The 7S Bundle: Key Components for Surgical Stewardship
1. Safe Operating Room Practices
Evaluate the safety and adherence to best practices within the operating room (OR) environment. Key elements include traffic control, minimizing the number of personnel in the room, and compliance with surgical attire standards. Ensure proper surgical hand antisepsis and use of alcohol-based skin preparation agents. Additional priorities include effective sterilization of instruments; routine monitoring and preventive maintenance of air handling systems; timely administration of surgical antimicrobial prophylaxis; and maintenance of patient normothermia before and during surgery. Hair removal, when indicated, should be performed using clippers (not razors) and ideally outside the OR. The use of wound protectors, meticulous tissue handling, environmental cleaning during room turnover and terminal cleaning, and safe medication handling and storage practices are also essential components of a safe surgical environment.
2. Screen - MRSA, MSSA and Risk Factors
Consider preoperative screening for Staphylococcus aureus (MRSA and MSSA) in patients undergoing high-risk inpatient surgery, along with assessment of relevant risk factors. such as diabetes, immunosuppression, obesity, cardiac conditions, previous surgery, previous infections, skin conditions, and other risk factors per surgical specialty.
Rapid diagnostic technologies, such as polymerase chain reaction (PCR), may be utilized to facilitate timely identification and intervention within 1 hour. Institute a pre-op decolonization protocol 5-days prior to surgery, that includes nasal antiseptic (alcohol based, iodine based, antibiotic mupirocin (Bactroban) and daily chlorhexidine body wash.
Surgeon should adjust the preoperative antibiotic prophylaxis for MRSA positive patients to an effective antibiotic, such as Vancomycin, that must be infused over a 60-minute pre-op time interval.
3. Shower (Preoperative Cleansing and Decolonization)
Instruct patients undergoing inpatient and outpatient surgery to perform preoperative bathing with soap and water, chlorhexidine gluconate (CHG) liquid solution, or CHG-impregnated cloths on the night before and the morning of surgery. In addition, consider universal nasal decolonization in the preoperative holding area. The use of nasal antiseptics—such as alcohol-based formulations or iodine-based products—has been associated with reductions in SSI risk.
4. Skin Antisepsis
Utilize alcohol-based antiseptic skin preparation solutions, including combinations such as CHG/alcohol or iodine/alcohol. Products with persistent antimicrobial activity may provide additional benefit in reducing microbial burden at the surgical site. Allow 3-minutes drying time to prevent fires - longer dry times may be necessary for neurosurgery where hair is involved.
5. Surgical Irrigation
Apply the principle that “the solution to pollution is dilution” by considering the use of antiseptic irrigation solutions to reduce contamination within the surgical field. For example, dilute antiseptic irrigants (e.g., sterilely prepared 0.05% chlorhexidine solutions pr iodine prepared solutions) may be used to remove debris and flush exogenous microbial contaminants prior to closure. Routine use of antibiotic irrigation solutions is not recommended since research has not demonstrated a reduction in SSIs.
6. Sutures - Antibacterial Coated with Triclosan
Use antibacterial coated sutures, impregnated with triclosan, as supported by CDC, WHO, SHEA, ACS, NICE and other SSI prevention guidelines, to reduce the incidence of surgical site infections by approximately 30%.
7. Skin Incisional Protection
Protect the surgical incision postoperatively with the use of topical skin adhesives (cyanoacrylate) to create a sealed microbial barrier that protects the incision for up to 10 days. Wit same day surgeries being performed for many surgeries this can provide a safe barrier from exogenous contaminates in the post-op setting (ex. home, rehab). If the patient is allergic to adhesives and cyanoacrylate products apply advanced dressings containing antibacterial agents (e.g., Silver-plated, PHMB). These measures may be maintained throughout hospitalization and into the postoperative period, as appropriate.
Summary
The 7S Bundle provides a surgical stewardship, structured, evidence-based approach to SSI prevention by addressing key perioperative risk factors across the surgical continuum. Each component should be evaluated and adapted based on organizational needs, patient population, and evolving evidence.
