulary
An antibiotic formulary is a local policy document produced by a multi-professional team, usually in a hospital trust or commissioning group, combining best evidence and clinical judgement [adapted from NICE clinical guideline 74 – full guideline]. See also the Department of Health’s UK five year antimicrobial resistance strategy 2013 to 2018 and Antimicrobial stewardship ‘Start smart – then focus’: guidance for antimicrobial stewardship in hospitals (England) published by the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI).
Surgery that requires antibiotic prophylaxis
Surgery that requires antibiotic prophylaxis is:
  • clean surgery involving the placement of a prosthesis or implant
  • clean-contaminated surgery
  • contaminated surgery
  • surgery on a dirty or infected wound (requires antibiotic treatment in addition to prophylaxis). [NICE clinical guideline 74 recommendations 1.2.11 (key priority for implementation) and 1.2.16]
Surgical site infection (NICE clinical guideline 74) also recommends that antibiotic prophylaxis should not be used routinely for clean non-prosthetic uncomplicated surgery because of the risk of adverse events, Clostridium difficile-associated disease, resistance and drug hypersensitivity [recommendation 1.2.12 (key priority for implementation)].
See the glossary of terms in NICE clinical guideline 74 for definitions of surgical wound classification.

Patient temperature

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

Adults having surgery under general or regional anaesthesia have normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery.

Rationale

During surgery patients are kept in a stable condition by the operating team. All tissues heal most effectively in optimal conditions of oxygenation, perfusion and body temperature. Inadvertent perioperative hypothermia is a common but preventable complication of perioperative procedures that is associated with an increased risk of surgical site infection and other postoperative complications. Surgical patients are at risk of developing hypothermia before, during or after surgery. Maintaining normothermia throughout this period (except if cooling is required for medical reasons) will therefore reduce the risk of infection at the surgical site and ensure that patients feel comfortably warm at all times.

Quality measures

Structure
Evidence of local arrangements to ensure that adults having surgery under general or regional anaesthesia have normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery.
Data source: Local data collection.
Process
Proportion of surgical procedures on adults under general or regional anaesthesia in which the person having surgery has their core temperature measured and documented in accordance with Hypothermia: prevention and management in adults having surgery (NICE clinical guideline 65).
Numerator – the number in the denominator in which the person having surgery has their core temperature measured and documented in accordance with Hypothermia: prevention and management in adults having surgery (NICE clinical guideline 65).
Denominator – the number of surgical procedures on adults under general or regional anaesthesia.
Data source: Local data collection.
Outcome
Proportion of surgical procedures on adults under general or regional anaesthesia in which the person having surgery is normothermic before, during (unless active cooling is part of the procedure) and after surgery.
Numerator – the number in the denominator in which the person having surgery is normothermic before, during (unless active cooling is part of the procedure) and after surgery.
Denominator – the number of surgical procedures on adults under general or regional anaesthesia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to measure and document core temperature in accordance with Hypothermia: prevention and management in adults having surgery (NICE clinical guideline 65) and maintain normothermia for adults having surgery under general or regional anaesthesia before, during (unless active cooling is part of the procedure) and after surgery.
Healthcare professionals measure and document core temperature in accordance with Hypothermia: prevention and management in adults having surgery (NICE clinical guideline 65) and maintain normothermia for adults having surgery under general or regional anaesthesia before, during (unless active cooling is part of the procedure) and after surgery.
Commissioners commission services from service providers that can demonstrate arrangements to ensure that they maintain normothermia for adults having surgery under general or regional anaesthesia before, during (unless active cooling is part of the procedure) and after surgery.

What the quality statement means for patients, service users and carers

Adults having an operation under a general anaesthetic or a regional anaesthetic (which affects a large part of the body, such as a limb or the lower half of the body) are kept comfortably warm (at normal body temperature) before, during and after the operation to help reduce the risk of infection.

Source guidance

  • Surgical site infection (NICE clinical guideline 74), recommendation 1.3.10.

