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Innovations in patient care: infection control passing sharp instruments in theatre (by a sharps container, or using verbal communication between the surgeon and the scrub nurse). To this date, there are no known cases of transmission of HIV from a patient to a health care provider in the operating room. However there are at least 57 documented cases of transmission to health care providers in settings outside of the operating room 38 . Hepatitis C poses a more serious risk of transmission, which is estimated to be 2% if the patient is infected with hepatitis C, and the health care provider as been stuck with a hollow needle 39 . After unintentional exposure, the site should be copiously washed, and consideration must be given to post-exposure prophylaxis against HIV. If possible, the patient should be tested for HIV. Factors influencing the choice for or against HIV post exposure prophylaxis include the type of exposure, whether the status of the patient is known at the time of exposure, and the availability of post exposure prophylaxis. The overall risk of transmission from a needle stick when the patient is HIV positive is estimated at 0.3%; high risk occupational exposure from an HIV positive patient is defined as a deep puncture with a hollow needle, a needle that is visibly contaminated, large bore needle, needle that was place directly in an artery or vein, high viral load of the patient, or a patient with end-stage disease 40 . Post-exposure prophylaxis should continue for 28 days and include both a nucleotide reverse transcriptase inhibitor (NRTI) and a protease inhibitor (PI); in the United Kingdom, the recommended regimen is now Combivir (lamivudine and zidovudine, both NRTIs) with lopinavir and ritonavir (PIs; supplied in combination as Kaletra) (Table 2). Summary of recommendations In conclusion, SSIs represent a major cause of morbidity in surgical patients, affecting only around 2% of patients with clean cases, but upwards of 15-20% of patients undergoing contaminated cases. 1. To limit the chance of SSIs, one should treat any endocrine or metabolic disorders in the patient, and optimize nutritional status. 2. Preoperative antibiotics should be given for clean-contaminated and contaminated cases (second or third generation cephalosporin). For clean cases, the evidence is mixed, and if given the best choice is a first generation cephalosporin. The antibiotic should be given before incision, but no longer than 60 minutes before, and should not be continued for more than 24 hours postoperatively. Antibiotics for dirty cases represent treatment of infection and thus are not considered prophylaxis. 3. Body hair need not be removed, and if the surgeon chooses to remove hair, it should be done by use of clippers or a depilatory agent; shaving causes an increased chance of wound infections and must be avoided. 4. Chlorhexidine is the best skin preparation agent. Soap followed by iodine, or 70% alcohol followed by iodone are the next best alternatives. 5. Intraoperatively, patients should retain normothermia, normoglycemia, and adequate perfusion and oxygenation. The surgeon should minimize tissue devitalisation, adhere to sterile technique, avoid hematoma formation, and close potential spaces. 6. Evidence supports closing primarily all wounds, and avoiding drain placement, or if used, such as in breast surgery, not leaving drains in post-operatively any longer than necessary. 7. If one suspects an SSI (redness, localised swelling, pain or tenderness, purulent discharge, relative warmth to the touch), maintain a low threshold for opening the wound which is the primary treatment. Antibiotics are secondary to adequate drainage. There are a number of reasonable choices for treating SSIs, and the choice of an agent should be dictated by culture results when possible. 8. Surgeons should be familiar with the risks of transmission of HIV, and the indications for and choices of post-exposure prophylaxis. All surgeons should be vaccinated against hepatitis B virus. ❏ Acknowledgement Reprinted with kind permission from Surgery in Africa Monthly Review – November 2008 Jonathan Samuel was born and raised in Santa Barbara, California. He completed his bachelor’s degree at Harvard University, and his Medical Degree from Northwestern University. He received a Master’s Degree in Public Health from the University of Michigan, prior to beginning his specialty training in general surgery at the University of North Carolina. For the past two years he has worked as a general surgeon and researcher at Kamuzu Central Hospital in Lilongwe, Malawi, where he currently resides. At KCH he is Director of Continuing Professional Development. He also lectures in surgery at the Malawi College of Health Sciences. He is a candidate member of the Association for Academic Surgery, and a resident member of the American College of Surgeons. Born in Chitipa, Malawi, and a fifth born in a family of eight, Dr Mulwafu went to Iponjola Primary School and proceeded to Chaminade secondary school. There he was selected to do further studies at Chancellor College in Zomba, Malawi, where he completed two years in the faculty of bachelor of science and then joined College of Medicine where he obtained his MBBS. From College of Medicine, Wakisa did his internship at Queen Elizabeth Central Hospital for two years and transferred to Kamuzu Central Hospital where he worked as a registrar in surgery for another two years. He specialized as an ENT surgeon at the University of Cape Town, where he completed one year of general surgery and four years of specialist training in ENT. Hospital and Healthcare Innovation Book 2009/2010 125
