Uçkay et al9 conducted a comprehensive literature search using National Library of Medicine Medical Subject Headings (MeSH) terms infection, orthopedic, and prevention. They identified peer-reviewed literature, which revealed that antibi-otic prophylaxis for patients undergoing orthopedic joint surgery, when administered within 30 to 60 minutes before incision, helps to reduce SSI rates to 1% to 3% compared with 4% to 8% without preoperative antibiotic administration.9Based on published evidence, the SCIP established that an antibiotic received prophylactically within 1 hour before incision reduces the risk of infection.6,16,18,21,22 When a fluoroquinolone or vancomycin is the indicated antibiotic, administration should occur within 120 minutes before incision to avoid an adverse reaction associated with rapid infusion.6 Appropriate antibiotic selection is based on rec-ommended guidelines for procedures targeted for national surveillance.23 Although research demonstrates that many antibiotic regimens are effective preventive agents, the professional consensus supports using narrow-spectrum, first- and second generation cephalosporins, which are inexpensive, safe to use, and bactericidal, and have long half-lives. Contributing factors include low ambient temperatures in the surgi-cal suite, use of cold skin preparatory agents, exposed open wounds, cool fluid administration, and the anesthetic effects on a patient’s ability to control and conserve heat.24,25 The body’s core temperature is controlled by the hypothalamus, or the thermoregulation center of the brain. When a difference between core and skin tempera-ture is detected, the thermoregulation threshold triggers autonomic defense mechanisms to produce heat through vasoconstriction and shivering.26 Anesthetic inhalation agents, propofol, and opioids impair thermoregulatory control by decreasing heat production and increasing cu-taneous heat loss through vasodilation. Muscle relaxants also compromise thermoregulatory control by preventing shivering.25 The deleterious effects of hypothermia are well doc-umented. Adverse outcomes of hypothermia include increased blood loss and transfusion requirements, prolonged postoperative recovery times, heightened postoperative pain, and impaired immune function.25 Hypothermia compromises neutrophil function and pro-motes vasoconstriction, which leads to tissue hypoxia and increased incidence of SSIs.27 Numerous studies have demonstrated the impact of hypothermia on SSIs. Kurz et al12 studied patients undergoing colorectal surgery who were randomly assigned to a hypothermic and a normothermic group. Rates of infection were 3 times higher in the hypothermic group.12 Patients in the hypothermic group had hospital stays nearly 1 week longer than did normothermic patients.12 In a 1999 meta-analysis, Mahoney and Odom24 reported a 64% increased rate of SSIs in hypothermic patients. Conversely, when normothermia was maintained, a cost savings of up to $7,000 per patient was realized. Evidence-based practices to prevent perioperative hypothermia include identifying risk factors, measuring temperature, and initiating preventive and active warming measures.28 Risk factors are independent pre-dictors used to determine the potential for developing hypothermia. They include extremes of age, female gender, length and type of procedure, administration of general and spinal anesthesia, ambient temperature of the operating room (OR), and preexisting conditions (ex-tensive burns, endocrine disorders, pregnancy, and large open wounds).27 No single method of measuring temper-ature is deemed the gold standard. Core temperature may be measured in the distal esophagus, pulmonary artery, nasopharynx, or adjacent to the tympanic membrane.25 Use of an esophageal temperature probe in the intubated patient is the most reliable method. Skin temperature is approximately 2°C less than core temperature; thus, forehead skin temperature measurement only estimates core temperature. Clinical research suggests that rectal temperature lags behind temperature measured in the esophagus and the pulmonary artery. Moreover, rectal temperature measurement fails to appropriately rise during malignant hyperthermia and therefore must be used with caution.25The American Association of Nurse Anesthetists Standards for Nurse Anesthesia Practice29 requires tem-perature monitoring of all patients receiving anesthesia for whom large temperature changes are intended, an-ticipated, or suspected. Therefore, patient temperature should be monitored at no less than 15-minute intervals during all general and regional anesthetic procedures of more than 60-minute duration and during all pediatric procedures that are 30 minutes or longer. The greatest decline in patient temperature occurs during the first hour of surgery.27 The CRNA should intervene immediately on entering the surgical suite by applying warm blankets to limit the patient’s skin exposure to low ambient temperature. The Association of Operating Room Nurses recommends ambient tem-peratures between 20°C and 25°C. On induction of anesthesia, forced-air warming should be initiated using the manufacturer’s guidelines for use. The literature supports the use of forced air as the best warming approach because of its ease of use, efficacy, safety, and price.25,30 The use of warmed intravenous fluids in combination with forced-air warming has been shown to positively impact core temperature.27In 1825, a French pharmacist published an article recom-mending that physicians and healthcare workers would benefit from moistening their hands with liquid chloride solutions when caring for patients with contagious dis-eases.31 In 1846, an obstetrician and surgeon by the name of Semmelweis encouraged healthcare workers to incor-porate hand washing into their practice as a means to prevent HAIs. Semmelweis observed that women who delivered in the hospital setting were dying of febrile illness at much higher rates, compared with women who deliv-ered at home. He discovered that the hands of healthcare workers were transmitting the toxins that were causing the febrile illness from patient to patient.31 After his dis-covery, he demanded that his nurses and physicians wash their hands with a chlorine solution before caring for a patient. This intervention by Semmelweiss was the first evidence of preventing HAIs by adhering to strict hand hygiene practices. Semmelweis would be disappointed in our progress of reducing HAIs, because they continue to occur at a rate of 10% of hospitalized patients.32 Many of these infections have been attributed to the lack of hand washing by healthcare providers. Numerous studies have proved that healthcare workers’ hands transmit microorganisms to patients.33 Evidence proves that effective hand washing is the cor-nerstone for preventing healthcare-associated infections. It is also important in preventing specific site infections such as catheter-related bloodstream infections, catheter-related urinary tract infections, ventilator-associated pneumonia, and SSIs.33 Studies continue to demonstrate that hand hygiene practices among healthcare workers is at an abysmally low rate. An observational study of the hand hygiene practices of anesthesia providers was performed at a major metropolitan medical center. The study ob-served the hand hygiene practices of anesthesia provid-ers following the World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care over a 4-week period. The results were daunting: “[T]he overall failure of hand hygiene ranged from 64% to 93% by pro-vider group with a mean aggregate failure rate of 82%”.32 The major categories where hand hygiene failures oc-curred were moving between patients in the preoperative phase, performing pain service interventions, using the keyboard when documenting in an electronic medical record, placing intravenous catheters and blood draws, preparing drugs and equipment for the following case, leaving soiled gloves on after airway manipulation, Foley catheter insertion or central or arterial line manipulation, and picking up something from the floor and using it.