1. Safe Operating Room Practices
Evaluate the safety and adherence to best practices within the operating room (OR) environment. Key elements include traffic control, minimizing the number of personnel in the room, and compliance with surgical attire standards. Ensure proper surgical hand antisepsis and use of alcohol-based skin preparation agents. Additional priorities include effective sterilization of instruments; routine monitoring and preventive maintenance of air handling systems; timely administration of surgical antimicrobial prophylaxis; and maintenance of patient normothermia before and during surgery. Hair removal, when indicated, should be performed using clippers (not razors) and ideally outside the OR. The use of wound protectors, meticulous tissue handling, environmental cleaning during room turnover and terminal cleaning, and safe medication handling and storage practices are also essential components of a safe surgical environment.
2. Screen - MRSA, MSSA and Risk Factors
Consider preoperative screening for Staphylococcus aureus (MRSA and MSSA) in patients undergoing high-risk inpatient surgery, along with assessment of relevant risk factors. such as diabetes, immunosuppression, obesity, cardiac conditions, previous surgery, previous infections, skin conditions, and other risk factors per surgical specialty.
Rapid diagnostic technologies, such as polymerase chain reaction (PCR), may be utilized to facilitate timely identification and intervention within 1 hour. Institute a pre-op decolonization protocol 5-days prior to surgery, that includes nasal antiseptic (alcohol based, iodine based, antibiotic mupirocin (Bactroban) and daily chlorhexidine body wash.
Surgeon should adjust the preoperative antibiotic prophylaxis for MRSA positive patients to an effective antibiotic, such as Vancomycin, that must be infused over a 60-minute pre-op time interval.
3. Shower (Preoperative Cleansing and Decolonization)
Instruct patients undergoing inpatient and outpatient surgery to perform preoperative bathing with soap and water, chlorhexidine gluconate (CHG) liquid solution, or CHG-impregnated cloths on the night before and the morning of surgery. In addition, consider universal nasal decolonization in the preoperative holding area. The use of nasal antiseptics—such as alcohol-based formulations or iodine-based products—has been associated with reductions in SSI risk.
4. Skin Antisepsis
Utilize alcohol-based antiseptic skin preparation solutions, including combinations such as CHG/alcohol or iodine/alcohol. Products with persistent antimicrobial activity may provide additional benefit in reducing microbial burden at the surgical site. Allow 3-minutes drying time to prevent fires - longer dry times may be necessary for neurosurgery where hair is involved.
5. Surgical Irrigation
Apply the principle that “the solution to pollution is dilution” by considering the use of antiseptic irrigation solutions to reduce contamination within the surgical field. For example, dilute antiseptic irrigants (e.g., sterilely prepared 0.05% chlorhexidine solutions pr iodine prepared solutions) may be used to remove debris and flush exogenous microbial contaminants prior to closure. Routine use of antibiotic irrigation solutions is not recommended since research has not demonstrated a reduction in SSIs.
6. Sutures - Antibacterial Coated with Triclosan
Use antibacterial coated sutures, impregnated with triclosan, as supported by CDC, WHO, SHEA, ACS, NICE and other SSI prevention guidelines, to reduce the incidence of surgical site infections by approximately 30%.
7. Skin Incisional Protection
Protect the surgical incision postoperatively with the use of topical skin adhesives (cyanoacrylate) to create a sealed microbial barrier that protects the incision for up to 10 days. Wit same day surgeries being performed for many surgeries this can provide a safe barrier from exogenous contaminates in the post-op setting (ex. home, rehab). If the patient is allergic to adhesives and cyanoacrylate products apply advanced dressings containing antibacterial agents (e.g., Silver-plated, PHMB). These measures may be maintained throughout hospitalization and into the postoperative period, as appropriate.
Summary
The 7S Bundle provides a surgical stewardship, structured, evidence-based approach to SSI prevention by addressing key perioperative risk factors across the surgical continuum. Each component should be evaluated and adapted based on organizational needs, patient population, and evolving evidence.
| SSI Assessment Tool 2022.pdf |
| Spencer M et al Perioperative_Hair_Removal_-_a_Review_of_Best_Practice_-_Journ_Perioper_Nursing_June_2018.pdf |
| Edmiston_et_al-2018- AORN Journal_-_An_Incision_Closure_Bundle_for_Colorectal_Surgery.pdf |
| Spencer M et al Reduction in Colon SSI using a CHG Surgical Irrigant AORN Conference Poster April 2017df |
| 7 S Bundle for Prevention of SSIs. APIC Poster 2014.pdf |
| Spencer M et al.Wound Prevalence Observational Study for the Prevention of Surgical Site Infections AORN April 2016 Poster |
| SSI Fishbone_diagram.ppt |