Innovations in patient care: infection control References 1. Ussiri E, Mkony C, Aziz M. Sutured and open clean-contaminated and contaminated laparotomy wounds at Muhimbili National Hospital: A comparison of complications. East and Central African Journal of Surgery 2004;9(2):89-95. 2. Eriksen H, Chugulu S, Kondo S, Lingaas E. Surgical-site infections at Kilimanjaro Christian Medical Center. Journal of Hospital Infection 2003;55:14-20. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57803 3. Fehr J, Hatz C, Soka I, Kibatala P, Urassa H, Smith T, et al. Risk factors for surgical site infection in a Tanzanian District Hospital: A challenge for the traditional national nosocomial infections surveillance system index. Infection Control and Hospital Epidemiology 2006;27(12):1401-4. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57804 4. Mzezewa S, Jonsson K, Sibanda E, Aberg M, Salemark L. HIV infection reduces skin graft survival in burn injuries: a prospective study. British Association of Plastic Surgery 2003;56(8):740-5. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57805 5. James J, Hofland H, Borgstein E, Kumiponjera D, Komolafe O, Zijlstra E. The prevalence of HIV infection among burn patients in a burns unit in Malawi and its influence on outcome. Burns 2003;29(1):55-60. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55214 6. Lord R. Anorectal surgery in patients infected with human immunodeficiency virus: Factors associated with delayed wound healing. Annals of Surgery 1997;226(1):92-9. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57806 7. Morandi E, Merlini D, Salvaggio A, Foschi D, Trabucchi E. Prospective study of healing time after hemorrhoidectomy: Influence of HIV infection, acquired immunodeficiency syndrome, and anal wound infection rate. Diseases of the Colon and Rectum1999;42(9):1140-4. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57807 8. Paiement G, Hymes R, LaDouceur S, Gosselin R, Green H. Postoperative infections in asymptomatic HIV-seropositive orthopaedic trauma patients. Journal of Trauma 1994;37(4):545-51. 9. Harrison W, Lavy C, Lewis C. One-year follow-up of orthopaedic implants in HIV-positive patients. International Orthopaedics 2004;28(6):329-32. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57808 10. Norrish A, Lewis C, Harrison W. Pin-tract infection in HIV-positive and HIV-negative patients with open fractures treated by external fixation: a prospective, blinded, case-controlled study. Journal of Bone and Joint Surgery 2007;89(6):790-3. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57809 11. Urbani G, Vries Md, Cronje H, Niemand I, Bam R, Beyer E. Complications associated with caesarean section in HIV-infected patients. International Journal of Gynaecology and Obstetrics 2001;74(1):9-15. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57810 12. Mauermann W, Nemergut E. The anesthesiologist's role in the prevention of surgical site infections. Anesthesiology 2006;105(2):413-21. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57811 13. Gardner D, Tweedle D. Pathology for surgeons in training-an A-Z revision text. 3rd ed. London: Arnold Publishers; 2002. 14. Tanner J, Moncaster K, Woodings D. Preoperative hair removal: A systematic review. Journal of Perioperative Practice 2007;17(3):118-32. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57812 15. Balthazar E, Colt J, Nichols R. Preoperative air removal: A randomized prospective study of shaving versus clipping. Southern Medical Journal 1982;75(7):799-801. 16. Adeleye A, Olowookere K. Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study. Surgical Neurology 2008;69(1):69-72. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57814 17. Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database of Systematic Reviews 2007(4). http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57815 18. Bibbo C, Patel D, Gehrmann R, Lin S. Chlorhexidine provides superior skin decontamination in foot and ankle surgery. Clinical Orthopaedics and Related Research 2005;438:204-8. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57816 19. Milstone A, Passaretti C, Peri T. Chlorhexidine: Expanding the armamentarium for infection control and prevention. Clinical Infectious Diseases 2008;46(2):274-81. