Martin Kiernan

Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients.

BACKGROUND Care bundles are a strategy that can be used to reduce the risk of surgical site infection (SSI), but individual studies of care bundles report conflicting outcomes. This study assesses the effectiveness of care bundles to reduce SSI among patients undergoing colorectal surgery. METHODS We performed a systematic review and meta-analysis of randomized controlled trials, quasi-experimental studies, and cohort studies of care bundles to reduce SSI. The search strategy included database and clinical trials register searches from 2012 until June 2014, searching reference lists of retrieved studies and contacting study authors to obtain missing data. The Downs and Black checklist was used to assess the quality of all studies. Raw data were used to calculate pooled relative risk (RR) estimates using Cochrane Review Manager. The I(2) statistic and funnel plots were performed to identify publication bias. Sensitivity analysis was carried out to examine the influence of individual data sets on pooled RRs. RESULTS Sixteen studies were included in the analysis, with 13 providing sufficient data for a meta-analysis. Most study bundles included core interventions such as antibiotic administration, appropriate hair removal, glycemic control, and normothermia. The SSI rate in the bundle group was 7.0% (328/4,649) compared with 15.1% (585/3,866) in a standard care group. The pooled effect of 13 studies with a total sample of 8,515 patients shows that surgical care bundles have a clinically important impact on reducing the risk of SSI compared to standard care with a CI of 0.55 (0.39-0.77; P = .0005). CONCLUSION The systematic review and meta-analysis documents that use of an evidence-based, surgical care bundle in patients undergoing colorectal surgery significantly reduced the risk of SSI.

A benchmark too far: findings from a national survey of surgical site infection surveillance

BACKGROUND The national surgical site infection (SSI) surveillance service in England collates and publishes SSI rates that are used for benchmarking and to identify the prevalence of SSIs. However, research studies using high-quality SSI surveillance report rates that are much higher than those published by the national surveillance service. This variance questions the validity of data collected through the national service. AIM To audit SSI definitions and data collection methods used by hospital trusts in England. METHOD All 156 hospital trusts in England were sent questionnaires that focused on aspects of SSI definitions and data collection methods. FINDINGS Completed questionnaires were received from 106 hospital trusts. There were considerable differences in data collection methods and data quality that caused wide variation in reported SSI rates. For example, the SSI rate for knee replacement surgery was 4.1% for trusts that used high-quality postdischarge surveillance (PDS) and 1.5% for trusts that used low-quality PDS. Contrary to national protocols and definitions, 10% of trusts did not provide data on superficial infections, 15% of trusts did not use the recommended SSI definition, and 8% of trusts used inpatient data alone. Thirty trusts did not submit a complete set of their data to the national surveillance service. Unsubmitted data included non-mandatory data, PDS data and continuous data. CONCLUSION The national surveillance service underestimates the prevalence of SSIs and is not appropriate for benchmarking. Hospitals that conduct high-quality SSI surveillance will be penalized within the current surveillance service.

Surgical site infection: poor compliance with guidelines and care bundles.

Surgical site infections (SSIs) are probably the most preventable of the health care‐associated infections. Despite the widespread international introduction of level I evidence‐based guidelines for the prevention of SSIs, such as that of the National Institute for Clinical Excellence (NICE) in the UK and the surgical care improvement project (SCIP) of the USA, SSI rates have not measurably fallen. The care bundle approach is an accepted method of packaging best, evidence‐based measures into routine care for all patients and, common to many guidelines for the prevention of SSI, includes methods for preoperative removal of hair (where appropriate), rational antibiotic prophylaxis, avoidance of perioperative hypothermia, management of perioperative blood glucose and effective skin preparation. Reasons for poor compliance with care bundles are not clear and have not matched the wide uptake and perceived benefit of the WHO ‘Safe Surgery Saves Lives’ checklist. Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon‐specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients.