Definitions of terms used in this quality statement

The following definitions have been adapted from NICE clinical guideline 65:
Adults
People aged 18 years and over.
Regional anaesthesia
Central neuraxial block.
Normothermia
A core temperature range of 36.5°C to 37.5°C.
Before surgery
The preoperative phase, defined as 1 hour before induction of anaesthesia (when the patient is prepared for surgery on the ward or in the emergency department).
During surgery
The intraoperative phase, defined as total anaesthesia time (including the time in the anaesthetic room before induction of anaesthesia).
After surgery
The postoperative period, defined as 24 hours after entry into the recovery area (which will include transfer to and time spent on the ward).
Perioperative pathway
The continuous period of the preoperative, intraoperative and postoperative phases.
Measurement and documentation of core temperature
In accordance with NICE clinical guideline 65, measure and document core temperature:
  • in the hour before the patient leaves the ward or emergency department [recommendation 1.2.4]
  • again before induction of anaesthesia and then every 30 minutes until the end of surgery [recommendation 1.3.1 (key priority for implementation)]
  • on admission to the recovery room and then every 15 minutes [recommendation 1.4.1 (key priority for implementation)]
  • on arrival at the ward [recommendation 1.4.2]
  • every 4 hours on the ward [recommendation 1.4.2].
This quality statement does not cover people undergoing therapeutic hypothermia or people with severe head injuries resulting in impaired temperature control. Other exclusions may apply at certain points on the perioperative pathway, such as when surgery needs to be expedited for clinical urgency. Hypothermia: prevention and management in adults having surgery (NICE clinical guideline 65) does not cover children and young people (aged less than 18 years), pregnant women or people undergoing local anaesthesia, but it is recognised that users of the quality standard may wish to consider how the quality statement on normothermia may apply to these groups.
Equality and diversity considerations
This quality statement may not apply to all pregnant women, because they are not covered by NICE clinical guideline 65. Because of the physiological changes in pregnancy, the needs of pregnant women may need to be considered separately from non-pregnant women for some types or aspects of surgery. Similarly, NICE clinical guideline 65 does not cover children (aged less than 18 years). Users of the quality standard will need to apply clinical judgement in considering how the quality statement on patient temperature applies to these groups.

Intraoperative staff practices

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

People having surgery are cared for by an operating team that minimises the transfer of microorganisms during the procedure by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

Rationale

In order to reduce the risk of surgical site infection, the risk of microbial contamination of the surgical site from the theatre environment needs to be minimised. Staff practices aimed at achieving this are known collectively as theatre discipline. In order to maintain theatre discipline, a number of practices should be followed that include using appropriate theatre wear and minimising movement of people in and out of the operating area. Effective hand decontamination will also reduce the risk of transferring microorganisms during the procedure, and this is most likely to be achieved if hand jewellery, artificial nails and nail polish are removed before decontamination takes place.

Quality measures

Structure
a) Evidence of local arrangements to ensure that operating teams remove any hand jewellery, artificial nails and nail polish before starting surgical hand decontamination.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that operating teams follow practices for surgical hand decontamination in accordance with Surgical site infection (NICE clinical guideline 74) recommendations 1.3.1 and 1.3.2.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that staff wear specific non-sterile theatre wear in all areas where operations are undertaken.
Data source: Local data collection.
d) Evidence of local arrangements to ensure that operating teams minimise any staff movements in and out of the operating area.
Data source: Local data collection.
e) Evidence of local arrangements to ensure that spot checks are carried out in relation to structure measures a), b), c) and d).
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that policies and procedures are in place and implemented to ensure that operating teams minimise the transfer of microorganisms during surgery by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.
Operating teams follow practices that minimise the transfer of microorganisms during surgery by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.
Commissioners commission services from service providers that have policies and procedures to ensure that operating teams follow practices that minimise the transfer of microorganisms during surgery by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

What the quality statement means for patients, service users and carers

People having an operation are cared for by an operating team that minimises the chances that microorganisms will be transferred during the operation by following best practice when cleaning their hands and by wearing the correct type of clothing, and by not moving in and out of the operating area unnecessarily.

Source guidance

Definitions of terms used in this quality statement

Best practice in hand hygiene
Best practice in hand hygiene includes the following:
  • The operating team should remove hand jewellery, artificial nails and nail polish before operations.
  • The operating team should wash their hands prior to the first operation on the list using an aqueous antiseptic surgical solution, with a single-use brush or pick for the nails, and ensure that hands and nails are visibly clean.
  • Before subsequent operations, hands should be washed using either an alcohol hand rub or an antiseptic surgical solution. If hands are soiled then they should be washed again with an antiseptic surgical solution. [NICE clinical guideline 74 recommendations 1.2.9, 1.2.10, 1.3.1 and 1.3.2.]
Best practice in theatre wear
Best practice in theatre wear includes the following:
  • Staff should wear specific non-sterile theatre wear (scrub suits, masks, hats and overshoes) in all areas where operations are undertaken.
  • Staff wearing non-sterile theatre wear should keep their movements in and out of the operating area to a minimum [NICE clinical guideline 74 recommendations 1.2.5 and 1.2.6].

