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preventing surgical site infections in the diabetic cardiac surgical patient

Preventing Surgical Site Infections in the Diabetic Cardiac Surgical Patient

Paula Pintar BSN, RN

Alverno College – MSN Student

Tutorial Project Spring 2010

navigation of tutorial
Navigation of Tutorial

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This button will return you to the previous slide.

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tutorial menu
Tutorial Menu



Stages of Surgical

Wound Healing

Activation of

Stress Response

And Surgery


Elements &

Nsg. Interventions


Site Infection

What is it?

Age &

Wound Healing

Key Risks


Wound Healing

Case Study

Part 2

Why are Surgical

Site Infections a




Wound Healing

Case Study

Part 1

Tying It All




Diabetes Mellitus



Wound Healing

Best Practice




Click on the button you would like to view more

information about.

learning objectives
Learning Objectives

The Learner Will:

Identify criteria used for classifying a surgical site infection (SSI).

Identify why Surgical Site infections are a problem.

Review of Diabetes Mellitus and the genetic link of incidence.

Identify what risk factors can put Diabetic patients at a higher risk to developing a Surgical Site infection.

Review the three main stages of wound healing: Inflammation, Proliferation, Remodeling.

Be able to correlate the factors of Age, Inflammation, and the Generalized Stress Response in the diabetic patient; relate how these factors impact the stages of wound healing.

Review Best Practice Standards and Nursing interventions for a Surgical Site infection prevention plan.

Apply Nursing indicators to a case study.

Understand how applying “best practice guidelines” will support positive outcomes for the patient, family, staff, health system, and community.

surgical site infection ssi what is it
Surgical Site Infection (SSI)What Is It?

Clinical and laboratory signs of infection at the surgical site within:

30 days of the surgery or

Within 1 year if an implant was used (heart valve/joint)

Criteria for Defining a Surgical Site Infection (SSI) Documented at various tissue levels:

Superficial (skin/subcutaneous)

Deep (soft tissue/muscle)

Deep/organ space (organ space)

Caused by:

Endogenous bacteria – patients’ own skin flora

Exogenous bacteria – environmental bacteria or surgical material

Source: 1

ssi as defined by the cdc
SSI As Defined by the CDC
  • Superficial
  • Infection within 30 days after procedure
  • Involves the skin and subcutaneous tissue (and meets one of the following criteria)
    • Has purulent drainage
    • Organisms cultured from fluid or tissue
    • Displays at least 1 of the following pain, local swelling, redness, and incision is opened by surgeon
    • Diagnosis of superficial incision SSI by the surgeon or attending MD


ssi as defined by the cdc7
SSI As Defined by the CDC
  • Deep Incisional SSI
    • Occurs within 30 days of procedure
    • 1 year if implant
    • Involves deep soft tissue ( fascial and muscle layers)
      • And patient displays at least one of the following
        • Purulent drainage
        • Spontaneously dehisces or opened by the surgeon and the patient has at least one of the following:
        • Fever, pain, abscess, or diagnosis by MD

Source: 1

ssi as defined by the cdc8
SSI As Defined by the CDC
  • Organ space
    • Occurs with in 30 days
    • 1 year if implant used
    • Includes any part of the body excluding skin, fascia, or muscle layer.
      • Must meet the following criteria
        • Purulent drainage from a drain that is place through a stab wound
        • Isolated organisms from an aseptic culture
        • Abscess
        • Diagnosis by MD

Source: 1

lets review
Lets Review
  • What are the 3 tissue levels of a Surgical Site









surgical site infection why is it a problem
Surgical Site InfectionWhy Is It A Problem?
  • According to the Institute for Healthcare Improvement (IHI)
  • 38% of all Healthcare Associated Infections are SSI’s
  • 2 – 5% of patients operated on will develop an SSI
  • Developing an SSI will extend the hospital stay by 5 to 7 days
  • One SSI will increase cost by $2,734 - $26,019 (estimated on 1985 dollars)
  • Estimated national costs of 130 million to 845 million dollars spent a year on SSI’s.

