Oromiya Regional Health Bureau
Haramaya General Hospital
Surgical site infect reduction: a quality
improvement Project
December, 2022
haramaya, Ethiopia
1
QI members
Dr Badhaasaa Beyene – Project leader and PI
Dr Basit Abrahim- Co-Investigator
Dr Solomon Tamirat – member
Mr Ahmed Abulselam (CEO) – member
Sr Woinishet - member (supervisor at OR)
Sr Muntaha Abdi - member
Mr Harif A–Member
Mr Habtamu G– member
Mr Ershad A - member
2
Abstract
Background
Surgical site infection is an old and ever-changing surgical problem that needs attention to decrease its
magnitude. Improvement in quality of service has shown effective in reducing the prevalence of surgical
site infection in developed countries using evidence-based strategies. This evidence-based finding was
introduced to health workers and staffs of Haramaya General Hospital working at surgical ward and
Operation Theatre.
Method
The quality improvement project is a routine activity evaluation at our hospital for the proper use of
resources based on evidence-based care (EBC). The project was designed as an observational follow up
for operated patient in our hospital from August 1 – December 31st, 2022. Problem identification was
done through brainstorming using driver diagram model and intervention introduced from Evidence
Based findings for health workers as fresher training. Continuous supervision was made for data
collectors and evaluation has been conducted every month.
Result
Two hundred seventy-six patients were followed over the project period. Surgical site infection was
developed in 8.3 %% of patients on average. The overall death rate during follow up period was 5
(1.8%) from which 4 (80%) were directly or indirectly associated with surgical site infection. Length of
hospital stay was significantly higher in patients who have developed surgical site infection; 19.6 + 11
days compared to 5.85 + 3 days in those surgical site infections didn’t develop.
Conclusion and recommendations
The rate of surgical site infection was significantly reduced following the introduction of EBC compared
to the pre-intervention period. The use of WHO surgical safety checklist usage has almost become
complete but more stress has to be made on the components, especially at the sign out period. The
infrastructure improvement and supplies weren’t optimal which need higher governmental
intervention and allocation of adequate budget. The hospital has to device a mechanism to trace and
follow a loss to follow up of postoperative patients to make sure surgical site infection occurrence.
Key words: SSI; EBC; superficial surgical site infection;
3
Introduction
Surgical site infections (SSIs) are defined as infections occurring up to 30 days after surgery or up to one
year after surgery in patients receiving implants[1, 2]. SSIs are classified into incisional [sub classified
into superficial (limited to skin and subcutaneous tissue) and deep incisional] and organ/space infections.
The development of SSIs is affected by the degree of microbial contamination of the wound during
surgery, the duration of the procedure and host factors such as diabetes, malnutrition, obesity, immune
suppression and a number of other underlying disease states[3]. About 80% to 90% of all postoperative
infections occur within 30 days after the operative procedure. Most of the wound infection manifest
within a week of surgery[2].
Surgical site infections are main part of Nosocomial infections [4]. Despite the advances made in
asepsis, antimicrobial drugs, sterilization and operative techniques, and availability of antimicrobial
prophylaxis, SSIs remain a substantial cause of morbidity, prolonged hospitalization and death[4, 5]. The
incidence of SSIs may be as high as 20%, depending on the surgical procedure, the surveillance criteria
used, and the quality of data collection[6]. SSI is associated with a mortality rate of 3%, and 75% of SSIassociated deaths are directly attributable to the SSI. SSI is the most costly HAI type with an estimated
annual cost of $3.3 billion, and is associated with nearly 1 million additional inpatient-days annually[5].
Aim of the project
▪ To decrease the rate of surgical site infection from base line of 13.8% by 50% at
December 31, 2022.
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Rationale
Surgical site infection is one of the most common complications in surgical patients reaching up to
36%[7] in some hospitals not only in studies done in Ethiopia but also in other developing countries
compared to less than 5% in developed countries. There is no published research concerning the
prevalence of the problem in our setup but from a pilot test taken from our hospital before intervention
was13.8 %. The infrastructural and hospital set ups , the number of patients admitted in single room,
huge number of attendants for single patient under care even during wound might contribute for this
raised figure in this set up.
