|Year : 2016 | Volume
| Issue : 1 | Page : 10-16
Surgical patients' safety in the polish hospital environment in the context of selected infection control practices in surgical wards
Anna Rozanska, Jadwiga Wojkowska-Mach, Małgorzata Bulanda, Piotr B Heczko
Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
|Date of Web Publication||31-Mar-2017|
Chair of Microbiology, Jagiellonian University Medical College, Czysta Street, 18, Kraków 31-121
Source of Support: None, Conflict of Interest: None
Background: Surgical site infections (SSIs) still continue to be a major cause of morbidity and mortality despite the improvement in methods for infection control as well as surgical practices. The aim of this work is the presentation and analysis of SSI control practices in selected surgical wards in Poland as compared to other European countries.
Methodology: The presented data were obtained using a standardised questionnaire within a European project devoted to describing and analysing the surveillance of nosocomial infections in individual European countries.
Results: In all studied wards, written procedures of SSI prevention were present, as well as obligatory training of ward personnel concerning infection control. Alcohol-based hand rub dispensers were available in over 75% points of care in most wards, as opposed to belt/pocket bottles, which were available for a small number of ward personnel. Alcohol solutions were most often used for skin preparation. Shaving immediately before operations was the most common way of hair removal. A WHO checklist was used in 20% of the studied wards.
Conclusions: Based on the results of the study, the organisation of surveillance infections in Polish surgical wards appears to be satisfactory. However, practical implementation of SSI prophylaxis calls for significant alterations, both in terms of executing training and implementing practices in the wards or the operating room. On the one hand, due to a lack of multicentre studies on the epidemiology of SSI in Polish surgical wards, actual exposure to SSI cannot be assessed.
Keywords: Hand hygiene, infection prevention, patient safety, skin disinfection, surgical site infections
|How to cite this article:|
Rozanska A, Wojkowska-Mach J, Bulanda M, Heczko PB. Surgical patients' safety in the polish hospital environment in the context of selected infection control practices in surgical wards. J Patient Saf Infect Control 2016;4:10-6
|How to cite this URL:|
Rozanska A, Wojkowska-Mach J, Bulanda M, Heczko PB. Surgical patients' safety in the polish hospital environment in the context of selected infection control practices in surgical wards. J Patient Saf Infect Control [serial online] 2016 [cited 2018 May 24];4:10-6. Available from: http://www.jpsiconline.com/text.asp?2016/4/1/10/203542
| Introduction|| |
Nosocomial infections (NIs) represent a major proportion of adverse healthcare events that negatively affect hospital treatment quality and patient safety.
Despite a steady improvement in infection control methods and surgical practice, surgical site infections (SSIs) remain an important cause of patient morbidity and mortality. According to data provided by the American National Healthcare Safety Network program, SSIs represent the third most common type of NI, accounting for 15% of all clinical infections, and as many as 38% of those observed in surgery patients. European data also attest to the seriousness of the issue; the reported incidence of SSIs can be as high as 20%, depending on the procedure, sensitivity of registration methods and definitions adopted.
Post-operative SSI complications prolong recovery time and sometimes cause permanent health damage and even death, as well as generate additional costs for healthcare providers, payers and patients.,,
Consequently, research into SSI surveillance, with special emphasis on effective prevention procedures, has burgeoned and continues to find multiple practical applications in the field. International and national sets of recommendations have been drafted to introduce pre-, intra-and post-operative procedures to minimise SSI risk. These guidelines include maintaining hand hygiene by medical staff involved in patient care, stabilising the condition of the patient (e.g., maintaining stable sugar levels, encouraging tobacco cessation), implementing peri-operative antibiotic prophylaxis and introducing rules of conduct in the event of colonisation (including symptomatic infections among staff), as well as adequate patient preparation/antiseptic preparation of the surgical site.,,
An indispensable first step in the effective implementation of SSI risk-reduction procedures is the establishment of an infection control team (ICT); this step alone, however, does not guarantee that theory will smoothly translate into practice. Among the barriers to implementing risk-reduction strategies is the scarcity of human and organisational resources, an inauspicious atmosphere surrounding infection surveillance, which may manifest itself in interpersonal communication issues and inadequate co-operation between the ICT and the staff in individual wards, as well as inefficient needs assessment, caused by a lack of epidemiological registration and analysis mechanisms in a given hospital, region or country.
