gms | German Medical Science

GMS Hygiene and Infection Control

Deutsche Gesellschaft für Krankenhaushygiene (DGKH)

ISSN 2196-5226

Educational film “Prevention of surgical site infections” – a contribution for quality assurance of the pre-, intra- and post-operative hygiene management

Research Article

  • author Karl Oldhafer - Clinic for General, Visceral and Thoracic Surgery, Celle General Hospital, Academic Teaching Hospital, Hanover University of Medicine, Celle, Germany
  • author Nils-Olaf Hübner - Institute for Hygiene and Environmental Medicine, Ernst-Moritz-Arndt University Greifswald, Germany
  • author Lars Leppin - Ethicon GmbH, Norderstedt, Germany
  • corresponding author Axel Kramer - Institute for Hygiene and Environmental Medicine, Ernst-Moritz-Arndt University Greifswald, Germany

GMS Krankenhaushyg Interdiszip 2009;4(2):Doc03

doi: 10.3205/dgkh000128, urn:nbn:de:0183-dgkh0001283

This is the translated version of the article.
The original version can be found at: http://www.egms.de/de/journals/dgkh/2009-4/dgkh000128.shtml

Published: December 16, 2009
Published with erratum: February 2, 2010

© 2009 Oldhafer et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Background: Procedures for prevention of surgical site infections are clearly regulated in evidence-based guidelines. However, realisation of guidelines is still crucial. Several tools for implementation are available. Studies about compliance in terms of implementation of guidelines and recommendations confirm the necessity to realize consequently evidence-based measures.

Material and method: To support the implementation of the guideline “prevention of surgical site infections” of the commission for hospital hygiene and infection prevention at the Robert Koch Institute in Berlin an educational film was produced.

Results: The film represents also the start of a practice-oriented training concept. The in-hospital stay of an exemplary surgical patient shows the prevention measures starting with information about prevention during the patient’s interview followed by pre-, intra- and post-operative prevention measures.

Conclusion: With the film a contribution is made to converse the World Alliance for Patient Safety of 2004. The involved societies and associations will promote the spreading of the film by adjust free of charge on their web sites.

Keywords: educational film, prevention of SSI, compliance


Introduction

Details of the measures taken to prevent post-operative wound infections, together with an assessment of the evidence on which they were based, were published by the CDC in 1999 [6] and later in updated form in 2007 by the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute [7], on both occasions in the form of guidelines. While clear guidelines provide a basis for the implementation of measures designed to prevent infections where the efficacy of such measures has been proven, the key is for those guidelines to actually be implemented.

The implementation of standards designed to prevent post-operative wound infections will always enjoy greater success where a range of other, interlinking, methods is also used at the same time. One prerequisite for the implementation of measures to prevent infections is the compilation of a hygiene programme or standard operating procedures that pay due consideration to current state of the art expertise and risk-benefit assessments of the various measures to be adopted. To ensure that the hygiene programme is adhered to by all personnel, every single employee must therefore be made aware of the problem and steps taken to monitor for compliance with the rules set down within the team. One effective way of monitoring implementation is to carry out inspections using checklists.

Studies to establish compliance have confirmed the need to implement evidence-based measures. For example, compliance for peri-operative antibiotic prophylaxis was found to be just 80% [8]. Optimal timing was observed in just 29% of cases [9]. In a prospective, double-blind cohort study, the introduction of a new compliance strategy improved the rate of timely peri-operative antibiotic prophylaxis from 5.9% to 92.6% (p<0.001) and peri-operative normothermia from 60.5% to 97.6% (p<0.001) [2].

During a review of selected hygiene measures adopted during surgery, the introduction of a so-called “clean practice protocol” resulted in significant improvements (compared with the preliminary audit) in all of the features assessed, from levels of compliance, for example, to a rise in hand disinfection rates from 28% to 87%, to correct glove use from 2% to 50% and attention to the question of the contamination of work clothing and to the general rules on non-contamination, which rose from 49% and 34% to 63% and 89% respectively [4]. In a study into the verification of patient identity and site of surgery checks, identity check rates rose from 63% to 93% of cases, while compliance with the [site of surgery] protocol rose from 32% to 52% [3].

Different people prefer different methods for absorbing learning materials and internalising the contents. Some prefer audio learning, finding it easier to absorb information given in an acoustic format, whereas for those who prefer to receive their information in a visual format, it needs to be presented in a clear and visually attractive way. For both of these learning formats, however, the implementation of guidelines in the form of an educational film is an ideal way of both delivering the information set out in the guidelines and of assisting with its subsequent implementation. The introduction of the German Association of Surgery’s Mediathek (media library) has shown that in surgery, educational films are an excellent channel for providing surgical information (http://www.dgch.de/de/wissen/mediathek/index.html.

There is basic and widespread acceptance amongst surgeons of educational videos as a learning medium and it is with this in mind that we have produced this film on the prevention of post-operative wound infections (Attachment 1 [Attach. 1]). The film also constitutes the starting point for a practice-based advanced training concept.


Method

The film’s script was based on the guidelines produced by the Commission for Hospital Hygiene and Infection Prevention [7]. Careful attention was also taken to ensure that the statements contained in the film reflected the guidelines. Special attention is drawn to certain topics through the use of animation, while others are treated in a humorous way to help viewers identify with the film’s message.

The action involves a patient’s operation, from the consultation between doctor and patient and the preparations prior to the operation, through to intra-operative and post-operative preventive measures.