Note:
•
Up to 60% of SSIs have been estimated to be preventable by using evidence-based
guidelines.
•
SSIs account for 20% of all HAIs in hospitalized patients.
•
Each SSI is associated with approximately 7–11 additional postoperative hospital-days.
•
Seventy-seven percent (77%) of deaths in patients with SSI are directly attributable to SSI[9].
3. Problem description and analysis
A driver diagram was used to clarify the existing problem and analysis of the problem was made using
analysis check list geared to pin point the root cause of the problem and thereby giving the possible
solution. The experience from developed countries shows quality improvement in surgical site infection
during the last one decade has good change according to different literatures [10]. WHO has developed a
world class guideline but it is not being used properly. As WHO report of 2018, surgical site infection is
one of the three most causes of morbidity and mortality in surgical patients despite improvement in
knowledge in that area and quality of care as well patient awareness concerning surgical site infection. It
occurs in 2%–5% of patients undergoing inpatient surgery. Approximately 160,000–300,000 SSIs occur
each year in the United States which associated with approximately 7–11 additional postoperative
hospital-days. These Patients have a 2–11 times higher risk of death compared with operative patients
without SSI[11].
5
Primary
drivers
Secondary
drivers
Change Ideas
albumin >3.5
decrease wt for
morbid obesity
Malnutrition
electrolyte and fluid
balance
Age factor
Patient
factor
judicious fluid
adm.
CD4 rise >200
control DM
Immunesuppre
sion
chemotherapy
after immune
reconstituted
radiotherapay after 2
weeks of surgery
Health
worker
factor
Surgical site
Infection
Technical
facor
gentle tissue handling
proper stitch
material use
Behavioural
room temp 2025 c
OR temperature
set up factor
OR
from up down
ventilation
OR structure
being compliant
to SOP
water proof and easly
cleanable
Follow OR SOP
aseptic technique
WHO guideline
Non
adherence to
SOP
prophylactic
antibiotic
specific case related
perioperative
care
decrease excess talk
OR traffic
limit number of theatre
prepation
attends.
Figure 1. Driver diagram model for problem identification and possible solutions (Developed from different literatures
mentioned in the introduction)
Methods
6
The QI Project specifically surgical site infection improvement projected has started from August 1st –
December 31st, 2022 in our hospital with more focus areas being surgical ward and Operation theatre.
The scope of projected was planned to include all patients operated as emergency and elective base in
Haramaya General Hospital during hospital stay until one month post discharge. Due to loss from follow
up which reach 75%, the post discharge follow up was dropped.
Using PDSA cycle, the underlying problems were assessed with the QI team. At the start of the project
base line infrastructural improvement was forwarded to the administration including the request for
purchasing basic surgical ward and operation theatre materials. According to problems with initial
PDSA, interventional measures were introduced on Health workers and supportive staffs how to improve
their daily activities which was training designed on SSI reduction. Data were collected using a checklist
attached with patient chart. There after repeated meetings were conducted and successive evaluation and
modifications made using PDSA cycle.
Measurements
The outcome measurement was the magnitude of surgical site infection after introduction of the quality
intervention while the process measure was the improvement in proper wound management, adherence
to sterile techniques in the OR and proper use of attire in the OR.
Interventions planned and forwarded
1. Infrastructure improvement (Forwarded to the administration and respective stakeholders)
1.1.Emergency OPD level
a. Adequate EOPD space to accommodate moderate to high patient load and able to manage
disaster/causality safely.
b. Install separate procedure room and dressing room
c. Decrease patient EOPD stay to 24 hours which can be done by another QI team.
• Installing radiant heater or AC and insulation of the windows of the OR was
recommended as hypothermia is one of the major risk factor behind patient complication
following surgery.
• Prepare sterile material storage locker/ sealed shelf.
• Make ready staff wear to be cleaned and kept in common shelf where the responsible
person will take care of it.
• Minimize OR traffic
• Prepare white board for procedure, instruments and materials announcement.
