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Innovations in patient care: infection control spp. (n=12) 2 . In another observational study in Tanzania, the overall rate of SSI was 24% among all surgical disciplines; wound classification associated with infection (dirty-infected wounds) had a risk ratio of 2.8 compared to clean wounds 3 . Overall, 144 of the 618 patients studied developed SSIs, with the most common isolates being S. aureus (37%), E. coli (11%), and Enterococcus spp. (5%). Especially concerning was the isolation of one strain of methicillin-resistant S. aureus (MRSA) and three isolates of vancomycin-resistant Enterococcus. Of the patients with SSIs in the study, 35% had cultures that yielded no growth or “no clinically significant organism.” The authors do not specifically mention whether anaerobic cultures were done, and no obligate anaerobes were identified, so the high rate of negative cultures may be in part due to failure to identify obligate anaerobes. Risk factors associated with SSIs The likelihood of developing an SSI is influenced by a number of factors. These factors fall into four major groups, which are: patient factors, anaesthetic factors, wound status, and surgeon factors. Patient factors General patient characteristics that play a role in SSI include: immunosuppression, malnutrition, endocrine & metabolic disorders, obesity, age (young and elderly), malignant disease and others. All these factors have their influence by lowering host immunity to various infections. Given the high prevalence of HIV among patients in developing countries, the impact of HIV on surgical outcomes is a topic of considerable interest. For example, HIV infection leads to a lower rate of both skin graft survival (69% vs. 22%) 4 , and overall patient survival among burn victims (for 21-30% burns: 100% mortality versus 50% mortality in HIV negative patients) 5 . Among HIV positive patients undergoing anorectal procedures, wound healing is poor 6,7 . A considerable body of research exists on the topic of surgical site infections and HIV as well. In orthopaedic trauma patients, the risk of postoperative infection is considerably higher in HIV positive individuals (16.7% versus 5.4%) 8 , though in elective orthopaedic cases with intact skin and use of implants, the rate of infection Table 1: Classification of the risk of SSI 13 WOUND CLASSIFICATION DESCRIPTION INFECTIVE RISK (%) Clean Uninfected operative wound, no acute
Innovations in patient care: infection control clots in the wound space and prevention of third spaces by tissue re-approximation. Prevention of SSIs Prevention is always better than a cure, and thus a careful assessment of risks related to SSIs is paramount. The goal of SSI management is to prevent or minimise the risk through careful planning. The following factors or methods external to the patient are critical to preventing SSIs: a) Theatre environment and care of instruments; maintenance of positive pressure ventilation of operating theatre, laminar airflow in high risk areas, and sterilisation of surgical instruments, sutures etc. according to guidelines, and b) Surgical team members educated in aseptic technique; staff with infections excluded from duty and scrubbing up followed by appropriate sterile attire. The following section outlines the evidence regarding hair removal, preparation of the sterile field, and wound closure technique. Prophylactic antibiotic use is discussed in section 6. Decisions regarding hair removal Hair removal is commonly performed prior to surgery, yet both the Centers for Disease Control and Prevention (CDC) and the Norwegian Centre for Health Technology Assessment recommend against hair removal 14 . The CDC recommends that, if performed, hair removal should be done by clipping or use of a depilatory cream, rather than by razor. A recent Cochrane Database of Systematic Reviews identified 11 studies that met criteria for inclusion in a meta-analysis of hair removal and infections; 3 of these studies compared shaving with clipping and found that shaving increased surgical site infections (relative risk 2.02, 95% confidence interval 1.21 to 3.36). Furthermore, shaving versus clipping leads to more skin trauma even under ideal conditions, providing further evidence that shaving should be avoided 15 . There were no studies meeting inclusion criteria that compared clipping of hair to no hair removal. Two studies compared shaving with no hair removal, and found that shaving increased infection (relative risk 1.59). However there were relatively few subjects in these two studies and hence the conclusion did not reach statistical significance. Evidence from within Africa supports the CDC recommendation against hair removal. Adeleye et al. recently reported their experience with 17 cranial procedures on black Africans, in which all of the fields were non-shaved, and reported no serious complications over a 2 to 6 month follow-up 16 . In conclusion, if hair is to be removed at all, it should be done by clipping and not by shaving. Furthermore, hair should not routinely be removed except in cases where the presence of hair interferes with the technical aspects of the surgery, which is a judgment that is best