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57817 20. Meier D, Nkor S, Aasa D, OlaOlorun D, Tarpley J. Prospective randomized comparison of two preoperative skin preparation techniques in a developing world country. World Journal of Surgery 2001;25(4):441-3. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57818 21. Marion C, Moss R. Primary versus delayed wound closure in complicated appendicitis: an international systematic review and meta-analysis. Pediatric Surgery International 2005;21(8):625-30. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57819 22. Dufour D, Jensen S, Owen-Smith M, Salmela J, Stening G, Zetterstrom B. Surgery for Victims of War. 3rd ed. Molde A, editor. Geneva: International Committee of the Red Cross; 1998. 23. Schein M. To drain or not to drain? The role of drainage in the contaminated and infected abdomen: An international and personal perspective. World Journal of Surgery 2008;32(2):312-21. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57820 24. Clegg-Lamptey J, Dakubo J, Hodasi W. Comparison of four-day and ten-day postmastectomy passive drainage in Accra, Ghana. East African Medical Journal 2007;84(12):561-5. 25. Classen D, Evans R, Pestotnik S, Horn S, Menlove R, Burke J. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New England Journal of Medicine 1992;326:281-6. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57821 26. Bratzler D, Houck P. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004;38:1706-15. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57823 27. Barie P, Eachempati S. Surgical site infections. Surgery Clinics of North America 2005;85:1115-35. 28. Sanchez-Manuel F, Lozano-Garcia J, Seco-Gil J. Antibiotic prophylaxis for hernia repair. Cochrane Database of Systematic Reviews 2007(3). http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57824 29. Osuigwe A, Ekwunife C, Ihekowba C. Use of prophylactic antibiotics in a paediatric day-case surgery at NAUTH, Nnewi, Nigeria: a randomized double-blinded study. Tropical Doctor 2006;36:42-4. 30. Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, et al. Surgical site infections after colorectal surgery: Do risk factors vary depending on the type of infection considered? Journal of Surgery 2007;142(5):704-11. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57825 31. Song F, Glenny A. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials. Health Technology Assessment 1998;2(7):1-110. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57827 32. Song F, Glenny A. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. British Journal of Surgery 1998;85(9):1232-41. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57826 33. Malomo A, Adeolu A, Odebode T, Komolafe E, Shokunbi M. Prospective comparative trial of ceftriaxone versus ceftazidime as prophylactic perioperative antimicrobials in neurosurgery. East and Central African Journal of Surgery 2007;12(1):89-92. 34. Finkelstein R, Rabino G, Mashiah T, Bar-El Y, Adler Z, Kertzman V, et al. Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methacillinresistant staphylococcal infections. Journal of Thoracic and Cardiovascular Surgery 2002;123(2):326-32. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57829 3 5. Abdulwadud O. What is the effectiveness of a dressing moistened with sodium hypochlorite (Dakin’s) solution compared to other dressings in improving wound healing? Clayton, Australia: Monash Medical Center 2000 November 28, 2000. 36. Fry D. Occupations risks of infection in the surgical management of trauma patients. American Journal of Surgery 1993;165(2AS):26S-33S. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57834 37. El-Awady M. Hepatitis B vaccination rates among medical personnel at Ain Shams University Hospital and obstacles to vaccine uptake. Journal of the Egyptian Public Health Association 1998;73(5-6):519-37. 38. Fry D. Occupational risks of blood exposure in the operating room. The American Surgeon 2007;73(7):637-46. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57833 39. Recommendations for prevention and control of hepatitis C virus infection and HCV-related chronic disease. Morbidity and Mortality Weekly Report 1998;47(19):1-39. 40. Hamlyn E, Easterbrook P. Occupational exposure to HIV and the use of post-exposure prophylaxis. Occupational Medicine 2007;57(5):329-36. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/57835 126 Hospital 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 and strategy: risk manag
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Innovation and stategy: Acceleratin
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Innovation and policy: disease surv
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Innovation and clinical specialitie
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Innovation in clinical specialities
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Page 133 and 134: IHF reference The International Hos
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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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