7
1.2.Surgical ward
General improvement:
Suggestion on availing standard patient beds, bed pans, general and clinical dirty bin, insulated doors and
windows, stretchers for patient transportations.
Make ready disinfectants for staff hand rub or tap water with soap.
To have all time available oxygen with cylinder or concentrator
Supply continuous consumables materials (disinfectants, safety box, bed sheet, blanket, etc.), staff safety
wears, and materials for wound care
To avail shower facility for admitted patients that will have impact on patient outcome.
2. Practice improvement
EOPD
Increase the alertness to accept and manage emergency patients
Decrease patient stay to 24hrs at emergency
Practice proper wound dressing at separate room.
Ward
✓ Accept emergency patients preoperatively and prepare for further management; specially give
prophylaxis antibiotics as it can be forgotten during emergency procedure in the OR.
✓ Practice proper nursing care starting from patient acceptance to discharge like, proper vital sign
monitoring, medication administration, chart keeping, bed making and proper wound care etc.)
✓ Avoid spectators during wound care and generally keep to one or less attendant per patient.
✓ Full time guard has to be at the get of the wards restricting and monitoring the traffic.
✓ To give continuous health education for patients and attendants while in patient or outpatient
2.3 Operation Theatre
2.4.1 Cleaning practice, ✓ Use of proper proportion of water and chemicals, techniques of cleaning.
✓ OR fumigation routinely (at least once monthly)
2.4.2 Material handling, sterilization and storage practice:
✓ Gown, drapes, and gauze/packs – starting from washing to sterilization strict clear
standard or operating procedure has to be followed
✓ Sterility indicators have to always be used.
✓ Storage place has to be secured from contaminants.
✓ Shouldn’t be opened for prolonged period if surgery is not going to start.
✓ Nonmetallic instruments has to be sterilized through high level disinfectants.eg
glutaraldehyde, enzymatic techniques
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2.4.3 Staff attire and practice (Uniform, mask, cape, ornamentals, and personal stuffs)
✓ Follow strict use of OR wearing norms. Those need to be worn in OR should be
ONLY worn in OR!
✓ Excess talk at operation scene should be avoided!
✓ SOP has to be prepared and operate accordingly
✓ Personal stuffs shouldn’t be taken to operation area(room)
✓ Jewelry shouldn’t be used when scrubbed
✓ Proper scrubbing technique should be practiced
✓ Patient skin should be scrubbed with double agents (eg. Alcohol - povidone, alcoholchlorhexdine, aqua(saline)
✓ Double gloving
✓ Changing of drapes if soaked intraoperatively
✓ Repeat prophylaxis antibiotic if procedure prolongs more than 3hrs
✓ Strict use of WHO surgical safety check list!
Interventions introduced
To come up with the appealing outcome according to the project proposal, intervention in different
aspect of contributing factors for surgical site infection was made.
These are:
•
Preparing training modules based on recent WHO/CDC infection prevention related to surgical
departments which fits for different level of careers (from cleaners to specialties).
•
Training was given for staffs working at surgical ward, and OR on the above training modules
aimed to reduce SSI.
•
OR and ward staffs improved their practice on wound care, wearing on job uniform, timely
giving of prophylactic antibiotics to improve SSI,
•
Cleaning and OR fumigation practiced regularly.
•
Close supervision for staffs on job was provided throughout the project period.
•
The QI team has been conducted a monthly meeting with identifying and suggesting and
evaluating the accomplished activities using repeated PDSA cycle
9
Result
The QI progress was evaluated for a period of five months with an outcome measurement, surgical site
infection reduction. A total of 276 patients were followed until discharge from hospital. During the
project period, the average surgical site infection rate was 8.3% (Figure 1).
Following the intervention, the practice of ward nurses on proper wound management has improved and
second cycle PDSA introduction. Thereafter remain according to the standard throughout the follow up
period (Figure2).