Surveillance of surgical site infection: more accurate definitions and intensive recording needed

Surgical site infection (SSI) continues to be a burden on systems that deliver healthcare and on patients who suffer morbidity, and mortality, associated with this complication of medical intervention. Surveillance of SSI is often an integral part of organizational infection prevention and control activities, but unless post-discharge surveillance is carried out in a robust manner the data may be inaccurate and misleading. Coupled with a lack of robust application of definitions, variations in methods of case-finding and incomplete follow-up, the results may lead to a false sense of security or conversely cause unnecessary anxieties. Data from national surveillance schemes that purport to be suitable for benchmarking are often at odds with published rates from well-designed studies and the reasons for this should be examined. If benchmarking is truly desirable and if clinicians are to have confidence in the outputs, surveillance schemes should ensure that participating organizations adopt a consistent approach to definitions, case-finding methodologies following discharge, and to robust follow-up, to ensure that every opportunity is taken to maximize the return rate and enhance data validity.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery.

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

Reliable surgical site infection surveillance with robust validation is required

We would like to thank Lamagni and her colleagues from the Health Protection Agency for their interest in our paper. While they state in their letter that post-discharge surveillance (PDS) is not used for benchmarking, and therefore NHS hospital trusts which conduct PDS are not penalized, we should like to point out that inconsistencies were also found among inpatient and readmission data which are used for benchmarking. Therefore trusts could be penalized. They also claim that the national surveillance programme, which collects inpatient and readmission data, produces reliable data. However, one of the authors of the Lamagni letter appears to contradict this in an article in the Journal of Infection Prevention (January 2013 issue): Wilson discusses various data collection methods, such as prospective, active, passive, staff reporting, telephone follow-up of laboratory reports only, liaison with ward staff and case note review, and states how each of these methods has a ‘major effect’ on reported surgical site infection (SSI) rates. All of these data collection methods are permissible in the current national surveillance programme, yet Wilson goes on to argue that a national surveillance system must prescribe data collection methods that minimize the risk of selection and measurement bias, thereby enabling comparisons between hospitals. Wilson further states e in effect supporting the claims of our paper e that reliable surveillance methods are desirable if data are to be trusted by surgical teams and also calls for robust validation systems. We should also like to point out the unreliability of using readmission data as a surrogate for post-discharge data. In the current climate many organizations are developing admission avoidance strategies. Increasingly patients with SSIs that may have caused readmission a few years ago may now be treated effectively in the community with therapies such as vacuumassisted closure, expert nursing wound management or

Assessment of the efficacy of a patient hand wipe: development of a test method

BACKGROUND Much attention has focused on hand decontamination for healthcare workers, but little attention has been paid to patient hand hygiene. Patients confined to bed are often unable to access handwashing facilities. They could use an alcohol hand rub, but these are not advised for soiled hands or social hand hygiene. One alternative is the use of a hand wipe. However, it is important to ascertain the effectiveness of hand wipes for removal of transient micro-organisms from the hands. AIM To develop a method to assess the antimicrobial efficacy of hand wipes compared with handwashing, and thus determine if a hand wipe can be acceptable for patient hand hygiene. METHODS The methodology was based on European Standards EN 1499 (2013) and EN 1500 (2013) as there is no standard for hand wipes. The hands of 20 healthy volunteers were contaminated artificially by immersion in Escherichia coli, and then sampled before and after the use of a reference soft soap or hand wipes for 60 s. The counts obtained were expressed as log10, and the log10 reductions were calculated. FINDINGS The hand wipe with no antimicrobial agent (control wipe) was inferior to the soft soap. However, the antimicrobial hand wipe was statistically non-inferior to the soft soap. A log10 reduction of 3.54 was obtained for the soft soap, 2.46 for the control hand wipe, and 3.67 for the antimicrobial hand wipe. CONCLUSION The evidence suggests that the antimicrobial hand wipe, when applied for 60 s, is at least as good as soap and water, representing an acceptable alternative to handwashing from a bactericidal perspective.

The role of antimicrobial sutures in preventing surgical site infection

INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patients pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).

