Critical Review of Infection Control Precautions for Patients after Elective Surgery

1.0-       Terms of Reference

• The aim of this report is to debate the effectiveness of interprofessional standards of infection control precaution for patients following surgical procedures.
• Factors influencing poor infection control and hygiene in relation to patient safety, including noted themes such as, hand hygiene, communication and interprofessional collaboration.
• To improve if possible, the efficiency of infection control, hand hygiene and use of personal protective equipment between the multidisciplinary team, introduce recommendations.
• Identify relevant themes in regard to hospital acquired infections and more specifically surgical site infections.
• It will acknowledge the relevant stakeholders and examine the perspectives and implications for each stakeholder in a national setting.

2.0-       Executive Summary

Hospital acquired infections (HAIs) can lead to longer stays, increased healthcare costs, and higher death rates (Haverstick, et al, 2017, p. e1). According to a study of HAIs conducted by Magill, et al, (2014) approximately 1 of every 25 patients in acute care hospital has at least one health care associated infection (Magill, et al, 2014, p. 1207).

This report highlights the importance of appropriate hand hygiene, efficient communication and the importance of interprofessional working in relation to patient safety in practice. Preparation of the surgical team and maintenance of a clean operating environment are crucial as there are a number of intraoperative risk factors that could contribute to the development of infections (International Society for Infectious Diseases (2018). It highlights that there is evidence to suggest that there is a high number of HAIs in the acute setting. The aim of this report is to discuss the prevalence and risks of HAIs and highlight some preventive measures that could possibly be recommended and implemented, specifically concerning SSIs.

Four stakeholders have been identified and their perspectives have been explored as well as how each stakeholder can work collaboratively to decrease the risks of hospital acquired infections.

3.0-       Introduction

A chain of infection is when a series of events have taken place for an individual to acquire an infection, to cause an infection, microorganisms need a host, a portal of entry and a portal of exit, where they become a source infection (Peto,2009, p. 93). The prevention of infection requires the understanding of relevant policies and protocols and the knowledge and skills to adapt them to the preoperative environment (Gilmour, 2010, p. 24).

HAIs according to the WHO add to functional disability and can increase emotional stress of the patient, in some cases it may lead to disabling conditions that reduce the patient’s quality of life (World Health Organisation, 2002, p. 1). Concern for increasing rates of infection has brought about the need for improved national surveillance and reporting of infection rates, as well as control of antibiotics and review of standard control of infection procedures (DoH, 2005, 2006, cited in Whittam, 2008, p. 64). In the healthcare setting the timely identification of HAIs are crucial steps for preventions, however the detection of transmission events is based on limited evidence (Faires, M, et al, 2014, p. 2).

A surgical intervention requires a break in skin integrity and the insertion of instruments and other foreign material into body tissue, therefore increasing the patient’s risk of infection (Gilmour, 2005, cited in Gilmour 2010, p. 24).Infection prevention includes various components, which aim at reducing the risk of infection for patients (Gilmour, 2010, p. 24). Surgical site infections (SSIs) complexifies 5% of all surgical procedures in the UK and is known to be a major cause of postoperative morbidity and a drain on healthcare resources (O’Donnell, et al, 2019, p. 1). This is mirrored in the guide to infection control in the hospital and operating room by the International Society for Infectious Diseases (2018). SSIs are the second most common type of adverse event among hospitalized patients, only surpassed by medication errors, and are known to be the most frequent cause of readmissions (Stevens, 2018, p. 1). Because SSIs are mainly acquired during the surgical procedure while the wound is open, several infection control practices merit scrutiny in the operating theatre (Stevens, 2018, p. 1).

4.0-       Main Body

4.1-       Themes

4.1.1  – Hand hygiene

LLapa-Rodríguez, et al (2018) states that hand hygiene is a simple action in the prevention of HAIs, being considered an excellent indicator of quality for patient safety (LLapa-Rodríguez, et al, 2018, p, 1579). The royal Australasian college of surgeons (2008, p. 29) also agree on the importance of hand hygiene, stating that it is the single most important facto in reducing HAIs. Bouwer, et al, (2017) suggest that one of the main causes of the spread of infections in the healthcare environment is by poor hand hygiene (Bouwer, 2017, p. 75). According to the WHO (2009, p. 28) a cause of poor compliance may be the lack of user-friendly hand hygiene equipment as well as lack of knowledge of good hand hygiene practice. Best practice in hand hygiene as highlighted by the NICE Guidelines (2013) suggest that the operating team should remove all hand jewellery, artificial nails and polish before operations to achieve best practice.