Information and advice on wound care

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

People having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

Rationale

Appropriate wound and dressing care promotes healing and reduces the risk of infection. Providing information and advice on this to people having surgery and their carers will reduce the risk of them doing something to the wound or dressing that might contaminate the site with microorganisms unnecessarily. If a person develops a surgical site infection, early treatment is essential to prevent the infection getting worse. Providing information on how to recognise problems with a wound and who to contact if they are concerned should lead to prompt treatment for those who need it and reduce infection-related morbidity.

Quality measures

Structure
Evidence of local arrangements to ensure that people having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.
Data source: Local data collection.
Process
Proportion of surgical procedures for which the person having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.
Numerator – the number in the denominator for which the person having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.
Denominator – the number of surgical procedures.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that protocols are in place to provide people having surgery and their carers with information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.
Healthcare professionals provide people having surgery and their carers with information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.
Commissioners commission services from service providers that can demonstrate that they have protocols to provide people having surgery and their carers with information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned.

What the quality statement means for patients, service users and carers

People having an operation and their carers are given information and advice about how to look after the wound when they go home, how to recognise problems with the wound and who to contact if they are concerned about it.

Source guidance

  • Surgical site infection (NICE clinical guideline 74), recommendations 1.1.2 and 1.1.3.

Equality and diversity considerations

Information should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. People having surgery and their carers or parents should have access to an interpreter or advocate if needed.

Treatment of surgical site infection

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

People with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Rationale

People who develop an infection need to receive the treatment that is most likely to be effective in order to minimise associated morbidity. It is also important that they are not given more treatment than they need, because antibiotic therapy carries risks of adverse reactions, the development of resistant bacteria and Clostridium difficile-associated disease. Taking into account local resistance patterns and the results of microbiological tests will help to ensure that people receive the most appropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that people with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.
Data source: Local data collection.
Process
Proportion of surgical site infections for which the person with the infection receives treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.
Numerator – the number in the denominator for which the person with the infection receives treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.
Denominator – the number of surgical site infections.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place (including development of, or access to, a local antibiotic formulary) to offer people with a surgical site infection treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.
Healthcare professionals offer people with a surgical site infection treatment with an antibiotic that covers the likely causative organisms and is selected in accordance with the local antibiotic formulary and based on local resistance patterns and the results of microbiological tests.
Commissioners ensure development of, or access to, a local antibiotic formulary and that they commission services from service providers that can demonstrate that systems are in place to offer people with a surgical site infection treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

What the quality statement means for patients, service users and carers

People with a surgical site infection are given an antibiotic that has been chosen because it is effective for the microorganisms most likely to have caused the infection. The healthcare team should look at the results of tests carried out on samples from the wound and they should also consider which antibiotics are most likely to work in the area local to the hospital, because the effectiveness of antibiotics can vary from place to place.

Source guidance

  • Surgical site infection (NICE clinical guideline 74), recommendation 1.4.9.

Definitions of terms used in this quality statement

Surgical site infection
The presence of a surgical site infection can be determined using the Surgical Site Infection Surveillance Service (SSISS) definitions in Protocol for the surveillance of surgical site infection: surgical site infection surveillance service, which are modified from those used by the US Centers for Disease Control (CDC). Other measures that are also based on clinical signs and symptoms are available. The term does not include colonisation.
Antibiotics
Antibiotics should be prescribed in accordance with the local antibiotic formulary. An antibiotic formulary is a local policy document produced by a multi-professional team, usually in a hospital trust or commissioning group, combining best evidence and clinical judgement [adapted from NICE clinical guideline 74 – full guideline]. See also the Department of Health’s UK five year antimicrobial resistance strategy 2013 to 2018 and Antimicrobial stewardship ‘Start smart – then focus’: guidance for antimicrobial stewardship in hospitals (England) published by the Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI).

Surveillance

This quality statement is taken from the surgical site infection quality standard. The quality standard defines clinical best practice for surgical site infection and should be read in full.