Conditions may vary across the world, and even within individual European Union (EU) member states, depending on specific socioeconomic and cultural factors. To describe and analyse NI surveillance systems at work in individual European countries, and in particular, to identify obstacles to introducing evidence-based procedures for NI prevention, the “Prevention of Hospital Infections by Intervention and Training” (PROHIBIT) project was carried out between 2010 and 2013. A further aim of the project was to investigate the possible uses of surveillance data for comparisons between individual hospitals at a national and European level. The project was divided into several modules; the particular objective of WorkPackage3 was to describe the current system of surveillance organisation in specific countries based on standardised surveys.
In Poland, the project was carried out in co-operation with the national consultant for epidemiological nursing under the honorary auspices of the chief sanitary inspector. The current paper aims to present the findings of the survey with regard to the functioning of surveillance systems in surgical wards across Poland.
| Methodology|| |
The study was conducted in 2011, based on a standardised survey that focussed on surveillance organisation in hospitals, specifically in three types of units: Intensive Care Units, surgical and non-surgical wards. These surveys were drafted at the Institute of Hygiene and Environmental Medicine at the Charité University of Medicine in Berlin and translated into Polish at the Chair of Microbiology of the Jagiellonian University Medical College in Kraków. They were then distributed among hospital staff; ICTs were asked to answer questions concerning the hospital and either ward staff or ICT members completed the other sections. Thirty-four European countries were invited to participate in the study, and 24 submitted their data for final analysis. A total of 512 wards in 294 hospitals completed the section focusing on surgical units.
In Poland, questionnaires were sent to thirty facilities. Ten wards from nine hospitals submitted data for analysis (compared to the European average of 12.25), including three small hospitals (up to 199 beds), two medium-sized hospitals (200–499 beds) and four large hospitals (more than 500 beds), most of them public (six facilities). [Table 1] presents the detailed characteristics of the hospitals participating in the study.
Survey questions focussing on surgical wards concerned:
- The structure and organisation of the unit, i.e., its size and profile, admission rates, nurse employment and availability of alcohol-based hand hygiene solutions
- The infection control programs implemented in the unit, including the scope and basis of individual procedures and the scope and audience of relevant training
- The scope of SSI surveillance
- Process and outcome indicators such as the use of alcohol-based hand hygiene solutions in 2010.
The study was approved by the Ethical Committee of Jagiellonian University (KBET/267/B/2014).
A Chi-square test was used for analysing the statistical importance of five process indicators in Polish versus all European hospitals participating in the study.
| Results|| |
The organisation of infection control in terms of the number and composition of ICTs and hospital-level committees complied with the relevant Polish legal requirements in all nine Polish hospitals that submitted data on surgical wards for analysis.
The mean number of beds per ward in Polish surgical units equalled 52 (standard deviation – 30.0) and the median was 37, only slightly higher than in the European group as a whole (30 beds). Both the mean and the median number of single rooms in Poland were nearly 50% lower than the corresponding European figure: 3.51 and 7.14, respectively. The bulk (i.e., 60%) of Polish hospital wards is general surgery units; other units perform specialised procedures, i.e., orthopaedic, vascular or cardiac surgery. The median admission rate for Polish wards, i.e., 2230.5, was much higher than in European hospitals (1478), exceeding the q3 value (the 3rd quartile, i.e., 75% percentile) of admissions in the entire group under analysis. The median length of stay was higher in Poland than in any other European ward, at 6.13 days, as compared to 5.63 days. The figures are reversed for bed occupancy: 56.8% in Poland and 75.03% in the European group.
Polish and European surgical units reported similar nurse employment rates; in both cases, the median value was 8 even though the number of nurses per bed indicator was lower in Poland than in the survey group as a whole: 0.16 and 0.27, respectively. Detailed data about the 10 Polish surgical units are shown in [Table 2].
Questions focussed on infection control in surgical units investigated, in particular, issues such as the amount and scope of training offered to the ward staff, availability and type of prevention strategies and selected practical measures recommended in accepted SSI prevention guidelines.
