INTRODUCTION:

Surgical site infections (SSIs) are a common healthcare-associated infection, occurring in 2–5% of the 30 million surgeries performed annually. They significantly raise healthcare costs and negatively impact patients by causing pain, increasing the risk of hospital readmissions, and often requiring additional procedures.¹ It has been identified as one of the major preventable complications linked to prolonged hospitalization.²

The CDC estimates 110,800 surgical site infections (SSIs) annually, causing significant morbidity, increased mortality, and $3.3 billion in costs. SSIs account for 20% of healthcare-associated infections, prolonging hospital stays by 9.7 days and adding $20,000 per admission.^3,4In England, healthcare-associated infections (HCAIs) have a 6.4% prevalence, with surgical site infections (SSIs) making up 15.7%. SSIs are largely preventable through targeted care bundles.^5,6

In India (2019-20), 18.88 million surgeries were performed in public health facilities, with 123 surgical site infections (SSIs) per 100,000 surgeries. Meghalaya, Assam, and Dadra & Nagar Haveli reported the highest SSI rates.⁷

The Institute for Healthcare Improvement introduced care bundles in 2001 to improve outcomes by consistently applying evidence-based interventions. Initially targeting VAP and CLABSIs, their success led to expansion for issues like surgical site infections (SSIs) and many of their national initiatives In US and England, have implemented SSI-focused care bundles.^{8,9,10,11,12,13}

Adhering to care bundles reduces surgical site infections (SSIs). Reporting and feedback enhance healthcare professionals' awareness of their role in patient safety and SSI prevention.¹⁴

SIGNIFICANCE AND NEED FOR THE STUDY:

Surgical site infections (SSIs) are the most common hospital-acquired infection, comprising 36.4% of National Health Care Safety Network-reported cases. Abdominal surgeries cause nearly 50% of SSIs, with liver transplants and colon surgeries posing the highest risks.¹⁵

The risk of contracting an SSI can be reduced by performing care according to infection prevention guidelines, but literature shows that adherence to these guidelines is repeatedly low.¹⁴Generally there are surgical site infections checklist in use in most of the hospitals but they lack comprehensiveness, Thus the researcher decided to develop and validate a checklist which contains items to be checked in the preoperative, intra-operative and post operative stages of a surgery by all operating staff including Anaesthetists, Surgeons, Scrub Nurse, Circulating Nurse, Technicians and General Duty assistants.

OBJECTIVES OF THE STUDY:

Primary objective: To assess the Adherence to Surgical Site Infection Prevention Bundle (SSIPB) among Operating room staff of a tertiary Care Hepatology Hospital.

Secondary objective: To determine association of Adherence to SSIPB with Surgery related Parameters

MATERIAL AND METHODS:

a quantitative research approach with cross sectional observational design was used.

Sample and Setting:

From May 22 to June 17, 2023, operating room staff at a tertiary care hepatology hospital were observed during 43 surgeries using a validated 61-item SSIPB checklist (16 pre-operative, 39 intra-operative, 6 post-operative items). Adherence levels were classified as excellent (90% - 100%), good (75% - 89%), moderate (50% - 74%), and poor (0% - 49%). Staff included surgeons, anaesthetists, nurses, technicians, and housekeeping. Event sampling was used, resulting in 344 observations and 2,967 recorded items.

Table 1: Observation Schedule of Operating Room Staff.

Sl. No	Category of OR Staff	Freq of observations	N0. of observations /items In checklist
1	Surgeon 1	43	688
2	Surgeon 2	43	688
3	Scrub nurse	43	817
4	Anesthetist	43	215
5	Circulating Nurse	43	86
6	Operating room Technician	43	172
7	General Duty Assistants (GDA)	43	86
8	Housekeeping	43	215
Total Observations		344	2967

Method of data collection:

A direct, non-participative observation method was used to assess operating room staff's adherence to the SSIPB checklist during scheduled daytime surgeries. Staff were observed based on checklist items relevant to their roles in the pre-, intra-, and post-operative periods. The researcher ensured close observation without interfering with surgical procedures.

Tools for data Collection:

Tool 1 consisted of socio demographic and clinical profile tool.

Tool 2 - adherence to SSIPB checklist, a validated 61-item checklist with three sections:

Pre-operative: 16 items (12 environment-related, 4 patient-related).

Intra-operative: 39 items (24 health care worker-related, 8 patient-related, 7 environment-related);

Post operative: 6 items (2 patient-related, 4 environment-related).

Ethical Clearance: the ethical clearance was obtained (CONEC /ILBS/MSC/01/22/007).

