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The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden

Annette Erichsen Andersson126*, Ingrid Bergh3, Jón Karlsson45, Bengt I Eriksson45 and Kerstin Nilsson1

Author Affiliations

1 University of Gothenburg, The Sahlgrenska Academy, Institute of Health and Care Sciences, Gothenburg, Sweden

2 Department of Anesthesia, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden

3 University of Skövde, School of Life Sciences, Skövde, Sweden

4 Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden

5 University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden

6 Department of Anesthesiology/Surgery, Sahlgrenska University Hospital/Östra, Smörslottsgatan 1, Gothenburg, SE-416 85, Sweden

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Patient Safety in Surgery 2012, 6:11  doi:10.1186/1754-9493-6-11

Published: 14 June 2012



Current knowledge suggests that, by applying evidence-based measures relating to the correct use of prophylactic antibiotics, perioperative normothermia, urinary tract catheterization and hand hygiene, important contributions can be made to reducing the risk of postoperative infections and device-related infections. The aim of this study was to explore and describe the application of intraoperative evidence-based measures, designed to reduce the risk of infection. In addition, we aimed to investigate whether the type of surgery, i.e. total joint arthroplasty compared with tibia and femur/hip fracture surgery, affected the use of protective measures.


Data on the clinical application of evidence-based measures were collected structurally on site during 69 consecutively included operations involving fracture surgery (n = 35) and total joint arthroplasties (n = 34) using a pre-tested observation form. For observations in relation to hand disinfection, a modified version of the World Health Organization hand hygiene observation method was used.


In all, only 29 patients (49%) of 59 received prophylaxis within the recommended time span. The differences in the timing of prophylactic antibiotics between total joint arthroplasty and fracture surgery were significant, i.e. a more accurate timing was implemented in patients undergoing total joint arthroplasty (p = 0.02). Eighteen (53%) of the patients undergoing total joint arthroplasty were actively treated with a forced-air warming system. The corresponding number for fracture surgery was 12 (34%) (p = 0.04).

Observations of 254 opportunities for hand hygiene revealed an overall adherence rate of 10.3% to hand disinfection guidelines.


The results showed that the utilization of evidence-based measures to reduce infections in clinical practice is not sufficient and there are unjustifiable differences in care depending on the type of surgery. The poor adherence to hand hygiene precautions in the operating room is a serious problem for patient safety and further studies should focus on resolving this problem. The WHO Safe Surgery checklist “time out” worked as an important reminder, but is not per se a guarantee of safety; it is the way we act in response to mistakes or lapses that finally matters.