All hospital units in the study implemented infection surveillance programs, and the relevant procedures were put in writing. Half of the units developed procedures based on national and international guidelines and current scientific findings; one unit additionally relied on the personal experience of the person in charge of the drafting process. The remaining units primarily relied on current research reported in relevant literature; in addition, depending on the unit, international and national recommendations and the personal experience of the authors were taken into account. A common reason for implementing infection control programs was the need to adjust the operation of the unit to ensure comprehensive patient safety. Three wards additionally admitted that the move was motivated by statutory requirements, four wished to collect data for internal benchmarking and four for external benchmarking purposes. Most wards (60%) implemented infection control mechanisms no more than 5 years before the survey; the figure was similar for the entire European group.
All surveyed wards regularly held mandatory staff training on infection control; only half, however, answered the question about its scope. In most cases (80%), training covered surveillance procedures for all infection types, multidrug-resistant microorganisms and hand hygiene. One unit indicated hand hygiene as the only subject matter. In the entire European group, 82% of hospital wards declared that they organised regular mandatory training. The scope of this training also significantly exceeded that reported in the Polish group; for the surveillance of different infection types, it ranged from 30% (for pneumonia) to 73% (for SSI). Like in Poland, however, the training also focussed mainly on hand hygiene (95%). Over the 12-month period before the study, special educational measures were implemented in 70% of Polish wards and only 19.5% of all surgical units that submitted answers to this part of the survey (their subject matter was not further specified).
Data on the implementation of selected SSI prevention measures and procedures in Polish hospital units and the mechanisms adopted in the European group as a whole are presented in [Table 3]. All Polish wards have written procedures for infection control. Only one-third rely on the (original or modified) WHO checklist, a low figure when compared to the European rate of 62%. In 70% of Polish wards, it is primarily the operating surgeon who implements peri-operative prevention mechanisms, compared to 54% in European hospitals. Surgical site preparation practices, and in particular hair removal methods and use of disinfectants, also differ between Polish and European wards. In Poland, 70% of wards remove hair by shaving and 30% by cutting, directly before surgery; relevant figures for the entire group are 41 and 24%, respectively [Table 3]. Polish wards primarily (50%) use alcohol for pre-operative skin disinfection. Both alcohol-based iodine solutions and non-alcohol-based 2% chlorhexidine solutions are used in 20% of Polish wards. In comparison, nearly half (47%) of all European wards use iodine solutions, one-fifth use alcohol and the rest rely on other agents. Octenidine-based disinfectants are the least frequently chosen, used in only 2%–12% of all hospital units [Table 3].
|Table 3: Implementation of evidence-based infection control practices in wards|
Click here to view
One of the outcome indicators investigated in this study was the use of alcohol-based hand hygiene solutions. In Polish units, the median rate was 10.25 ml/patient day lower than the corresponding figure for European wards (13.75 ml). Alcohol-based hand-hygiene solutions were available in two out of 10 (20%) Polish units in the form of pocket/belt bottles, compared to 173 out of 512 (34.2%) in the entire European group.
However, Polish wards surpass their European counterparts in terms of the availability of alcohol-based agents at the point of care [Table 3].
| Discussion|| |
In Poland, NI surveillance, including infection surveillance in surgery patients, is mandated by law; relevant regulations (legally equivalent to an act of parliament) have already been in place for more than 10 years. In compliance with statutory requirements, most Polish hospitals have established nosocomial ICTs, composed of adequate numbers of qualified staff.
Surgery patients are at a high risk of developing NIs of all kinds and SSIs in particular. For this reason, it is particularly important to implement special measures in surgical wards. All Polish hospital units in the survey have implemented SSI prevention guidelines and put them in written form. It should also be noted that they all hold regular mandatory staff training devoted to infection control. Only one-third indicated that their reason for implementing SSI prevention measures was the need to register infections for mandatory reporting to an external control body. Most wards (90%) justified their move by citing the need to improve patient safety. Accordingly, effective infection surveillance systems seem to be promoted by an auspicious patient safety and service quality climate; their organisation cannot be criticised before more detailed analysis of these factors.
However, based on a close inspection of survey data, we can identify several areas in which improvements to the situation are advisable or indispensable.