Widmer (2013) suggests that many causes of infection outbreaks have been traced to the contaminated hands of the surgical team, despite wearing sterile gloves, possibly facilitated by not routinely using double gloves (Widmer, 2013, p. s36). This suggests that although protocols and policies exist, some staff are choosing not to follow them. A survey study by Ogle (2003) suggests that the cause of surgeons to not double glove was because they felt two pairs of gloves compromised their surgical skills (Ogle, 2003, p. 2). However, Edlich, et al (2005) suggests that it takes time to gest use to double gloving (Eldich et al, 2005, cited in Phillips, 2011, p. 13). Thomas-Copeland (2009) goes on to suggest that anybody whom finds their dexterity reduced should allow time to adjust (Thomas-Copeland, 2009, cited in Phillips, 2011, p. 13).

           4.1.2- Antibiotic prophylaxis

As mentioned previously the infection of a surgical wound is relatively common, however the risk can be reduced with the use of antibiotic prophylaxis as suggested by Stonebridge, et al (2006). The goals of antibiotic prophylaxis are to reduce the incidents of SSIs and to minimise adverse events. Prophylactic administration of antibiotics has been proven effective in reducing the rate of postoperative infections for surgical procedures, in a meta-analysis of randomised controlled trials of spine fusion surgery, Barker, et al (2002) noted a significant reduction on SSI (Barker, et al, 2002, cited in Tsai and Caterson, 2014, p. 4). Similarly, other studies have observed the effectiveness of prophylaxis antibiotics in general orthopaedics, total joint replacements and spinal surgery (Henley et al, 1986 and Lindwell, et al, 1987, cited in Tsai and Caterson, 2014, p. 4). However, a study by Vohra, et al (2017) concluded that although antibiotic prophylaxis appears to reduce superficial SSI at 30 days, there was no evidence antibiotic prophylaxis significantly reduced the rates of SSIs (Vohra, et al, 2017, p. 2238). The results from this study suggests that more studies are needed looking at the potential benefit of prophylaxis antibiotics.

Stonebridge, et al (2006) states that the value of antibiotic prophylaxis is related to the impact of local SSI, for example, in colorectal surgery, it reduces mortality, while in orthopaedic surgeries it reduced long-term morbidity Stonebridge, et al, (2006, p. 130). Broom, Broom (2018) highlight the issues of inappropriate prolonged prescription of antibiotic prophylaxis and compliance issues with timing, choice and dose. Inappropriate antibiotic prophylaxis poses a short-term risk to patients by their unnecessary usage, and mid to long-term risks of contributing to antibiotic resistance (Broom, Broom, 2018, p. 124).

        4.1.3- Interprofessional collaboration

Interprofessionalism and interprofessional health care, defined by Stern (2006) are terms used primarily to describe the delivery of care by different health care professionals (Stern, 2006, cited in Matthew, et al, 2011, p. 383). Gorman (1998) describes the operating theatre as being the ultimate example of multi-professional teamworking in health care (Gorman, 1998, cited in Coe and Gould, 2008, p. 609). Col, et al, (2011) states that understanding the roles of the individual profession is imperative in developing an atmosphere of collaboration, however understanding professional values and contributions of other participants are also important in creating an effective care team (Col, et al, 2011, p. 412).

Interprofessional working underpins a large majority of modern healthcare, which is critical in the operating theatre were different health professionals such as nurses, surgeons, ODP’s and anaesthetists work independently in complex arrangements where patient centred care is the focus (Healey, et al, 2006, p. 487). This suggests that the level of teamwork in the operating department is critical for patient centred care, inter-group relations.  However, Coe and Gould (2008) suggest concerns over the level of interprofessional conflict and aggression reported in the operating departments (Coe and Gould, 2008, p. 609). Ways of overcoming conflict within the operating department as suggested by Jones and Prescott (2010, p. 21) is to implement action learning into practice. Engagement with action learning helps to develop a range of valuable transferable skills, in addition to learning other ways of working and perspectives, as well as developing problem-solving skills and critical thinking (Jones and Prescott, 2010, p. 26).

4.1.4- Communication

A study conducted by Nestel and Kidd (2005) state that communication in the operating theatre is often diverse and complex, the results suggest that active listening is important as well as basic interpersonal skills such as clarity of speech, being polite and courteous. The most notable themes in Nestel and Kidd’s study appear to be factors that indirectly influence communication, especially confused and conflicting role perceptions.  Answers to questions in this study focused on the nurses’ roles but it is possible that perceptions of surgeons’ and anaesthetists’ roles also lacked clarity (Nestel and Kidd, 2005, p. 6).

