Healthcare-associated infections (HAIs) are infections that occur while receiving health care. Patients with medical devices (central lines, urinary catheters, ventilators) or who undergo surgical procedures are at risk of acquiring HAIs.
Healthcare-associated infections continue to be a tremendous issue today.
Surgical site infections (SSIs) are the most common healthcare-associated infections among surgical patients. It is obviously important to improve patient safety by reducing the occurrence of surgical site infections. SSIs remain a major clinical problem in terms of morbidity, mortality, length of hospital stay and overall direct and not-direct costs in all regions of the world. Despite progress in prevention knowledge SSIs remain one of the most common adverse events in hospitals.
Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have recently published guidelines for the prevention of surgical site infections.
However knowledge, attitude, and awareness of infection prevention and control (IPC) measures among surgeons are often inadequate and a great gap exists between the best evidence and clinical practice with regards to SSIs prevention. Despite clear evidence and guidelines to direct SSIs prevention strategies, compliance is uniformly poor.
Despite evidence supporting the effectiveness of best practices, many surgeons fail to implement them, and evidence-based processes and practices that are known to reduce the incidence of SSIs tend to be underused in routine practice.
Preoperative antibiotic prophylaxis (AP) is a cornerstone of SSIs prevention. The use of AP contributes considerably to the total amount of antibiotics used in hospitals and may be associated with increases in antibiotic resistance and healthcare costs. AP has been shown to be an effective measure for preventing SSIs, but its use should be limited to specific, well-accepted indications to avoid cost, toxicity, and antimicrobial resistance, and should never substitute good medical practice of infection prevention and control.
High rates of inappropriate use of prophylactic antibiotics in surgery continue to be reported in the literature. Since clinicians are primarily responsible for the decision to use antibiotics, changing the attitudes and knowledge that underlie their behavior are crucial for improving antibiotic prescription. Due to cognitive dissonance (recognising that an action is necessary but not implementing it), changing behaviour is extremely challenging.
In hospitals, cultural, contextual, and behavioral determinants influence clinical practice. Improving behaviour in infection prevention and control practices remains a challenge. Understanding the determinants of healthcare workers’ behaviour is fundamental to develop effective and sustained behaviour change interventions.
Raising awareness of IPC to stakeholders is a crucial factor in changing behaviors. Probably clinicians are more likely to comply with guidelines when they have been involved in developing the recommendations. One way to engage health professionals in guideline development and implementation is to translate practice recommendations into a protocol or pathway that specifies and coordinates responsibilities and timing for particular actions among a multidisciplinary team. There is now a substantial body of evidence that effective team-work in health care contributes to improved quality of care.
Leading international organizations, such as the WHO, acknowledge that collaborative practice is essential for achieving a concerted approach to providing care that is appropriate to meet the needs of patients, thus optimizing individual health outcomes and overall service delivery of health care.
IPC teams have been shown to be both clinically effective and cost-effective, providing important cost savings in terms of fewer HAIs, reduced length of hospital stay, less antimicrobial resistance and decreased costs of treatment for infections.
The use of such approaches reinforces the concept that each one brings with them their particular expertise and is responsible for their respective contributions to patient care. In this context the direct involvement of surgeons may be crucial.
Surgeons with satisfactory knowledge in surgical infections involved in infections prevention and control team may integrate the best practice among surgeons. Studies have demonstrated that the incidence of SSIs varies widely between hospitals and between surgeons, suggesting that working practices play a critical role in the prevention of these infections and that more may be done to improve infection control in routine surgical practice. Identifying a local opinion leader to serve as a champion may be important because the “surgeon champion” may integrate best clinical practices and drive the colleagues in changing behaviours.
We believe that the concept of the “surgeon champion” can be a crucial way to improve infection prevention and control across the surgical pathway.
Massimo Sartelli
sfide infettive in Ospedale 