RESULTS:

Regarding demographics, 34.88% of patients were over 50 years old, 27.91% were below 30, 20.93% were aged 40-49, and 16.28% were 30-40 years. The majority (62.79%) were male, and 37.21% were female. Clinically, 39.53% were pre-obese, 34.88% had normal weight, 13.96% were obese, and 11.63% were underweight. All received pre-operative antibiotics within 60 minutes. Co-morbidities included obesity (53.49%), hypertension (11.6%), diabetes (9.3%), and others (16.28%). Regarding surgery, 39.53% were admitted the day before, 32.56% on the same day, and 16.28% two days prior. Most surgeries (97.67%) were elective, with 60.47% being laparoscopic and 39.53% open. Surgery duration was under 2 hours in 58.14% of cases. Most surgeries (76.74%) were abdominal. 79.07% of surgeries were clean, and 20.93% were clean-contaminated. Blood loss was minimal in 86.05% of the surgeries. The operating room team included 8 staff members, observed daily by the researcher. Overall adherence to the SSIPB checklist was excellent in 97.67%, with 2.33% showing good adherence. No staff showed moderate or poor adherence (table 2).

Figure 1 shows that the adherence to the Surgical Site Infection Prevention Bundle for the entire surgery showed the highest compliance in Surgeon 2 at 99.71%, followed by Surgeon 1 at 99.56%. Scrub nurses showed 99.39% adherence, and circulating nurses had 97.67%.

Table 3 presents adherence to the SSIPB for pre-operative observations, using frequency and percentage distribution. The data shows that 95.35% of staff adhered to the item on "Cleaning and decontamination of environmental surfaces prior to surgery." Adherence was also high for "Operating room ventilation with positive pressure" and "Operating room temperature maintenance" at 86.05%. The item on "Humidity maintenance between 20%-60%" had 72.09% adherence. Notably, several key items achieved full adherence (100%). For the adherence in the intraoperative items, 100% adherence was observed for scrub nurse, surgeon 1, and surgeon 2. Other adherence rates included 95.35% for the sequence of surgical hand scrubbing by the scrub nurse, 88.37% for maintaining 4-8 staff in the operating room, and 69.77% for keeping the operating room door closed except for urgent reasons. For adherence in the post-operative observations showed 100% adherence to items such as ensuring patient vitals and normothermia (36ºC or above), terminal cleaning, and scheduled fumigation. However, adherence to biomedical waste segregation and proper disposal of sharps was 55.81%.

Fig. 1: Category-wise adherence to Surgical Site Infection Prevention Bundle

Table 2: Level of Adherence to Surgical Site Infection Prevention Bundle N=43

Level of adherence to SSIPB	F (%)	Mean	SD
Excellent Adherence (90-100%)	42 (97.67)	97.25	2.85
Good Adherence (75-89%)	1 (2.33)	97.25	2.85

Table 3: Item-wise analysis of Adherence to Surgical Site Infection Prevention Bundle in terms of pre-operative observations N=43

Sl. No.	Item	Adherence		Non-Adherence		Not Applicable
Sl. No.	Item	f	%	F	%	f	%
1.	The environmental surfaces were thoroughly cleaned and decontaminated before surgery.	41	95.35	2	4.65	0	0
2.	The operating room ventilation was maintained with positive pressure (manometer reading above 2.5 Pascal).	37	86.05	6	13.95	0	0
3.	The operating room temperature was kept between 21ºC ± 3ºC.	37	86.05	6	13.95	0	0
4.	The operating room Humidity was maintained between 20% - 60%	31	72.09	12	27.91	0	0
5.	Processing indicators were placed outside each package to indicate their "Processed" status.	43	100	0	0	0	0
6.	Parametric chemical indicators, confirming effective sterilization, were placed and inspected.	43	100	0	0	0	0
7.	Operating room equipment, such as the C-arm, microscope, and overhead light, were kept covered.	43	100	0	0	0	0
8.	All instruments, equipment, and supplies used in the sterile field were maintained sterile according to aseptic principles.	43	100	0	0	0	0
9.	Contamination was avoided while opening sterile equipment and supplies on the sterile field.	43	100	0	0	0	0
10. 11.	Movement in and around the sterile field was minimized by reducing traffic in the operating room (OR). Proper surgical attire, including masks, caps, and shoe covers, along with sterile drapes, scrub suits, gloves, and gowns, were ensured.	43	100	0	0	0	0
12	Patient related factors The quality of water for surgical scrubbing was verified by reviewing the water report.	43	100	0	0	0	0
13.	The surgical site was prepared suing a clipper (Applicable to surgeries in males, n=27)	27	100	0	0	16	-
14.	The area was clipped no more than 2 hours before surgery. (Applicable to surgeries in males, n=27)	27	100	0	0	16	-
15.	Surgical antibiotic prophylaxis was administered 60 minutes before surgery.	43	100	0	0	0	0
16.	Re-dose of Prophylactic antimicrobial was administered (If duration of surgery more than 4 hours or if major blood losses occur (>1.5 L in adults or 25mL/kg in children). (Applicable to surgeries) (n=10)	10	100	0	0	33	-

Table 4: Association of adherence to Surgical Site Infection Prevention Bundle with surgery related parameters n= 43