Quality statement

People having surgery are cared for by healthcare providers that monitor surgical site infection rates (including post-discharge infections) and provide feedback to relevant staff and stakeholders for continuous improvement through adjustment of clinical practice.

Rationale

Surveillance data on surgical site infection rates can inform and influence steps taken to minimise the risk of infection, as well helping to clearly communicate the risks to patients. Some infections take time to develop and may not become apparent until after the patient has been discharged from hospital. Therefore surveillance for infections in hospitalised patients only is likely to underestimate the true infection rate – a problem exacerbated by the increasing trend towards shorter postoperative hospital stays and day surgery. Therefore, systems that identify surgical site infection after patients leave hospital enhance the value of surveillance and the provider's ability to deliver interventions to reduce the risk of infections based on their own results, leading to continuous quality improvement.

Quality measures

Structure
a) Evidence of local arrangements to ensure the existence of surveillance systems that capture inpatient and post-discharge surgical site infections.
Data source: Local data collection. Also contained within Prevention and control of healthcare-associated infections (NICE public health guidance 36): quality improvement statement 3, evidence of achievement 6.
b) Evidence of local arrangements to ensure surveillance data on surgical site infection rates (including post-discharge infections) are fed back to relevant staff and stakeholders.
Data source: Local data collection. Prevention and control of healthcare-associated infections (NICE public health guidance 36): quality improvement statement 3, evidence of achievement 13.
c) Evidence of local arrangements to ensure that surveillance data on surgical site infection rates (including post-discharge infections) are used for continuous improvement through adjustment of clinical practice.
Data source: Local data collection.
Outcome
Readmissions for surgical site infection.
Data source: Local data collection. Data collected as part of the Surgical Site Infection Surveillance Service (SSISS) are published by Public Health England in annual reports available through their website. This includes readmissions data from individual hospitals, collected as part of the Department of Health’s mandatory surveillance scheme (orthopaedic surgery).

What the quality statement means for service providers, healthcare professionals, public health practitioners and commissioners

Service providers ensure that systems are in place to monitor surgical site infection rates (including post-discharge infections) and provide feedback to their clinical and non-clinical staff and stakeholders for continuous improvement through adjustment of clinical practice.
Healthcare professionals and public health practitioners act on information provided to them on surgical site infection rates (including post-discharge infections) to adjust clinical practice for continuous improvement.
Commissioners commission services from service providers that can demonstrate that they monitor surgical site infection rates (including post-discharge infections) and provide feedback to relevant staff and stakeholders for continuous improvement through adjustment of clinical practice.

What the quality statement means for patients, service users and carers

People having an operation are cared for by healthcare services that monitor surgical site infection rates, share this information with patients and relevant staff, and use it to help improve services and minimise future infection rates.

Source guidance

Definitions of terms used in this quality statement

Surgical site infection
The presence of a surgical site infection can be determined using the Surgical Site Infection Surveillance Service (SSISS) definitions: Protocol for the surveillance of surgical site infection: surgical site infection surveillance service, which are modified from those used by the US Centers for Disease Control (CDC). Other measures that are also based on clinical signs and symptoms are available. The term does not include colonisation.
Surgical site infection rates (including post-discharge)
Many surgical site infections present after discharge from hospital. Comparison of post-discharge surveillance data is difficult because it depends on the methods used to detect infections. The method of surveillance should be clear so that comparisons can be made. A Protocol for the surveillance of surgical site infection: surgical site infection surveillance service is available from Public Health England. The Department of Health UK five year antimicrobial resistance strategy highlights access to and use of surveillance data in the context of bacterial resistance.
Staff and stakeholders
Staff may include the board and individual clinical units in a hospital setting. Stakeholders include patients, GPs, commissioners and other local health and social care organisations [adapted from NICE public health guidance 36: quality improvement statement 3].

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Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

a process that transfers heat to the patient
American Society of Anesthesiologists
the expected normal temperature range of adult patients (between 36.5°C and 37.5°C)
the temperature of the blood and internal organs
the reading produced by a thermometer with no correction factors applied
core temperature below 36.0°C
the reading produced by a thermometer after a correction factor has been applied, examples include infrared tympanic, infrared temporal, infrared forehead and forehead strips
the core temperature

Paths in this pathway

Pathway created: August 2012 Last updated: March 2017

© NICE 2017

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