Results

The film begins with a series of key messages on the frequency and range of pathogens, how infections can be transmitted, and patient-related risk factors when it comes to post-operative wound infections. The pre-operative preparations focus on screening for MRSA, on hand disinfection, the removal of hair around the area to be operated on if necessary, and the application of antiseptic to the skin. The main areas of peri-operative prevention of infection dealt with in the film are antibiotic prophylaxis, the use of protective drapes and surgical gowns in the operating room, surgical hand disinfection, protective covering for the patient, and peri-operative preparations.

During the operation itself, the steps needed to ensure compliance with the rules on intra-operative hygiene, the prevention of hypothermia, compliance with the principles of surgical techniques, the rules on the need to change gloves, the use of suture material impregnated with an antiseptic, and the sealing off of the operating theatre are all dealt with, all being measures designed to help prevent infections. Strict indications on the use of drains and implants are also designed to reduce the risk of infection.

The film ends with information on the procedures to be used for changing dressings in a hygienic manner.

The film is available for downloading from the article site (Attachment 1 [Attach. 1]).


Discussion

Post-operative wound infections are a dreaded complication in surgery [6]. They are stressful for the patient, they entail extended post-operative treatment and thus longer stays in hospital, thereby leading to additional costs [1]. Even though they cannot be prevented altogether, they can be significantly reduced providing appropriate preventive measures are taken. The theory behind such measures is discussed during medical studies, but generally takes only a secondary role during lectures and in practical training sessions. The first instruction on the practical measures needed to ensure hygiene in the operating theatre may be delivered during surgical training, although it might only be addressed as late as the practical term in the surgery department. Experience shows that this instruction is not structured and is largely dependent on the staff involved (theatre nurses and assistant doctors).

This educational film is not only aimed at medical students and assistant doctors receiving advanced training, but at anyone who provides surgical treatment, irrespective of their professional sphere. It is designed to help improve awareness of the problem of post-operative wound infections by showing evidence-based and practice-oriented solutions with a view to reducing the risks, sparing patients suffering and at the same time reducing the heavy economic costs of having to deal with post-operative wound infections.

The film is designed to provide answers to the following questions:

  • What can be transmitted and how can the transmission of infections be prevented or restricted?
  • What is unavoidable and in what areas can the risks be minimised?
  • What is normal procedure, and what is the evidence-based standard for the prevention of infections?
  • How can the prevention of infections be optimised through the interlinking of hygiene standards (multi-barrier strategy, care bundles)?
  • What is the role of quality assurance?

The question of how effective a lecture can be was shown in an evaluation carried out at the First German Symposium on Surgical Site Infections held in Hamburg in 2008 where levels of awareness between the start and the end of the lecture were compared (see Table 1 [Tab. 1]).

With the aim of reinforcing and supporting the message of this educational film, with effect from 2010, a two-day course will be offered covering the theory behind the prevention, diagnosis and treatment of surgical site infections. The course is designed along practical lines and offers in-depth, hands-on modules for interested surgeons (specialists and doctors undergoing advanced training) under the sponsorship of the relevant specialist companies involved. This course is designed to achieve the following objectives:

  • Raising awareness of the problem of SSIs
  • Provision of evidence-based and practical solutions for the prevention, diagnosis and treatment of SSIs
  • Minimising the risks of a post-operative wound infection so as to prevent patient suffering
  • Reduction of the economic cost of dealing with SSIs.

The course is divided into the following modules:

  • Preventive measures during the pre-, peri-, intra- and post-operative stages of patient care
  • The impact of surgical operating techniques on the risk posed by SSIs
  • Modern wound care
  • The role of physical therapy
  • Diagnosis (clinical, laboratory and microbiological)
  • Presentation of case studies
  • Developments in the operating theatre of the future
  • Economic assessment

Conclusions

This educational film contributes to the implementation of the World Alliance for Patient Safety 2004. To further the distribution of this film, it will be posted on the websites of the following specialist companies and federations, from where it can be downloaded free of charge: the German Association for Surgery, the German Association for Trauma Surgery, the German Association for General and Visceral Surgery, the Surgical Infection Society Europe, the German Association for Hospital Hygiene, the German Hernia Association, the Professional Association of German Surgeons and the Association of Hospital Managers in Germany.


References

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De Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387-97. DOI: 10.1016/j.ajic.2008.12.010 External link
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Forbes SS, Stephen WJ, Harper WL, Loeb M, Smith R, Christoffersen EP, McLean RF. Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and postintervention study. J Am Coll Surg. 2008;207(3):336-41. DOI: 10.1016/j.jamcollsurg.2008.03.014 External link
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Garnerin P, Arès M, Huchet A, Clergue F. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8. DOI: 10.1136/qshc.2007.022301 External link
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Howard DP, Williams C, Sen S, Shah A, Daurka J, Bird R, Loh A, Howard A. A simple effective clean practice protocol significantly improves hand decontamination and infection control measures in the acute surgical setting. Infection. 2009;37(1):34-8. DOI: 10.1007/s15010-008-8005-3 External link
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Oldhafer K, Jürs U, Kramer A, Martius J, Weist K, Mielke M. Prävention postoperativer Infektionen im Wundgebiet. In: Robert-Koch-Institut, Hrsg. Richtlinie für Krankenhaushygiene und Infektionsprävention. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention beim RKI. Lieferung 5. München: Elsevier; 2007. p. 1-34.
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Erratum

The english version was added belatedly.