Source: 1

what does this mean at a local level
What Does this Mean at a Local Level?

Higher cost related to longer stays

Decreased patient turnover translates into less income for healthcare facility

Healthcare facility develops a reputation of poor patient outcomes.

Decreased reimbursement by The Centers for Medicare and Medicaid (CMS) as of October 1, 2008 stopped reimbursement for hospital acquired infections

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Source: 16

what does this mean at a local level12
What Does this Mean at a Local Level?
  • Negative Outcomes Linked to SSI’s
  • Trend is toward public reporting of infection rates for healthcare facilities.
  • This will impact consumer decisions as to where they will go to have procedures performed.
  • Consumers have greater access to information - Intranet
  • Milwaukee has number of facilities with duplicative resources. Patients may begin shopping around for facility with lowest infection rates.

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Source: 16

lets review13
Lets Review
  • According to the Institute for Healthcare Improvement (IHI)

38% of all Healthcare Associated Infections are SSI’s.

  • Developing an SSI will extend

the hospital stay by 5 to 7 days.

  • Increased reimbursement by

The Centers for Medicare and Medicaid (CMS)

as of October 1, 2008 started for

hospital acquired infections.

  • Trend is toward public reporting

of infection rates for healthcare facilities.









now with the problem identified
Lets take a closer look at a patient population (diabetes mellitus), and apply nursing indicators and medical knowledge to decrease and prevent the development of Surgical Site Infections. Now With The Problem Identified…

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significance of diabetes mellitus
Significance of Diabetes Mellitus

Diabetes mellitus affects approximately 2.8 million people in the United States

The disease is a metabolic process that results from a lack of insulin secretion or action.

Insulin is a hormone that is secreted by the beta cells in the pancreas.

This hormone then allows the cells in our body to absorb the glucose and convert it into energy to maintain metabolic processes.

There are two main types of diabetes mellitus that the majority of diabetics are classified into.

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Source: 6

diabetes mellitus genetic link
Diabetes Mellitus & Genetic Link

Type 1:

This is characterized by an complete lack of insulin secretion and elevated blood sugar, related to destroyed pancreatic beta cells (6)

Usually occurs at an early age (childhood)

5 to 10% of the diabetic population have this type of diabetes (~ 1 million people) (6)

These individuals have been associated with an autoimmune link to the disease. (4)

This autoimmune response is the cause of beta cell destruction (4)

The other factor identified is an exposure to an environmental mediator, such as having an infection. (6)

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Source: 4, 6

diabetes mellitus age link
Diabetes Mellitus & Age Link

Type 2 :

This is characterized by having insulin resistance

Approximately 90 to 95% of diabetics present with this type (~19 million people)

18 -20% of persons 65 and older have diabetes

40% have the disease or precursor to disease

Obesity and older individuals is commonly associated with Type 2

There is multiple hypothesis as to the causal agents of this form.

Due to the variability of the causal agents, it is difficult to predict or identify specific factors that lead to disease.

It is known that autoimmune destruction of the beta cells, as in Type 1 does not occur.

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Source: 6

diabetes mellitus link to developing an ssi
Diabetes Mellitus & Link to Developing an SSI
  • Studies correlating elevated levels of hemoglobin A1C 6.5 (HgA1C) and uncontrolled blood sugars in the postoperative period have had a higher incidence of postoperative wound infections.
    • Blood glucose levels >200mg/dL in immediate postoperative period and up to 48 hours post operatively are a key link to SSI development.
    • Phagocyte activity is altered by the elevated blood glucose levels.

Source: 6

lets review19
Lets Review
  • What is the key reference data used to monitor blood sugar stability over time?

