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TORONTO - Alberta surgeons aren't always following guidelines aimed at minimizing the risk patients will develop an infection as a result of their surgery, a new survey reveals.

And experts in infection control and health-care safety say the findings are probably reflective of surgical practice in other parts of the country as well.

"We have a long ways to go. It's really hit or miss right now whether or not you're going to get all these things done properly," said Marlies van Dijk, a nurse and leader of the Western Canada efforts of Safer Healthcare Now!, a campaign to promote practices that improve patient safety.

"We know that we ought to be doing better," said Dr. Andrew Simor, head of microbiology at Toronto's Sunnybrook Health Sciences Centre.

"And I think this study very neatly shows ... that indeed at least among surgeons in Alberta - and I suspect they're probably representative of surgeons across the country - there is clearly an opportunity for great improvement."

The study was done by researchers in the University of Alberta's medical faculty. Neither van Dijk nor Simor was involved in the study.

The aim was to see if Alberta surgeons were following four evidence-based recommendations for reducing surgical site infections, which are estimated to make up about 17 per cent of all infections people acquire in hospitals.

The guidelines were published by the U.S. Centers for Disease Control in 1999 and three of the four are accepted as essential practice for minimizing infection risks. The evidence is not conclusive for one, the recommendation that patients should be asked to bathe with an antiseptic soap before surgery.

The other three guidelines say surgeons or their surgical team members should remove body hair, if necessary, with clippers, not razors; clean skin with antiseptic products in a prescribed manner before making an incision; and ensure antibiotics given before surgery to lower infection risks are timed appropriately.

The researchers sent out surveys to 589 surgeons registered in the province in the summer of 2006, receiving responses from 247 of them - about 42 per cent. The report on their findings will be published in the December issue of the journal Infection Control and Hospital Epidemiology.

While the results suggest surgeons are in the main following the guidelines, there were some key areas where improvements are needed, suggested Dr. Sarah Forgie, a pediatric infectious diseases specialist and the senior author of the paper.

For instance, 32 per cent of surgeons who responded to the questions about hair removal said they used razors instead of clippers - a clear breach of protocol.

"They shouldn't be shaving with a razor. It should be clippers - 100 per cent. I can't think of a reason why you would do it otherwise," said Philip Hassan, CEO of the Canadian Patient Safety Institute.

Even when handled with care, razors make tiny nicks and abrasions - entry points for bacteria on the skin. In fact, studies have shown a five per cent increase in surgical site infection rates in patients whose hair was shaved rather than clipped.

"I don't know what to think," Forgie said about that finding. "What a lot of hospitals have done is they actually throw out all the razors so that can't happen."

While all surgeons were using recommended antiseptic agents for cleaning the skin before making an incision, about one-third said they applied it by wiping back and forth.

Antiseptics like chlorhexadine or iodine are supposed to be applied in a circular fashion from the intended site of incision outwards, so that any germs on the skin are moved away from where the cut will be made. Wiping back and forth can recontaminate areas after they've been cleaned.

Questions designed to find out how well surgeons were doing at timing the administration of antibiotics for surgery - a procedure known as antibiotic prophylaxis - showed a lot of variability in practice.

The idea behind antibiotic prophylaxis is to load up a person's blood stream and tissues with the drugs just before an incision is made. That's the time when the risk of introducing bacteria into the body is greatest.

Forgie said from the results, it looks as if a number of surgeons worked within systems that saw patients getting the antibiotics earlier than advised.

The guidelines say the drugs should be administered no more than one hour before the cut is made. If the surgery is a long one, additional doses should be given during the procedure. But the drugs should be given at doses that ensure concentrations taper off within a few hours of the end of the operation, with 24 hours considered the outside limit.

"The chances of you getting an infection if your antibiotic isn't given properly is about six to seven times greater," Hassan noted.

Increasing compliance on this front will require the involvement of many members of the surgical team, Forgie and others said. That's because often nurses or anesthetists actually administer the antibiotics, and they may do so based on the scheduled time of a surgery that may end up being delayed.

Or they could be following a surgeon's order that isn't as specific as it needs to be, van Dijk said.

"The order should say 'Give within 60 minutes of incision.' Instead, historically they have said: 'Give on call to OR.' So on the floor the nurse says 'OK, call to OR. Start the IV."'

"Four hours later the guy has his incision.... You never know what's going to happen if it's given that early," she said.

Likewise, many surgeons seem to be ordering doses that keep concentrations of the antibiotics high beyond the 24-hour cutoff. That raises the risk patients will develop antibiotic resistant infections.

"If you give more you're not doing any good, but you're increasing the risk of side-effects, C. difficile, things like that," Simor said.

The survey also found that only 23 per cent of surgeons recommended their patients bathe before surgery with an antiseptic soap.

But Forgie said she wasn't worried about that finding. While it has been shown that bathing with antiseptic soap lowers the bacterial count on a person's skin, studies haven't shown that the practice actually lowers rates of surgical site infections.