Espin and Lingard (2001) state that effective communication is critical to the smooth functioning of an interprofessional surgical team of complex representatives from nursing, surgery and anaesthesiology; all disciplines with different health care models (Espin and Lingard, 2001, p. 672). Language can impact significantly on the ways in which health care professionals relate and collaboratively work together (Marshall, et al, 2011, p. 452). Jargon from different interprofessional teams could affect communication between different health care professionals. A study by Marshall, et al (2011) found that there is a variety of challenges when in comes to interprofessional jargon, stating that healthcare professionals need to avoid the use of exclusionary jargon so that all members of the healthcare team, including patients and families can adopt a more collaborative practice (Marshal, et al, 2011, p. 453).

4.2-       Stakeholders

This section will cover the perspectives of four chosen stakeholders, identified below in relation to infection control.

4.2.1- Theatre Nurse

The perioperative nurse is responsible for implementing aseptic practice and monitoring the aseptic technique of the entire surgical team, Goodman and Spry (2017, p. 95). Theatre nurses are often seen as an important component within the theatre team and is crucial in assisting the surgeon during surgical procedures.

Goodman and Spry (2017, p. 95) describe the responsibilities of the perioperative nurse as one whom continuously monitors the operating room environment to ensure adherence to aseptic principles and compliance with their aseptic practice. There has been issues regarding operating staff defining the role of a theatre nurse which has lead theatre nurses managing work outside their role. McGarvey, Chambers and Boore (2001) state that if nurses working in the operating department are to secure a future in providing care for surgical patients then it is important to clarify and articulate their role (McGarvey, Chambers and Boore, 2001, p. 2).

The Royal Australasian College of Surgeons (2008, p. 4) state the importance of teamwork in surgical practice with an emphasis on close working with not only surgical staff but non-surgical staff such as nurses. Good and appropriate communication, respect and courtesy should be the focus for all interactions with staff and patients. However, a focus group interview, exploring the perception and experiences of communication in the operating theatre by Nestel and Kidd (2006) highlighted issues on how nurses perceived to be treated in the operating theatre by surgeons. Participants found that they experienced poor communication with surgeons and expressed that they felt respect, common courtesies and manners were often absent. Nurses also reported inadequate communication between surgeons, which led to frustration and friction within the interprofessional team (Nestel and Kidd, 2006, p. 4). This issue has been highlighted in other studies with authors arguing that the nurse-doctor communication in the operating theatre show heavy signs of hierarchical tendencies, Nestel and Kidd’s (2006) study further highlights the nurses expressions of frustration on the issues of power and hierarchy in the operating theatres (Nestel and Kidd, 2006, p.5).

4.2.2- Service Users

As mentioned previously, the prevalence of SSIs are common in the hospital setting, there is also research on the risk, cause and prevention, however there is little research on the effect SSIs have on patients who experience them. Surgical infections can be considered as patient or procedure related, patient related factors that increase the risk of infection include, malnutrition or obesity, Smoking and steroid use (Bowley, 2006, p. 46).

A qualitative interview study by Tanner, et al (2012) highlights how SSIs affect the lives of patients. Patients reported experiencing pain and weakness as a result of the SSIs in addition to their physical symptoms, participants also reported feelings of mental distress and depression (Tanner, et al, 2012, p.166). Other studies exploring the experiences of patients after surgery found that communication was imperative, with the fear of the unknown leading to added anxiety (Lie et al, 2010; Chan et al, 2011, cited in Tanner, et al, 2012).

A study by Tartari, et al, (2017) suggests more educational opportunities need to be implemented to improve patient engagement. Educational interventions are likely to be more effective multifaceted and broadly applicable to meet various health needs across the general population (Tartari, et al, 2017, p. 4). Tartari, et al (2017) also highlights how nurses, surgeons and other health professionals could a meet different learning needs and achieve patient engagement by considering broader ways of sharing information through illustrations, computer technology, smartphone apps or audio videos on prevention of SSIs (Tartari, et al, 2017, p. 4).