K level


In Correct


C reactive protein

Hgb A1C

Finger stick glucose

Blood pressure

Urine glucose

review of the surgical wound healing process
Review of the Surgical Wound Healing Process

There are 3 main stages of wound healing

1. Inflammation

2. Proliferation

3. Remodeling

Within each stage there is a complex system of cellular functions that occur. (5)

Factors that can impede good wound healing are:

Poor diet/uncontrolled blood sugars

Compromised blood flow

Disruption of inflammatory response


Effects of age (14)

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Source: 5,14

surgical wound healing stages
Surgical Wound Healing Stages

Stage 1 Inflammatory (acute)

Incision – initial vasoconstriction followed by platelet aggregation to damaged endothelium (14)

Followed by a dilation of capillaries

Around 24 hours macrophages enter the area and remain there to clean up cellular debris and stimulate the healing process (5)

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Source: 5,15

surgical wound healing stages22
Surgical Wound Healing Stages

Stage 2 – Proliferation

24-48 hours after wound occurrence the fibroblast and vascular endothelial cells begin formation (5)

This is a fragile period for the wound due to new capillary growth (14)

Then formation of new dermal layers begins (14)

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Microsoft Clipart

Source: 5,15

review of surgical wound
Review of Surgical Wound

Stage 3 – Remodeling

Occurs post wound by about week 3

Formation of a scar develops

During this process the healing wound experiences a decrease in vascularization with the continuing development of scar tissue.

Source: 14

lets review24
Lets Review

Stages of Wound Healing

Stage Definition


New capillary growth


Wound stabilization

Debris removal


Click on stage definition

age wound healing
Age & Wound Healing
  • Immunosenescence or age-related changes impact the immune system, putting these individuals at a higher risk for infection.
  • By age 50 the thymus gland has decreased in size.
  • The function of the helper T cells deteriorates
  • Which in turn prolongs the inflammation phase of wound healing.
  • During cardiopulmonary bypass blood cells are “bypassed” in normal circulation. This activates the cytokine response and activation of the phagocyte cells.

Stages of Wound Healing




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inflammation wound healing
Inflammation & Wound Healing

Stages of Wound Healing




  • The key mediators in inflammation are Cytokines & Chemokines
  • These proteins activate the macrophages and lymphocytes.
  • Other contributing risk factors are high blood pressure, altered platelet function, systemic inflammation noted by elevated C-reactive protein.
  • There is a thickening of the blood vessel walls that supply nerves. This causes a decreased blood supply to tissues.
  • Elevated blood glucose levels cause damage to small blood vessels. In time this causes defects in the cell structure at the microcirculation level.

Source: 14

genetics wound healing
Genetics & Wound Healing
  • Diabetes has the genetic disease link that contributes to poor wound healing.
  • Hyperglycemia will affect phagocyte function by lessening the chemotaxic and phagocytic action of the neutrophils.

Source: 14

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a closer look at the generalized stress response gsr dm and ssi
A Closer Look at the Generalized Stress Response (GSR), DM and SSI
  • During periods of stress such as surgery and anesthesia
  • There is an increase release of growth hormones
  • With this response there is a mobilization of fatty acids from the adipose tissue.
  • This decreases the cellular utilization of glucose causing a rise in blood glucose levels
  • During periods of stress, diabetic patients react with a variety of metabolic processes despite optimal insulin management

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Source: 7

review of the gsr
Review of the GSR
  • GSR – also known as “fight or flight response”
  • It is the sympathetic nervous system release of Catecholamine's:
    • epinephrine
    • adrenalin
  • The elderly individual has a slower response to epinephrine and it takes them longer to recover from its effects.
  • Excretion of these catecholamine's is also slower.
  • Lets take a closer look at what happens to blood sugar in response to stress response. (next slide)

Source: 15

action of the gsr
Action of the (GSR)

Click on

each object in order




Adrenal medulla

Releases Epinephrine



Blood Glucose is the

Body’s goal


Liver releases glucose

into blood


Release of fatty acid

from the fat cells


Stops insulin release

from beta cells

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of glycogen stores


Decrease glucose


into muscles

Source: 15

generalized stress response dm
Generalized Stress Response & DM

The Diabetic patient experiencing stress will have added risk to SSI development

Sporadic, transient increases of cortisol can affect blood sugar control

There is an increased secretion of cortisolin response to stress, (it can cause damage to brain neurons over time) if the levels become too high.