left to the operating surgeon within the context of these recommendations. Preparation of the surgical field Two factors relate to the surgical field – the choice of skin preparation, and the method of draping. In developing countries, the choice of drapes has been limited due to cost constraints, whereas in developed countries, sterile, adhesive iodineimpregnated drapes (commonly known as Ioban) are available. These adhesive drapes are placed over the skin after preparation and application of standard side drapes. However, this practice has demonstrated no benefit in randomized controlled trials. Furthermore, adhesive drapes without iodine increase SSI rates (relative risk 1.23, p=0.03) 17 . Thus the avoidance of adhesive drapes as an adjunct to standard cloth drapes is best avoided. Several methods of skin preparation are available, including chlorhexidine, iodine, spirit, and over-the-counter soap. Bibbo et al. compared chlorhexidine and isopropyl alcohol to povidoneiodine in a randomized of 127 patients undergoing foot surgery and found that chlorhexidine preparation resulted in a lower rate of culture-positive skin swabs (38% versus 79%) 18 . Chlorhexidine, an antiseptic solution that has been used worldwide since the 1950s, is a safe and effective product with broad antiseptic activity. Chlorhexidine gluconate is a water soluble, cationic biguanide that binds to the negatively charged bacterial cell wall, altering the bacterial cell osmotic equilibrium and is available in a variety of concentrations (0.5%–4%) and formulations (with and without isopropyl alcohol or ethanol). Chlorhexidine (0.05% solution) has broad activity against gram-positive and gram negative bacteria, facultative anaerobes and aerobes, yeasts, and some lipidenveloped viruses, including HIV. Chlorhexidine is not sporicidal 19 . Meier et al., recognizing the scarcity at times of conventional skin preparation solutions, compared the use of over-the-counter soap followed by methylated spirit, to the use of iodine 20 . The study randomized 200 patients undergoing elective inguinal hernia repair in Nigeria. In group 1, the subject’s skin was prepared by scrubbing with soap and water, blotting with a sterile towel, and applying spirit. In group 2, skin was prepared by scrubbing with povidone-iodine then blotting with a sterile towel and applying povidone-iodine paint. There was no difference in surgical site infections between groups 1 and 2 (5.1% versus 5.9%, respectively). To this date, no studies have compared using soap and spirit versus chlorhexidine. Thus the current evidence supports the use of chlorhexidine for preparation of the surgical site. If chlorhexidine is not available, scrubbing with soap followed by painting with spirit (70% alcohol/30% water) appears equally efficacious as scrubbing and painting with povidone-iodine. Wound closure techniques and use of drains There is little disagreement that clean wounds should be closed primarily. However, the choice of whether to close primarily or leave open, contaminated and clean-contaminated wounds is not as straightforward. If a wound is not closed primarily (closed at the time of surgery), it can be left open to heal by secondary intent, or evaluated for closure at a later date (delayed primary closure, or DPC). DPC of a surgical wound involves placing sterile dressing over the wound at the conclusion of the case, and then removing the dressing usually several days later. If the wound bed appears clean and without devitalized tissue, the wound is then closed with sutures. One prospective randomized study from Tanzania found that the rate of infection was higher when clean-contaminated or contaminated wounds were left open, as opposed to closed (30.2% versus 2.1%) 1 . It must be noted that those subjects in the group whose wounds were left open were heterogeneous, and included a combination of delayed primary closure (DPC) and secondary healing techniques. Marion et al. conducted a metaanalysis of primary versus DPC in complicated appendicitis, and 122 <strong>Hospital</strong> and Healthcare Innovation Book 2009/2010
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International Hospital Federation I
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Introduction Sterile Barrier System
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Contents Healthcare transformation
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International Hospital Federation H
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Introduction Introduction ERIC DE R
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Innovation and strategy 14 Creativi
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Innovation and strategy: creativity
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Innovation in clinical specialities
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Page 119 and 120: Company Profile: Wipak Medical Wipa
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Page 141 and 142: IHF reference JAPAN JAPAN HOSPITAL
Page 143 and 144: IHF reference KENYA THE NAIROBI HOS
Page 145 and 146: IHF Corporate Member Profiles GE He
Page 147: How Can Health Organizations Get th
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