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Wound infections after surgery: Which bundle of measures are effective?

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At the end of 2019, the roundtable on “Wound infections after surgery: Which bundle of measures are effective?” of the “Initative Sicherheit im OP” (Initiative for Safety in the Operating Room) took place in Vienna. At the round table, which was organised jointly with the “Plattform Patientensicherheit” (Patient Safety Platform), experts from various disciplines and professions discussed which measures of SSI prevention have proven to be particularly effective and which steps are necessary for further improvement.

The key statement of the expert round was: For the prevention of surgical site infections (SSI), it has proven effective to combine particularly important measures into a bundle of measures (“bundle strategy”), to implement this bundle and to monitor compliance with it.

“According to the European Centre for Disease Prevention and Control (ECDC), surgical site infections (SSI) are among the most common nosocomial infections. The proportion of SSI per 100 surgical interventions varies between 0.6 and 9.6 percent depending on the type of intervention and the predisposition of the patients”, reported Dr. Ojan Assadian (President of the Austrian Society for Hospital Hygiene). “With regard to all nosocomial infections, the ECDC assumes that 20 to 30 percent of such infections can be prevented by appropriately targeted hygiene and control programmes”.

Recommendation of the experts

A number of factors increase the risk of postoperative infection. Some factors can be influenced by patients or medical staff, but others are not (yet), Prof. Assadian explained. “Since infections often have more than one cause, single measures for prevention are not sufficient. For this reason, bundle strategies are now used in hygiene, in which clinically better investigated individual measures are combined to form meaningful combinations,” said Prof. Assadian. “These bundles include measures that should be followed by the treatment team or the patient him/herself before, during and after the operation. Therefore, appropriate information and training of the patient prior to a planned operation are essential elements in increasing patient safety”.

Section head Dr. Silvia Türk (Austrian ministry for Labour, Social Affairs, Health and Consumer Protection) indicates, that “a successful approach against such infections is a medical necessity, saves many humans from suffering and reduces follow-up costs for the health system”.

Bottom-up culture

Dr. Brigitte Ettl (Hospital Hietzing Vienna; President of the Patient Safety Platform) explains: “The responsibility for hygiene in hospitals cannot be delegated. This is about leadership responsibility and setting an example.” The fact that the specified hygiene measures apply to all employees must be clearly communicated. If an employee violates them, there must be a private discussion and, in case of recurrence, disciplinary measures.

“For a successful fight against nosocomial infections, we need to rethink and take a consistent approach. We need to move towards education, training, transparency and the drawing of consequences”, demanded the Viennese patient advocate Dr. Sigrid Pilz. Clear definition of procedures and rules, accompanied by clear documentation, is required. Taking hand disinfection as an example: “Today, we have digital control for so many things, why not in this context as well? One should use chips to check who disinfects their hands in a hospital and who doesn’t. Anyone who does not do so has to expect disciplinary measures.”

Antibiotic Stewardship

“A very essential point in the prevention of SSI is a rational antibiotic management, which we now call antibiotic stewardship. Antibiotic prophylaxis during operations is often not state of the art. Antibiotics are often administered too early, in too high doses and for far too long”, said Prof. Dr. Heinz Burgmann (Head of the Clinical Department of Infections and Tropical Medicine, Medical University Vienna). “A recent German study shows, that 13 to 15 percent of all antibiotics used are administered in hospitals, so we are talking about a considerable quantity dimension”. However, every unnecessary antibiotic administration harms the patient, increases the antibiotic consumption unnecessarily and increases the risk of resistance developing. Hospitals should work in an interdisciplinary team to determine how antibiotic prophylaxis must be carried out in general and define standards and exceptions must be justified.

“The anaesthetist is the medical manager in the operating room and our scope of duties is correspondingly broad”, said Prof. Dr. Klaus Ulrich Klein (University Clinic for Anaesthesia, General Intensive Care Medicine and Pain Therapy, Medical University Vienna). “Many routine measures in our daily practice have an influence: For example, the adequate and timely use of antibiotics, adherence to hand hygiene according to WHO standards, the wearing of gloves, especially during intubation and when putting on medication, or the disinfection of the workplace and working environment”.

Digitalisation and medicine

An important trend is digitalisation: “Today, data networking and systems with artificial intelligence offer help in decision-making and in identifying errors. It has been shown that a drop in body core temperature or a derailment of the blood sugar level is associated with increased infections. With the help of digital systems, a warning and a therapy suggestion can be made immediately”, says Prof. Klein.

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