The issue at hand is the infection of the sternal incision site after a cardiovascular surgery has been performed. There are two different types of sternal wound infections: a superficial sternal wound infection (SSWI) and a deep sternal wound infection (DSWI) (Lazar, Salm, Engelman, Orgill, & Gordon, 2016). “The Centers for Disease Control and Prevention (CDC) has specific criteria that must be met to use these specific classifications, including wound depth and signs of infection” (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61). 

Who is affected?
SWI’s can occur in any individual that undergoes a corrective surgical procedure that aids in stabilizing, or bettering their cardiovascular system. There are also those that are at higher risk of developing this type of infection. Some of the higher risk individuals include those who have: chronic infections, older age, diabetes, a body mass index (BMI) >40, chronic lung disease, and use tobacco (Bell, Hinderer, Winter, & Alessandrini, 2017). Berríos-Torres (2017) explains the CDC guidelines and states, “Surgical patients initially seen with more complex comorbidities and the emergence of antimicrobial-resistant pathogens increase the cost and challenge of treating SSI’s” (para. 1).

How?
A patient can develop a SWI from a variety of different contributing factors. One component is by not following strict hygienic precautions, such as hand hygiene, amongst the staff and the patient themselves. Poor hand hygiene is a risk factor that is present in the preoperative, intraoperative, and postoperative phases of surgery (Bell, Hinderer, Winter, & Alessandrini, 2017). This action alone increases the likelihood of microorganisms being introduced to the surgical site of the sternum. Another contributing element would be the non-application of sternal precautions. Sears (2019) states, “Sternal precautions are used after open heart surgery to avoid pulling apart the breast bone as it is healing. They are meant to protect the patient and prevent possible infection of the healing sternal incision” (para. 1). Other ways the incision site may become infected is through tobacco use and poor glycemic control in diabetic patients; as both behaviors cause delayed surgical wound healing (Bell, Hinderer, Winter, & Alessandrini, 2017).

Where?
A sternal wound infection can develop in both hospital, and home setting. This infectious complication tends to emerge and show signs and symptoms within 30-days of cardiac surgery (Yusuf, Chan, Renz, & Trampuz, 2018). Within these 30-days, the patient is usually discharged early, unless experiencing other postop complications in which continuous hospital monitoring is necessary. Once the patient suspects infection at home, readmission to the hospital is vital.

When?
A sternal wound infection can develop any time during the recovery period after surgery. The healing process of the sternal incision site takes around 4-8 weeks following open heart surgery, or other surgeries involving a sternotomy (Sears, 2019). Typically, either type of sternal wound infection can occur within a 30-day time frame postoperatively (Rickard et al., 2015).

Why?
As stated previously, sternal wound infections can arise in patients following surgery due to varying contributing factors. The most common risk factors include: poor glycemic control in diabetic patients, insufficient hygienic care, and by not following strict sternal precautions after surgery (Bell, Hinderer, Winter, & Alessandrini, 2017).

“The cost of OHS without complications averages around $78,318, although, in some cases, it exceeds $160,000. With SWI, cost increases by 2.8 times” (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61). Cotogni, Barbero, and Rinaldi (2015) explain that costs escalate due to the additional antibiotic treatments and correctional surgical procedures, as well as increased hospital stay time.

The mortality rate of individuals with sternal wound infections may be twice as high as those without. The development of a postoperative sternal infection is not only associated with increased morbidity, but death as well (Meszaros et al., 2016). "Mortality associated with superficial

SWIs ranges from 0.5% to

9%. Mortality associated with

DSWI ranges from 10% to 47%" (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61).

"One study of patients with postoperative SWIs after OHS found that 37% had problems carrying a grocery bag and 67% had problems putting on a coat 6 years or more after their surgery" (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61) .

"Research has shown that the combination of 2% chlorhexidine gluconate and 70% isopropyl alcohol is superior to iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74% w/w) in terms of reducing bacteria from the skin, with decreasing positive culture rates from 65% to 30%" (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 63).

As stated previously, sternal precautions are put into place as protective measures to reduce the incidence of dehiscence, which consequently causes infection. When done correctly, sternal precautions prevent the excessive pulling on the sternal incision (Sears, 2019).

Protective precautions are a type of isolation precaution that is set into place to protect immunocompromised patients who are susceptible to infection. Proper hand hygiene amongst staff and visitors is a vital element of this protocol. There should also be no ill visitors, as well as, dedicated patient specific equipment to help reduce the spread of bacteria (Annual Orientation to Sentara, 2014).

Is this improving or worsening the issue?
Nurses who adamantly follow these steps after a patient undergoes surgery help promote a path for better patient outcomes. 

The nurses that neglect one or all of these duties impact the successfulness of the patient's healing process. Without providing proper care or education to individuals in need, the nurse's disregard ultimately affects the quality of care given.