A group of professional associations produced guidance for practitioners on how to apply infection prevention best practice across the surgical pathway
Reducing rates of surgical site infections (SSIs) is a key component of healthcare quality and safety activity. However, the multiple teams and settings associated with the surgical care pathway make it difficult to ensure staff are aware of SSI rates, and that guidance is consistent and complied with. A group of professional associations has developed a toolkit providing a structured framework for assessing compliance.
Citation: Wilson J (2016) Guidance on preventing surgical site infection. Nursing Times; 112: 35/36, 13-15.
Author: Jennie Wilson is associate professor, University of West London, writing on behalf of the OneTogether Partnership.
- This article has been double-blind peer reviewed
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Infections associated with healthcare are a major risk to patients, and their prevention is recognised as a key component of care quality and patient safety. Attention has been focused on measures to reduce bloodstream infections caused by pathogens such as meticillin-resistant Staphylococcus aureus. However, there has been less consideration of other serious and more common healthcare-associated infections (HCAI) such as surgical site infection (SSI).
SSI is the third most common cause of HCAI after pneumonia and urinary tract infection, accounting for 16% of all such infections (Health Protection Agency, 2012). However, among surgical patients it is the most common HCAI, affecting at least 5% (Smyth et al, 2008). Since SSIs are unlikely to become apparent until at least four or five days after surgery – several months in the case of implant surgery – the risk is difficult to measure accurately, as many infections occur after patients have been discharged from hospital. While patients with severe SSIs may be readmitted, many others might be treated in the community (Public Health England, 2015; 2014). In such cases, the health professionals involved in an operative procedure remain unaware the patient has developed an SSI and cannot connect the quality of infection control practice in the peri-operative period with SSIs.
Although national regulations in UK countries require hospitals to conduct surveillance of SSIs for major orthopaedic procedures, surveillance of other categories of surgical procedures is limited (Public Health England, 2015; Health Protection Scotland, 2012; NHS Wales, 2011).
The significant morbidity and mortality that result from SSIs are also poorly recognised; they double the length of post-operative stay, incurring additional costs and reducing the availability of beds for other patients (Coello et al, 2005; Jenks et al, 2014). Coello et al (2005) also found that patients who developed deep or organ/space SSIs had an increased risk of death; the risk more than doubled for hip prosthesis surgery and increased seven times for vascular surgery. Other studies have illustrated the long-term impact of SSIs on patients’ health. Whitehouse et al (2002) found that SSIs after orthopaedic surgery quadruple the costs of care and decrease patients’ quality of life.
A range of evidence-based guidance on preventing or reducing the risk of SSI is available, including guidelines on preventing SSI and inadvertent hypothermia (National Institute for Health and Care Excellence, 20013a; 2013b; 2008); on theatre practice and air handling systems (Hoffman et al, 2002; Woodhead et al, 2002) and prophylactic antimicrobial therapy (European Centre for Disease Prevention and Control, 2013; NICE, 2013a; 2013b; Scottish Intercollegiate Guidelines Network, 2008). However, in the multidisciplinary surgical environment it can be difficult to ensure evidence is incorporated into best practice across the surgical pathway (Leaper et al, 2015).
The OneTogether Partnership
Multi-organisational collaborations focused on quality improvement have been shown to be effective in improving patient outcomes through the dissemination of evidence-based practices (Nadeem et al, 2013). OneTogether represents such a collaboration involving professional organisations with an interest in SSI prevention: the Association for Perioperative Practice (AfPP), the Infection Prevention Society, College of Operating Department Practitioners and the Royal College of Nursing. Initiated in 2012, the partnership aims to promote and support the adoption of best practice to prevent SSI across the surgical patient pathway.
OneTogether secured support from 3M, which provides technical expertise and financial support for producing educational material and holding educational meetings to disseminate material to clinical practitioners; a memorandum of understanding ensures that outputs are free from commercial influence or endorsement, are jointly owned by the partners and freely available.
Application of current guidance
In 2013, OneTogether held a workshop attended by 84 theatre nurses, infection prevention specialists and operating department practitioners from 75 NHS and private hospitals in England. Delegates discussed how infection prevention guidance in relation to surgery is applied in practice and explored the challenges affecting compliance (Wilson et al, 2015).