Prevention is better than cure: The role of infection prevention in the control of antimicrobial resistance:

On the 18th of November, Europe will again be holding Antibiotic Awareness Day (EAAD). Antimicrobial resistance (AMR) is a topic high on national and international agenda at the present time and is likely to remain so for the foreseeable future. Resistance is rising, associated costs, both human and financial, are significant and there are no new antimicrobial classes riding over the horizon to reverse this situation. The question of ‘where does infection prevention fit into the AMR programme’ has never been more relevant. An antibiotic after all could really be considered to be a fire extinguisher that puts out the flames of infection; however, there are a number of criteria that have to be met before ignition takes place, many of which may be modified, or at least mitigated, in order to prevent infection and therefore the use of antibiotics. Colonisation by potential pathogens is a natural human state and infection could be considered (like a weed) to be an organism out of place. Prevention interventions are therefore twofold: to reduce the risk of transfer of pathogens to others and to protect the person from themselves. When considering the routes of transmission from person to person, a number of interventions are possible, from advanced source control (Apisarnthanarak et al., 2014), through environmental hygiene (Anderson et al., 2017) to hand hygiene (Sickbert-Bennett et al., 2017). There are interventions at each point in the transmission journey, yet the evidence is that these are not reliably implemented (Anderson et al., 2011; Mitchell et al., 2015) leading to continuing risks to patients. Hand hygiene, despite healthcare providers reporting extremely high levels of compliance, is an area that still needs to be given attention as many practitioners are well aware of suboptimal compliance in their organisations. Interventions aimed at protecting the patients from themselves has probably the greater evidence base, since there are less links in the chain to cause confounding. We have the evidence for interventions that demonstrate that the right practices, implemented consistently, for every patient will reduce infections and yet study after study demonstrates that even in research studies, interventions are not reliably implemented. A 2016 meta-analysis that examined the effectiveness of bundles has concluded that insertion and maintenance bundles for central venous lines are effective (Ista et al., 2016); however, these authors also decided to analyse reported compliance with the bundles of the included studies. They found that, even in research studies of bundle implementation, compliance was rarely reported, with over two-thirds of papers not reporting compliance at all, and of the studies that did report, it was suboptimal in every single one. Many of the studies included in the meta-analysis showed no benefit from the use of a bundle; however, in failing to report the compliance with the bundle, the validity of findings from studies that do not present compliance data could be questioned Compliance with infection control first appeared in 1966 (Kunin and McCormack, 1966) and since that time the evidence base for effective interventions has steadily grown. We now know what to do (or what should be done); however, it seems that we do not yet know how to get fellow healthcare professionals to implement interventions of benefit to patients in a sustainable manner. The reasons for this require urgent study and those designing intervention studies should consider including implementation scientists in their research teams as the evidence to date is that we have either not been doing this well or that we are not reporting this aspect. The study previously mentioned (Ista et al., 2016) noted the high proportion of studies that have studied clinical outcomes of bundle interventions but not whether the interventions were actually implemented. Reviewers of papers submitted to journals should be asked to consider this aspect when considering if a paper is suitable for publication. Studies of protocol compliance could precede further investigation of the reasons for non-implementation. Perhaps we have been using the wrong terminology. Prevention is better than cure: The role of infection prevention in the control of antimicrobial resistance

Lessons in implementing infection prevention

This paper has been developed from a conference presentation given by Professor Alison Holmes at the IPS Learning Labs launch event (2015). In it the implementation of research into clinical practice is discussed with reference to the upcoming Health Foundation Spotlight Report. The difficulties of engaging those in clinical practice are discussed with the importance of involvement of clinical leaders being highlighted. The importance of recognising that implementation science as a social process to bring credibility and legitimacy is also stressed. Following this, the Spotlight Report that is focused on strengthening implementation in the UK is discussed. There remains considerable scope for improvement and the impact of surveillance, targets and fatigue are considered. The tension between top–down and bottom–up approaches to implementation are discussed and a recommendation for a blended approach when implementing measures that are the components of an organisational infection prevention and control strategy is proposed. There also needs to be more scrutiny of the reasons for the failure of research implementation through an examination of the ‘soft periphery’ that comprises the organisational structure, systems and people that will be responsible for implementing and sustaining an intervention.