This is a Positive feedback system – an example of this is when an elderly person secretes cortisol in response to stress. Repeated exposure to the neurons causes the damaged. Therefore the neurons can no longer sense the level and the hypothalamus continues to secrete the hormone.

To view graphic of Positive Feedback

System, click HERE

Source: 15

graphic of generalized stress response
Graphic of Generalized Stress Response

Positive Feedback System

Source: 15

wound healing increased risk of ssi occurrence
Wound Healing & Increased Risk of SSI Occurrence

There is a 20% decrease in the dermal layer

This translates into less strength and elasticity

Blood vessels supplying the dermis are also more fragile

These conditions translate into a decrease of vascular circulation with a decrease in oxygen delivery to the wound site.

Elderly persons have stiffer arteries and narrower capillaries which will accentuate the effects of diabetes

Stages of Wound Healing




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Source: 14

a closer look at the who what and why of ssi development
A Closer Look at the Who, What, and Why Of SSI Development
  • Early detection of infection is difficult as aged (65 or older) individuals present with atypical signs and symptoms: lack of elevated white blood cell count and temperature
  • Persons with diabetes mellitus have neuropathic and peripheral vascular disease which will impact circulation to the wound site.
  • Age is a predisposing factor resulting in decreased function of systems with an increased susceptibility to stressors.

Stages of Wound Healing





case study part 1
Case Study – Part 1

Lets apply this knowledge to a case study:

65 year old Caucasian, widowed female who is overweight (101 kg.) has a sedentary life style and lives alone.

She has had poor medical care due to lack of financial resources.

She thinks she recalls a doctor telling her in the past that she may have diabetes or “something.”

The patient is now in the Cardiovascular Surgical Intensive care unit following surgery of a 4 vessel myocardial revascularization.

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case study part 136
Case Study – Part 1

Post operative day #1 Patient presents with the following:

Elevated blood glucose for the last 4 assessments: 190, 200,207,195

Fatigue and difficult to arouse

Low blood pressure :100/60

Sinus tachycardia: 120 bpm

Urine output: 25-30cc/hr

Low grade temperature: 99.1 blood temp

Slight elevated white blood cell count: 11,000

Elevated C-reactive protein (CRP) level: 2

Decreased bilateral pedal pulses: + 1

Cool bilateral lower leg extremities: new on assessment

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case study part 137
Case Study – Part 1

Indicators that may lead to an SSI




Unstable blood sugars


Lack of family support

Risk Factors



Low grade temperature

Decreased pedal pulses

Cool lower leg extremities





Sinus tachycardia

Increased WBC

Decreased urine output

Increased CRP

Click an indicators on the right to see what

Physiological system they belong to.

best practice standards bundle elements
Best Practice Standards – “Bundle” Elements
  • A “Bundle” is a group of researched based best practice interventions.
  • It is shown that when bundle elements are implemented together patient outcomes improve.

Source: 2

best practice standards bundle elements39
Best Practice Standards – “Bundle” Elements

Strict adherence to hand hygiene

Treat all remote infections to the elective surgical site prior surgery

Do not shave hair at surgical site, but use clippers. This will cause less microabraisions to the skin.

Control serum blood sugar levels, avoid hyperglycemic states.

Recommend stopping tobacco use

Antiseptic showers prior surgical procedure

Use appropriate surgical skin prep

Surgical team hand & forearm antisepsis

Administration of appropriate antimicrobial prophylaxis drug at the correct time, and dose prior surgical incision (30min.)

