Surgical Skeletal Pin Site Infection Control: Translating Evidence, Implementing Change

Poster Presentation EBP Initiative 

Surgical Skeletal Pin Site Infection Control: Translating Evidence ~ Implementing Change 

In an attempt to describe the process to translate research and best practices into a change in policy, this abstract focuses on reducing (SSI) surgical site infection for orthopaedic patients with external fixators. It will identify sucesses and challenges encountered during implementation of new policy and procedures related to reduction of skeletal pin sites. Positive patient outcomes are achieved through identification and implementation of evidence-based prevention measures pertaining to Surgical Site Infection (SSIs) to provide orthopaedic nurses with the knowledge base needed to effectively deliver high quality, continuity of care among patients undergoing surgery of the musculoskeletal system. The target audience is any professional interested in implementing surgical skin site infection protocols to provide positive patient outcomes.

Skeletal pins or wires are inserted into the bone through skin incisions. Some pins and wires penetrate through the bone and exit on the other side of the extremity; other pins penetrate just into the bone. When pins or wires are attached to a rigid external frame, an external-fixator system is created. The assumption has been that the open wound around the pin is a potential portal for entry of bacteria into the pin tract. Skeletal pins located in soft tissue area are at greater risk for infection. Skeletal pins could be sited into the cranium, pelvis and upper or lower extremities. 

ARMC does not currently have a policy and procedure pertaining to skeletal pin care. ARMC orthopedic surgeons have an order set that provides 2 options for cleansing solutions: 100% peroxide & 50% peroxide-50%sterile water solutions. There is wound research (2002) (in vivo and in vitro) showing that hydrogen peroxide and Betadine at certain concentrations may be cytotoxic to osteoblasts and damaging to healthy tissue. Chlorhexidine has been proven to be more effective in preventing SSIs when compared to iodine-based solutions (Digison, 2007) Chlorhexidine 2 mg/mL solution is considered to be the most effective cleansing solution for skeletal pin site care (Holmes & Brown, 2005). Recent guidelines from the Orthopedic Nursing Society (2013) support change in pin care cleansing solutions from peroxide to chlorhexidine. With hybrid (EMR) electronic medical record systems, change in ordersets for pin site care involve new policy and procedure implementation: supported by input from Orthopedic Surgeons, Nursing, Pharmacy, Purchasing and Clinical Informatics. This abstract chronicles the process to undergo implementing change in best practice in skeletal pin site care; highlighting the  efforts of the professionals involved in this endeavor. Positive patient outcomes in surgical skin site infection prevention is the measurable goal.

References

Holmes, S. & Brown, S. (2005). Skeletal pin site care: National Association of Orthopaedic Nursing guidelines for orthopaedic nursing. Orthopaedic Nursing, 24(2), 99-107

Lethaby A, Temple J, Santy-Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD004551. DOI: 10.1002/14651858.CD004551.pub3.

Kaysinger, K. K., Nicholson, N. C., Ramp, W. K., & Kellam, J. F. (1995). Toxic effects of wound irrigation solutions on cultured tibae and osteoblasts. Journal of Orthopaedic Trauma, 9(4), 303–311.

Rabenberg, V. S., Ingersoll, C. D., Sandrey, M. A., & Johnson, M. T. (2002). The bactericidal and cytotoxic effects of antimicrobial wound cleansers. Journal of Athletic Training, 37(1), 51–54.

Smith, M & Dahlen, N. (2013). Clinical Practice Guideline Surgical Site Infection Prevention. Orthopaedic Nursing, 32(5), 242-248.