Concerning OR practices, improvement in proper mask and cape use from a base line of 66.7% of the
team reached 96% at the end of the project. There was resistance in using WHO surgical safety checklist
especially during duty times which ranged from 90% practice during the first month of intervention
(figure3). The practice of prophylactic antibiotics administration was there before the intervention, but it
has been given for all patients undergoing surgery. So after the project has started, the administration of
surgical antibiotic prophylaxis (SAP) was restricted according to the guideline.
Overall impact of surgical site infection outcome was also assessed in terms of patient hospital stay and
showed a longer hospital stay in those SSI was developed. The mean days of hospital stay for those who
developed SSI 20 + 11 days. From those who have developed SSI, 2.3% of patients were died.
10
80
68
70
63
60
51
50
43
40
51
48
51
41
Male
40
34
Female
30
Total
30
20
20
17
15
11
10
9
10
Base line
August
September
10
0
October
November
December
Figure1. Sex composition of patients developed surgical site infections at HGH, August – December
2022.
25.00%
20.00%
20.00%
15.00%
11.80%
10.00%
9.80%
7.40%
6.30%
5.00%
5.80%
0.00%
Baseline
August
SSI
September
October
National goal
November
December
Average SSI
Figure2.
Pattern of SSI at HGH during follow period
11
120.00%
100.00%
80.00%
60.00%
nursing practice on wound
management
40.00%
20.00%
0.00%
Figure3. Surgical ward nursing practice on wound management (a cumulative judgment on sterility
techniques, techniques of dressing, and waste disposal) at HGH, 2022
120.00%
Level of practice
100.00%
80.00%
60.00%
OR staff SOP adherence
Surgical safety checklist
40.00%
prophylactic antibiotics
20.00%
0.00%
Figure4. OR staff practice including sterile practice, WHO surgical safety checklist usage and
prophylactic antibiotics administration
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Table1. Trends of the SSI and its Outcome at HGH, August 1 – December 2022
SSI
LOH(mean
+ SD)
Time (months)
June,
August
September
2022
(base line)
6(20%)
6(11.8%)
5(9.8%)
SSI developed
SSI not developed
Overall
October
November
Decem
ber
4(6.3%)
5(7.4%)
3(5.8%)
19.66 + 11.412
5.85 + 3.412
7.90 + 7.28
*LOH=length of hospital stay
Strength and Limitation of the Project: The project is of its kind to be conducted in our
hospital which has introduced EBC for the better patient care. It has improved the way we do our routine
activities making patient care efficient and effective. The operation theatre was not to the standard and
the ward patient care was not optimal. The duration of the project was also a limited period which may
not be adequate to conclude the overall status of surgical site infection. Post discharge follow up was not
possible due to different obstacles mainly as a result of loss to follow up.
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Conclusion and recommendations
The rate of surgical site infection was significantly reduced following the introduction of EBC compared
to the pre-intervention period. The use of WHO surgical safety checklist usage has almost become
complete but more stress has to be made on the components, especially at the sign out period. The
infrastructure improvement and supplies weren’t optimal which need higher governmental
intervention and allocation of adequate budget.
There were areas of improvements like proper wound care, administration of prophylactic antibiotics and
cleaning practices. A Patient who has developed SSI had relatively longer hospital stay; more than
double of what is stated in literatures.
We recommend the hospital quality care team, OT team and surgical ward staffs to follow and monitor
surgical activities which includes inpatient care of surgical patients, proper wound care, OR practice
especially WHO safety checklist use which has faced sever resistance and need close supervision. The
administration of HGH also has to fulfill basic and standard materials for surgical care, standardize the
infrastructure aforementioned in method part. HGH has to prepare a tracing mechanism and reaching
patients lost to follow up during the post discharge period so that the status of surgical site infection can
be known.
14
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
J. Rose, T. G. Weiser, P. Hider, L. Wilson, R. L. Gruen, and S. W. Bickler, "Estimated need for surgery
worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate,"
The Lancet Global Health, vol. 3, pp. S13-S20, 2015.
R. M. Pearse et al., "Mortality after surgery in Europe: a 7 day cohort study," The Lancet, vol. 380, no.
9847, pp. 1059-1065, 2012.