4.2.3- Operation Department Practitioner

Traditionally, surgeons and anaesthetists have been primarily assisted by theatre nurses, this role has changed over the years and a relatively new profession is the Operation Department Practitioner (ODP) (Timmons and Tanner, 2004, p. 645). The complexity of working within the surgical environment requires the ODP, who work alongside a variety of different professionals, which require high developed communication and teamwork skills, Abbott and Booth (2014, p. 1). Timmons and Tanner (2004) describe ODP’s as members of the surgical teams working in operating theatres alongside a multi-professional team during operations, they provide care to patients before, during, and after surgery (Timmons and Tanner, 2004, p. 650). ODPs because regulated within the Health and Care Professions Council in 2017, and was taken under the allied health professions, during this the interprofessional working of theatre nurses and OPDs increased, with both professions working side by side (Rich, 2019, p. 488). However, this side by side working has not always been cohesive. Timmons and Tanner (2004) state that tensions and conflict between ODPs and theatre nurses may arise due to ODPs being a relatively new profession and being sufficiently similar to nurses (Timmons and Tanner, 2004, p. 663).

4.2.4- Surgeons

After marriage many surgeons remove their wedding ring during surgical procedures to reduce the risk of infections and to follow protocol. Stein, and Pankovich-Wargula (2009) suggest that this can be disheartening for some surgeons that always feel compelled to wear a band (Stein, and Pankovich-Wargula, 2009, p. 86). Theatre staff are sometimes reluctant to remove their wedding bands when scrubbing up. Higher microbial counts after washing found in health workers who prefer not to remove rings (Salooiee and Steenhoff, 2001, p.17), which in turn could increase the risks of HAIs. In a study by Bernthal (1997) and Salisbury, et al (1997) it revealed an increased bacterium count under rings and watches, where staff had not completed proper scrubbing under or around jewellery (Bernthal, 1997 and Salisbury, 1997, cited in Stein and Pankovich-Wargula, 2009, p. 86). However, it needs to be noted that neither of these studies recorded if these conditions leaded to a higher rate of HAIs. Most crucial factors in the prevention of HAIs, although difficult to measure, are the judgement and proper technique of the surgeon and surgical team, as well as the overall health of the patient (Nichols, 2001, p. 221). Everyone working in perioperative environment shares the responsibility for reducing the number of microorganisms in the operating room to the lowest level possible Goodman and Spry (2017, p. 95).

5.0-       Conclusion

This report has identified barriers to infection control in the surgical setting, as well as discussed, the identified themes and relevant stakeholders’ perspectives. The identified themes of hand hygiene highlighted possible issued with staffs understanding of policies and protocols as well as appropriate PPE, such as wearing wedding bands. Communication and interprofessional working has been highlighted and the barriers identified within has been discussed and analysed. The perspectives of the identified stakeholders have been discussed and evaluated in regard to infection control and interprofessional working.

6.0-       Recommendations     

Recommendations have been designed using the SMART tool (MacLeod, 2012, p. 70).

Recommendation 1:

Specific: Understanding each health professional’s role within the operating theatre to reduce lack of understanding on staff responsibilities. Measurable: Opportunities for staff to discuss roles and responsibilities with each other, with added feedback. Achievable: Yes, if time could be allocated for separate groups from the surgical team to meet. Realistic: No, different groups of staff with different roles would need to meet and it is unlikely many could allocate their time, however if it was allocated as training and efficient staff coverage was made it could be realistic. Staff may not want to attend face to face, and some may feel uncomfortable discussing their role or may feel it unnecessary. Timeframe: This could be achieved at any point of time in the healthcare professionals’ career; however, it would be more beneficial and achievable to complete this while training in a surgical environment.

Recommendation 2

Specific: Hospital staff should receive training in regard to understanding their local policies and procedures to reduce the risks of HAIs, receiving additional training when policies have been updated. Measurable: Relevant staff should receive practice skill sessions to assess their competencies in regards to the local policies. Achievable: Yes, if staff are willing and they are able to receive time for training. Realistic: Yes, however staff scheduling may cause issues with relevant staff being able to have time off work, as well as cost to provide training. Timeframe: Staff availability and recommendations on if this should be repeated annually.

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7.0-       Glossary of Terms

• Aseptic practice/ technique: The practice by which contamination from microorganisms is prevented. (Goodman and Spry, 2017, p. 356)
• Infection: Infection occurs when harmful pathogenic microorganisms invade the human body and cause disease or even lead to death. Not all microorganisms are harmful, under the right condition’s infections can occur, highlighting the importance of preventing and controlling infection has its relation to maintain a safe environment (Whittam, 2014, p. 64).
• Microorganism: Any organism of microscopic size, such as a virus, bacterium, or protozoon. It may or may not be a pathogen, i.e. capable of causing disease, Mallik, Hall and Howard (2009, p. 462).

8.0-       Abbreviations

• DoH               Department of Health
• HAIs              Hospital Acquired Infections
• ODP              Operation Department Practitioner
• PPE               Personal Protective Equipment
• WHO             World Health Organisation
• SSIs              Surgical Site Infections