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Factors other than dress code 'key to cutting surgery infections'

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Skin preparation, wound hygiene and sharing data on outcomes appear to be more important factors than adherence to dress codes for reducing infections following surgery.

Maintaining sterile operating conditions and tracking and reporting outcomes were most effective in minimising surgery-related infections, according to US researchers.

“The best performing hospitals were vigilant about skin prep, using a clean closure and giving antibiotics appropriately”

Thomas Aloia

They identified two areas that stood out as significant, namely mandating sterile operating conditions at or close to the wound itself, and tracking in-hospital outcomes on surgical site infections (SSIs) and sharing that information with staff.

The study authors noted that a large number of infection control practices, including polices on operating room attire, had been adopted in an effort to reduce SSI rates. But they claimed few had “proven benefits” and many were “costly, time-consuming, and detrimental to provider morale”.

For their study, the researchers surveyed lead surgeons at 20 Texas hospitals about their team’s compliance rates with a range of infection control practices.

The survey asked respondents to use a four-point scale to rank adherence to infection control practice by surgeons, anaesthetists, and nursing staff.

They were asked to rank staff adherence to 38 practices in six categories – attire, pre-operative preparation, during-surgery protocols, antibiotics, post-operative care, and outcomes reporting.

The researchers also collected data on SSIs during July 2016. They then compared the practice compliance rates between the best and worst performers on outcome.

“Policies regulating the attire of operating room personnel had no measurable impact on infection rates”

Thomas Aloia

They found almost all hospitals reported maximum adherence to metrics on the removal of patient hair around the wound site with clippers and proper use and dosing of preventive antibiotics.

However, they noted that a group of hospitals that were most compliant with eight other practices demonstrated the lowest surgical site infection rates.

These practices included patients showering before an operation and best practice preparation of the skin in the operating theatre, as well as use of clean instruments, gowns, and gloves for closing wounds and changing dressings.

In contrast, they found that “attire practices”, particularly those that applied to operating staff away from the immediate field of surgery, had no impact on SSI rates.

These practices included implementation of specific rules for surgical caps, undershirts, and shoes and shoe coverings, restrictions on jewellery and nail polish, coverage requirements for forearms and head and facial hair, and even the presence of personal bags in theatre.

“This analysis suggests that the subset of infection control practices that focus on perioperative patient skin and wound hygiene and transparent display of SSI data, not operating room attire policies, correlated with SSI rates,” said the authors in the Journal of the American College of Surgeons.

“Our research team found that policies regulating the attire of operating room personnel had no measurable impact on infection rates,” said lead author Dr Thomas Aloia, from the University of Texas in Houston.

“Although we would never advocate sacrificing safety, such regulations don’t seem to have data to back them up,” he said, regarding dress codes.

Dr Aloia noted that every hospital wanted to lower surgical complication rates and, in particular, wound infection rates, but had limited resources to carry out quality assessment and improvement.

University of Texas

Factors other than dress code ‘key to cutting surgical infections’

Thomas Aloia

“What’s important about this study is that it brings feasibility to hospitals that may be considering 80 possible variables to intervene on,” he said.

“To get off to a strong start, they can begin by looking at conditions right at the wound and their reporting practices,” he said. “A focus on these elements should produce the biggest impact for quality improvement initiatives.”

Dr Aloia suggested the study findings could “really help” hospitals to “appropriately scale” what they were going to emphasise in their attire policy and other standard operating procedures.

“The best performing hospitals were vigilant about skin prep, using a clean closure and giving antibiotics appropriately – all those things that happened right at the level of the wound,” he said.

“In addition, the hospitals that reported out their data on a formal basis – monthly or quarterly – to their surgeons, departments, and institutions also had the highest performance,” he added.

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