They reported problems in translating evidence-based guidance into everyday practice and poor compliance with best practice, especially for peri-operative warming, skin preparation and management of the surgical environment. An absence of local policies, knowledge and training in relation to guidance was considered a key factor. Lack of leadership to drive implementation of guidance, poorly defined responsibilities and lack of ownership of good practice across the multidisciplinary team were also identified as particular barriers (Wilson et al, 2015).
These findings demonstrated the need for a closer working relationship between infection control and operating department staff to identify problems with compliance with best practice, develop local policy and translate it into systems that define responsibilities for all multidisciplinary team members.
Developing an assessment toolkit
To support this aim the partnership has developed the OneTogether Assessment Toolkit for infection prevention practice, which provides a structured framework for assessing compliance throughout the pre, intra and post-operative stages of the surgical pathway. The standards included in the toolkit are derived from national evidence-based guidelines or expert recommendations from professional bodies (PHE, 2014; AfPP, 2016; 2014; HPS, 2012; NICE 2008a; 2008b; Department of Health, 2007). Table 1 (attached) illustrates the seven fundamental standards of care covered by the assessment tool. These are also summarised in a poster designed to support the toolkit and enhance theatre practitioners’ knowledge about guidance on preventing SSI; the poster is available for download at joinonetogether.com/resources.
Assessment should be conducted together by theatre, and infection prevention and control practitioners and include practice in operating theatres, surgical wards and pre-admission clinics. It should be conducted separately for different surgical specialties as the practices in the operating theatre and along the surgical pathway may differ. Several periods of data capture may be needed to gather a complete picture of compliance across all seven areas of care.
The toolkit defines a set of specific criteria required to meet the expected standard of care within each area and asks reviewers to consider for each criterion whether the standard is both ‘defined’ (clearly described in a local policy), and ‘applied’ (consistently performed). Information on the application of standards can be gathered through observing practice and questioning relevant staff. The toolkit then allocates scores to give a percentage compliance for each area of practice.
The completed assessment gives an overview of compliance with best practice across the seven areas of infection prevention and enables improvement activity to prioritise aspects of care with the poorest compliance. By distinguishing between the definition and application of the standard, the toolkit also helps to focus on whether local policy needs to be developed and its implementation improved. It is recommended that staff in the area being assessed are made aware of the assessment and its results. However, the usual governance platforms should be used to review the results; action planning following the assessment is best achieved using a multidisciplinary approach involving theatre and infection prevention teams. Improvement can then be measured by repeat data capture using the assessment toolkit.
Pilot of the toolkit
The toolkit was pilot tested by seven hospitals in 15 theatres; this demonstrated overall 62% compliance with all the areas of practice, although this varied between hospitals and specialties. Participants found the toolkit easy to use and valuable for identifying gaps in infection prevention practice. Recommendations for improvements to the toolkit and guidance on its use were incorporated into the final version, which is available online as a PDF and Excel spreadsheet for recording scores available here. You can also find more information here and here - OneTogether Infection Control Assessment Toolkit and OneTogether Infection Prevention Assessment Tool.
Assuring best practice in the prevention of SSIs is made more difficult because the patient pathway crosses physical and cultural boundaries, and infection control teams may perceive the operating theatre to be an impenetrable and complex environment. In addition, the absence of data on SSI rates means the imperative of addressing infection prevention practice may not be obvious to theatre staff.
The OneTogether Assessment Toolkit provides a structured framework against which to measure compliance with evidence-based practice and use the results to identify where improvements are required. Such actions are essential to ensuring the quality and safety of care is delivered to all patients undergoing surgical procedures and ensuring that their risk of developing SSI is minimised.
- Surgical site infections are a common problem causing patient harm and increased healthcare costs
- The multiple teams and environments on the surgical pathway make it difficult for staff to understand the impact of SSIs
- Interpretation and implementation of national evidence-based guidance on preventing SSIs is inconsistent
- Many surgical pathways lack clear local guidance on minimising patients’ risk of SSIs
- An assessment tool has been developed to evaluate local guidance on SSI prevention and its implementation
Association for Perioperative Practice (2016) Standards and Recommendations for Safe Perioperative Practice (4th edn). Harrogate: AfPP.
Association for Perioperative Practice (2014) A Guide to Surgical Hand Antisepsis. Harrogate: AfPP.
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