Source: 2

bundle elements nursing interventions
Bundle Elements & Nursing Interventions

Pre-surgical baths have shown to decrease skin flora and multi-drug resistant bacteria (MDRO's) such as Methicillin resistant Staphaureus, vancomycin resistant Enterococci that may lead to surgical site infections.

Most SSI’s are caused by the patients own bacterial flora

20% Staphylococcus aureus

14% Coagulase negative staphylococcus

12% Enterococci

Source: 2

bundle elements nursing interventions41
Bundle Elements & Nursing Interventions

Glucose control intra-operative and postoperative (target less than 200 mg/dL)

Unstable blood sugars affect the neutrophils ability to provide adequately functioning phagocytes

Maintaining the postoperative dressing for 24-48 hours

This is a critical time period when wound site is gaining stability in cellular repair and revascularization.

Source: 10

bundle elements nursing interventions42
Bundle Elements & Nursing Interventions

Appropriate surgical antimicrobial prophylaxis given at:

The appropriate time – 30 minutes prior cut time

Provides a therapeutic blood & tissue level of antibiotic at time of surgery

Appropriate dosage – weight based. Repeat dose if surgery extends past the ½ life of the drug

Appropriate agent – for gram negative and gram positive organisms

Discontinue antibiotic 24 hours post surgery – assists in decreasing resistance. Doses past 24 hour time frame of wound closure have not proven beneficial.

Source: 1, 3

bundle elements nursing interventions43
Bundle Elements & Nursing Interventions

Clipping surgical site in place of shaving

Eliminates micro abrasions to the skin that provides an entry portal for microorganisms

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Source: 2

bundle elements nursing interventions44
Bundle Elements & Nursing Interventions

Maintain normothermia (greater that 36.0 Celsius) pre, intra, and postoperatively

Decreases vasoconstriction in blood vessels.

Normothermia will promote the blood flow and oxygen delivery to the cells

Fosters immune function preservation

If normothermia maintained produces less overall stress to diabetic patient

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Source: 9

let s review
Let’s Review
  • Bundle elements produce better patient outcomes.
  • Application of bundle practices are researched based.
  • Using appropriate antibiotic therapy is a key bundle component.







what s new not much
What’s New?...Not Much!
  • Decreased emphasis and incentive for drug manufactures to develop new generations of antimicrobials to treat infections.
  • More deaths related to Methicillin-resistant Staphylococcus aureus (MRSA) in U.S. facilities than from HIV/AIDS & Tuberculosis combined.
  • Only 83 antibacterial in clinical trials – very small number in late stage testing
  • Only 5 pharmaceutical companies still support antibacterial programs.

Source: 3

antibiotic manufacturing strategies
Antibiotic Manufacturing Strategies
  • Infectious Disease Society of America (ISDA) is working on a plan in cooperation with the pharmaceutical industry and academia to create and sustain research and a long term plan.
    • Incorporate big pharmacies, and small entities
    • Create incentives for pharmaceutical companies to participate in antibiotic research and development.

Source: 3

case study part 2
Case Study – Part 2

Lets apply this knowledge to our case study:

Post operative surgical day #3 Assessment findings:

Blood Sugar range 185-220 over last 48hours

Temp. 99.1-100.9(oral ranges)

WBC 11,000

CRP level 3

Sternal incision warm, red, small opening at bottom draining creamy white fluid

Wound culture showing Moderate PMS’s & Moderate colonies of Staphylococcus aureus

Fatigues easily

Stable SBP, Sinus tachycardia (105-110bpm), U.O. 30cc/hr

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case study part 249
Case Study – Part 2

Diabetes affect 2.8 million people in the United States. Identify three case study laboratory results that may be indicators of an SSI.

Temperature, WBC, CRP, U.O., Positive wound culture, Fatigue

What assessment finding is a response to activation of the Generalized Stress Response?

Increased Heart Rate, Warm draining wound, Positive wound culture

During cardiovascular revascularization surgery, what process causes a cytokine response?

