Hitting infection where it hurts


An educational initiative by the Royal College of Surgeons should cut the risk of post-operative infection dramatically, writes SARAH CONROY

IN RECENT years a primary concern for patients being admitted to hospital has been the risk of contracting Methicillin-resistant Staphylococcus Aureus, commonly known as MRSA.

Many cases of MRSA arise from the transfer of germs from patient to patient due to lack of good hygiene. To address this, hospitals have revised their hygiene practice. Measures have included the introduction of hand-sanitising kits and tougher visitor regulations to reduce the risk of infections being brought in from outside.

However, the concern over post-operative infections lingers. In response, the Royal College of Surgeons Ireland (RCSI) is introducing a Surgical Development Initiative for trainee surgeons which will focus on maximising patient safety and preventing infections following surgery.

This educational initiative will target trainees beginning their surgical study at the RCSI this month.

It will focus on improving current hand hygiene practices, the timely prescription of antibiotics prior to procedures, the care of surgical sites after surgery and the prevention of bloodstream infection – which can result from infected intravascular devices, such as catheters or “drips”.

Acute healthcare-associated infections (HCAI) affect between one in 10 and one in 20 patients following a procedure.

The infections can occur at the site of the wound, in the wound or in the bloodstream resulting in septicaemia. Although some infections are easily treated, others can be a great deal more severe and, if not diagnosed and treated in time, can be fatal.

Infectious complications are the main cause of post-operative morbidity in abdominal surgery. They often occur after a patient has undergone long hours in theatre as a result of a complex surgical procedure.

According to a report compiled by the Royal College of Physicians of Ireland (RCPI), common HCAIs include: “infection of the urinary tract, cystitis, [infection of] the lower respiratory tract, pneumonia, an infected diabetic ulcer, [infection of] the bloodstream or any part of the body that has been operated on”.

The RCSI project is in keeping with similar moves by international organisations.

“RCSI’s new Surgical Development Initiative is in line with the World Health Organisation’s [WHO] recent prioritisation of patient safety, to prevent healthcare-associated infections,” says Arnold Hill, professor of surgery at RCSI and consultant breast and general surgeon at Beaumont Hospital.

In tackling post-operative infections, WHO, in consultation with international experts and following a large multi-centre trial involving surgical professionals, recently published its WHO Surgical Safetychecklist.

The WHO checklist has shown improved compliance with standards and a decrease in complications from surgery in the eight pilot hospitals where it was used for evaluation.

It demonstrated a decrease in mortality from 1.5 per cent to 0.8 per cent and a drop in surgical site infection (SSI) rates from 6.2 per cent to 3.4 per cent.

According to the RCSI, which has endorsed the checklist, “WHO recognises that, in surgery, mistakes can be made. The checklist is there to minimise the chances of these mistakes happening. It makes sure that what should be done is done.”

Localised pain, redness, itching, restriction in movement and wound discharge are all symptoms of possible surgical site and healthcare-associated infections. So too are abscesses and cellulitis, which can present themselves up to a week after surgery, even when a patient has been discharged from hospital.

Several factors can increase the risk of SSIs occurring. The length of time of a procedure is one factor: the longer that tissues are exposed during a procedure, the more susceptible they are to bacteria. Another factor is a diminished immune system. Thus, diabetes, malnutrition or immunosuppressive therapy used in treatment for cancer increase the risk of an SSI developing.

Currently, more than 20,000 people are diagnosed with cancer in Ireland annually. It is a growing figure, as is the number of vulnerable patients contracting HCAIs.

“While some of these infections may be community-associated, eg influenza, many will be HCAIs acquired in hospital wards, day treatment centres, outpatient clinics and hospices,” according to the RCPI. As a result, this new initiative is timely.

Prof Hilary Humphreys, of the RCSI department of clinical microbiology and microbiology at Beaumont Hospital, believes education is paramount in decreasing the threat of post-operative infections, and in increasing patient welfare.

“Education to improve practice is a key component in preventing healthcare-associated infection. This RCSI initiative will maximise patient safety by enhancing the education of surgical trainees,” she says.

The web-based initiative will be delivered over the next two months to the 85 first-year students and 75 second-year students at RCSI. It will assess the trainee surgeons’ current practice and their knowledge of interventions to minimise HCAI, as well as facilitating access to national and international guidelines. The students’ use of online tutorials will also be monitored.

The RCSI, according to Prof Humphreys, remains “committed to promoting safe surgery and advancing the highest standards of surgical care for patients”.

Mortality fell from 1.5% to 0.8% and surgical site infections fell from 6.2% to 3.4% when the WHO checklist was used in eight pilot hospitals