SRG-POL-003: Surgical site infection prevention

Policy · SRG-POL-003 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 2.3

At a glance

Every procedure follows the surgical site infection prevention bundle.
The bundle is a set of checkable practices, not general good intentions.
Compliance is checked and reported each month.
Infections are recorded and reviewed.
Stop and get help straight away if: a procedure is started without the bundle, or a surgical site infection is found with no review.

1. Purpose

To prevent surgical site infections with a set of practices that can be checked (2.3).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

Infections after surgery are preventable with a set of checkable practices. A bundle, followed for every procedure and measured, is what makes prevention real.

5. Responsibilities

Role	Responsibility	Competence
Infection prevention lead	Owns the bundle and the surveillance	Clinician
Theatre manager	Checks compliance each month	Management

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Prepare the patient.

Apply the bundle before surgery: hand hygiene, skin preparation, hair removal only where needed, and antibiotic timing.

Key point: Before the first cut.

Step 2. Keep the field clean.

Follow the sterile technique checklist during the case and record any break.

Key point: A break is recorded.

Step 3. Check and report.

Check compliance each month (SRG-FRM-004) and report it to the infection control committee.

Key point: Measured, not assumed.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Procedures with the bundle completed	At least 90%	Monthly	Infection prevention lead	Escalate to chief executive
Surgical site infections reviewed within 7 days	100%	Monthly	Infection prevention lead	Escalate to chief executive

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
SRG-SOP-003	Surgical site infection prevention bundle	Procedure
SRG-FRM-004	Surgical site infection bundle compliance record	Record
HH-SOP-001	Hand Hygiene at the Point of Care	Hand hygiene

17. Evidence

Reference	Note
E-009	Based on the WHO Global Guidelines for the Prevention of Surgical Site Infection (2018).
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

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References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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