The process of “bypass”, anesthesia, maintaining normothermia

In reference to question 3, what stage of wound healing is critical to a diabetic with uncontrolled blood sugars?

Inflammation, Proliferation, Remodeling

How is the proliferation stage of wound healing affected by diabetes?

Microcirculation, cellular regeneration , decrease in metabolic needs

What three nursing interventions can be initiated to help decrease the risk of patients developing an SSI?

Hand Hygiene, Blood glucose control, Maintaining normothermia, quick ventilator weaning, frequent turning of patient

tying it all together
Tying It All Together
  • Surgical Site Infections affect patients, families, hospital systems, and communities.
  • They add to personal pain and suffering, mortality and financial burdens.
  • Research has identified that using the “Bundle” method of preventive measures is more effective in preventing SSI’s than when elements are applied inconsistently and individually.
  • Diabetics are at a higher surgical risk due to the inflammation correlation process of their disease.
tying it all together51
Tying It All Together
  • Nursing Interventions
  • Key “take away” – Astute assessments and documentation of subtle indicators
    • Hand hygiene before all patient cares, tight control of blood sugars, slight elevated WBC, mental status changes, low grade temps, maintain surgical wound dressing in place for 24 – 48 hours.

Barnard, B. (2003). Best practices prevention of surgical site infections. Infection Control Today, 1-6. Retrieved February 23, 2010 from

Beaver, M. (2008). CABG wound are best practices are elusive. Infection Control Today, 1-4. Retrieved February 23, 2010 from

Boucher, H.W., Talbot, G.H., Bradley, J.S., Edwards, J.E., Gilbert, D., Reice, L.B., etal. (2009). Bad bugs, no drugs: no ESKAPE! An update from the infectious diseases society of america, 48, 1-12. Infectious Disease Society of Americal

Connection diabetes and inflammation. Science Daily, 1-2. Retrieved March 22, 2010, from

De la Torre, J. & Chambers, J.A. (2008). Wound healing, chronic wounds. Plastic Surgery, 1-5. Retrieved March 21, 2010, from the Medsape database.

Diagnosis and classification of diabetes mellitus. American Diabetes Association, 1-11. Retrieved March 15, 2010, from

Engelic, G., Wright, D.G., Hartshorn, K.L. (2001). Acquired disorders of phagocyte function complicating medical and surgical illness. Clinical Infectious Diseases, 33, 2040-8.

Kurz, A. Sesslelr, D.I., Lenhardt, R. (1996). Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospitalization. New England Journal of Medicine, 334, 1309-1216. Retrieved March 26, 2010, from


Mercandetti, M. & Cohen, A.J. (2008) Wound healing, healing and repair. Plastic Surgery, 1-5. Retrieved March 26, 2010, from Medscape database.

Microsoft clipart online.

Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al (Ed.), Concepts of altered health in order adults (pp.36-55). Philadelphia, PA:Wolters Kluwer Health/Lippincott Williams & Wilkins.

Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al (Ed.), Diabetes mellitus and the metabolic syndrome (pp. 1047-1077). Philadelphia, PA:Wolters Kluwer Health/Lippincott Williams & Wilkins.

Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al (Ed.), Inflammation, tissue repair, and wound healing (377-399). Philadelphia, PA:Wolters Kluwer Health/Lippincott Williams & Wilkins.

Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al (Ed.), Stress and adaptation (198-238). Philadelphia, PA:Wolters Kluwer Health/Lippincott Williams & Wilkins.

Stone, P.W., (2009). Changes in medicare reimbursement for hospital-acquired conditions including infections. Association for Professionals in Infection Control and Epidemiology, 37, 12!-18A.

Swenson, B.R., Hedrick, T.L., Mezger, R., Bonartt, H., Ruett, T.L., Sqwyefr, R.G. (2009). Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin prparitn protocols. Infection Control and Hospital Epidemiology, 30, 964-971.

the end
The End

Thank you for your attention and participation!