S. Mukhopadhyay, K. Ojomo, K. Nyberger, and J. G. Meara, "Lancet commission on global surgery," Iran J
Pediatr, vol. 27, no. 4, pp. 1-7, 2017.
C. GlobalSurg, R. Karlo, E. Domini, and J. Mihanović, "Mortality of emergency abdominal surgery in high-,
middle-and low-income countries," British Journal of Surgery, vol. 103, no. 8, p. 971, 2016.
B. M. Biccard et al., "Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day
prospective observational cohort study," The Lancet, vol. 391, no. 10130, pp. 1589-1598, 2018.
T. Ahmad et al., "Global patient outcomes after elective surgery: prospective cohort study in 27 low-,
middle-and high-income countries: the International Surgical Outcomes Study group," British Journal Of
Anaesthesia, vol. 117, no. 5, pp. 601-+, 2016.
J. A. Forrester et al., "Development of a surgical infection surveillance program at a tertiary hospital in
Ethiopia: lessons learned from two surveillance strategies," Surgical Infections, vol. 19, no. 1, pp. 25-32,
2018.
B. Badhaasaa B., Fufa M., Mohammed M., Gelana F., "Postoperative complication and associated factors
among patients operated at Hiwot Fana specialized University hospital, Harar, eastern Ethiopia: A
prospective cohort," 2019.
W. H. Organization, "Protocol for surgical site infection surveillance with a focus on settings with limited
resources," ed: WHO, Geneva, Switzerland. Available at: https://www. who. int …, 2018.
W. G. A. b. t. G. R. Committee, "Global guidelines for the prevention of surgical site infection," Geneva:
World Health Organization, 2016.
W. H. Organisation, Global guidelines for the prevention of surgical site infection,, second edition ed.
Geneva, 2018.
15
ANNEX
Activity Monitoring Tool
This activity will be monitored through the separate checklist prepared for data collectors and supervisors as follows:
Socio demographic status of the patient
Urgency of surgery □ Emergency □ Urgency □Elective
Comorbidities □ Yes □ No;
Co-morbidities optimized: □Yes □ No
ASA class □ I □ II □ III □ IV □ V
16
▪
▪
▪
▪
▪
▪
▪
Was SSI diagnosed? □ Yes □ No
Was the patient readmitted? □Yes □No
Was the patient re operated? □Yes □No
Other post-surgery complications. □Yes □ No if yes, specify -------------------Duration of hospital stay_________________________
Cost charged for treatment approx. (calculated from payment receipt ________
Level of satisfaction to care given: □very good □ good □ unsatisfied □no comment
Supervision and evaluation tool
17
The following will be filled with supervisors or SSI QI committee on weekly period taking the data
of every day performance.
Ward:
1.
2.
3.
4.
5.
Do you use basic dressing set for every patient yes/no
Sterilization ward/CSR
Indicator use yes/no if no, reason--------------Hand wash/ alcohol rub before and after every contact yes---------------------/no-----------If no, reason ----------------------------------
Practice
CHG showering,
Shaving
yes
no
------------- ------
----------
-------------------
------------
Wound care with D set. ------------------------Prophylactic Antibiotic
--------------
--------------------------
-----------
On practice evaluation
During dressing (tally)
1.
2.
3.
4.
5.
Yes/
Used sterile set, and sterile glove
-----------------disposable glove used
----------------hand rub or wash
------------------use other protective (mask ,goggle, apron ) ----------Number of attendants watching during the wound care per room
no
-----------------------------------------------------------------------------
Room 1--------- Room 2-------- Room 3----------- Room 4 -------------6. Patients with SSI ----------7. Total patients got postoperative wound care -------OR (Tally)
1.
2.
3.
4.
5.
6.
7.
8.
9.
OR thermometer installed yes /no
Room temp. --------Proper gown, mask and cape usage yes (tally)_______________/no____________
Operation team scrubbed with ________
Patient skin cleaned with ______
Hair removal for indicated _______
Prophylactic ant
Indicated____ given _______
WHO check list used yes-----------------------------/ no-----------------------------Sterility indicator use yes/no
18