Sl. No	Variable		Mean±SD	F/t	P
1.	Type of Surgery
		Elective	97.27±2.92	0.031	0.861
		Emergency	96.55± -	0.031	0.861
2.	Laparoscopic surgery
		Yes	96.80±3.45	2.196	0.146
		No	97.94±1.55	2.196	0.146
3.	Duration of Surgery
		<2	97.18±2.69	3.165	0.035*
		2-4	95.99±4.17
		4-6	100.00±0.00
		> 6	97.74±1.68
4.	Surgical Site
		Abdomen	97.09±3.12	2.486	0.123
		Other	97.84±1.71	2.486	0.123
5.	Wound class/Grading
		Clean (C)	97.09±3.12	0.349	0.558
		Clean-Contaminated (CC)	97.84±1.71
		Contaminated (CO)	0
		Dirty (D)	0
6.	Number of Drain
		Yes	97.31±2.57	0.127	0.723
		No	96.92±4.42	0.127	0.723
7.	Area/Site of Drain
		Abdomen	96.92±4.42	0.127	0.723
		NIL	97.31±2.57	0.127	0.723
8.	Blood loss during Surgery (In ml)
		200	97.14±3.00	0.695	0.409
		200-750	97.95±2.06
		750-1500	0
		1500-2000	0
		>2000	0
9.	Use of C-arm
		Yes	97.22±2.28	0.421	0.520
		No	97.27±3.33	0.421	0.520

*p ≤ 0.05; Significant

Table 5: Post Hoc analysis of duration of surgery with adherence to SSIPB N=43

Sl. No	Duration of Surgery	Mean Difference	SE	p
1.	<2 hours	-6.03	2.21	0.057
	2-4 hours	-	2.45	0.034*
	4-6 hours	-	2.45	0.034*
	>6 hours	2.48	1.87	1.000

*p ≤ 0.05; Significant

Table 4 shows the association between adherence to SSIPB and surgery-related parameters. The post hoc analysis for the results indicates that the duration of surgery (in hours) was significantly associated with adherence (p ≤ 0.05), as the duration of the surgery increased the adherence levels decreased.

Table 5 reveals the post hoc analysis using bonferroni test for the duration of surgery to the adherence to SSIPB. The adherence to SSIPB is higher in surgeries 2-4hours and 4-6 hours of duration of surgery (p = 0.034) as compared to the surgeries with longer duration (>6 hours).

DISCUSSION:

In this study, operating room staff, including surgeons, nurses, anesthetists, technicians, and support staff, were observed using a 61-item checklist. Surgeons showed the highest adherence to SSIPB (98.71%), while technicians had the lowest (78.49%). Unlike this staff-wise adherence focus, a similar study observed 49 surgical team members, including doctors, medical students, and nursing technicians, emphasizing item-wise adherence to preoperative and postoperative interventions.¹⁶A similar study in Gaza Strip hospitals found that surgeons demonstrated the highest adherence to preventive intraoperative measures for surgical site infections, highlighting their critical role in improving surgical outcomes and reducing postoperative SSI complications.¹⁷Another study observed 132 OR staff (90 physicians and 42 nurses) for adherence to SI protocols, reporting an overall adherence of 40.1%, lower than in the current study. Unlike the current study, it found no significant association between adherence and demographic variables such as sex, age, occupational rank, or training duration. However, the current study identified a significant association between adherence and surgery-related factors, particularly surgery duration.¹⁸

LIMITATIONS OF THE STUDY:

The present study focuses on observing adherence to protocols by the operating room (OR) staff during the preoperative, intraoperative, and immediate postoperative periods within the OR itself. However, it does not extend to observations in the postoperative period within the surgical ward or include long-term follow-up to assess the incidence and prevalence of surgical site infections. Additionally, the non participatory observation conducted by the researcher, with the subjects aware of being observed, may have introduced an element of bias.

CONCLUSION:

The study results indicate that 97.67% of the operating room staff exhibited excellent adherence, while 2.33% demonstrated good adherence to SSIPB. The high adherence of scrub and circulating nurses to SSIPB underscores the critical role of nurses in ensuring adherence to standard protocols and sets a benchmark for high standards of infection prevention in operation theatres.

CONFLICT OF INTEREST:

The authors have no conflict to declare.

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Received on 16.03.2025 Revised on 20.04.2025

Accepted on 23.05.2025 Published on 25.10.2025

Available online from November 04, 2025

Asian J. Nursing Education and Research. 2025;15(4):247-252.

DOI: 10.52711/2349-2996.2025.00050

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Table 4: Association of adherence to Surgical Site Infection Prevention Bundle with surgery related parameters n= 43

1.

Type of Surgery

97.94±1.55

0

0

Sl. No

Duration of Surgery

Mean Difference

SE

p

1.

<2 hours

-6.03

2.21

0.057

2-4 hours

-

2.45

0.034*

4-6 hours

-

2.45

0.034*

>6 hours

2.48

1.87

1.000

*p ≤ 0.05; Significant

Table 5 reveals the post hoc analysis using bonferroni test for the duration of surgery to the adherence to SSIPB. The adherence to SSIPB is higher in surgeries 2-4hours and 4-6 hours of duration of surgery (p = 0.034) as compared to the surgeries with longer duration (>6 hours).