The survey showed significant disparities between Polish and European surgery wards, especially in terms of the number of single rooms, mean length of stay, annual admission rate, the nurse per bed ratio and availability and use of alcohol-based hand hygiene solutions. European hospitals have twice as many single rooms as their Polish counterparts. In Poland, the number of nurses per bed is lower by 40%; bed occupancy, on the other hand, is 20% lower. These disparities are mainly due to the (under) funding of Polish healthcare. According to Organisation for Economic Co-operation and Development data, Polish per capita spending on healthcare in 2009 amounted to approximately USD 1394 (compared with the mean figure of 3233) and was lower than in any other EU member state except Estonia.
On the other hand, failure to implement simple, low cost, easy-to-use solutions, such as the WHO checklist, cannot be attributed to underfunding; rather, it stems from the lack of appropriate post-graduate training in infection control for doctors and nursing staff, as well as ICTs. The same holds for the low use of alcohol-based hand hygiene agents (10.25 ml per patient day in Poland vs. 13.75 ml in Europe), which may stem from the widespread distrust of personal/pocket dispensers. This aversion ignores their important advantage: They are available everywhere and at all times. The lack of appropriate habits and low awareness of the importance of hand hygiene both contribute to the situation. The low rate of implementation of these solutions is particularly dangerous since as the survey showed, in Poland, smaller numbers of staff are involved in caring for a larger number of patients.
The low consumption of alcohol-based hand rub solutions for hand hygiene revealed in this study seems to confirm poor compliance with preventive procedures in this matter reported in the study by Garus-Pakowska et al.,
An important problem for the implementation of advanced infection control procedures is the prevalent attitude towards staff training. On the one hand, Polish surgical wards tend to rely on inefficient forms of labour organisation, for example, showing a preference for shaving over other methods of hair removal. On the other hand, regular staff training has not yet addressed many important subjects that are essential for surgical patients. It is important to bear in mind the fact that the subject literature has repeatedly emphasised the importance of ceasing the practice of pre-operative hair removal for the prevention of SSI risk.,
It is also difficult to explain the Polish choice of primary surgical site disinfectant, which is different than in other surveyed countries. The consensus now is that preferred agents for skin application should be alcohol-based solutions containing iodophors, chlorhexidine gluconate or other substances., Accordingly, only 30% of surveyed wards conform to the relevant international recommendations.
Unfortunately, an objective estimate of the impact of prevention procedures on SSI risk in Polish hospitals is not yet possible. Attempts at benchmarking based on epidemiological indicators reported in literature on other European countries are essentially problematic because of the basic differences in hospital service delivery, available resources and various socioeconomic determinants that affect patient populations.,
In addition to the need for improving patient safety, only one-third of surveyed wards indicated their intention to collect data for external benchmarking; 50% mentioned both external and internal benchmarking. Infection surveillance involves registration, analysis, feedback reporting on results and conclusions to the ward staff and benchmarking based on data from other facilities, with special attention paid to patient profile, specialisation of the ward and other factors determining infection risk. So far (as of 2013), Poland has introduced only one voluntary program bringing together more than a dozen hospitals (2% of the general number); this will permit collection of data for future benchmarking but only after a few more years have passed.
Even though research into SSI epidemiology has been underway in Poland for more than 10 years, no multicentre evidence is available from shared national infection surveillance programs using standardised definitions, patient qualification principles, etc. Several attempts to establish such programs have been made,,, but they have not met with full approval and willing cooperation.
Improving the practices that influence patients safety affects not only the quality of healthcare but also protects hospitals against claims connecting with adverse effects.
| Conclusions|| |
The infection surveillance system currently implemented in Polish surgical wards seems satisfactory, conforming to all legal requirements and international recommendations. However, the practical implementation of SSI prevention calls for significant improvements, in terms both of staff training and of the practices introduced at the level of individual wards and operating theatres.
Because of the lack of multicentre research on SSI epidemiology in Polish surgical units, it is impossible to estimate actual SSI risk; this is precisely the reason why a common national SSI surveillance program should be introduced.
This work was supported by funding from the European Community (PROHIBIT consortium agreement 2009-241928). The funding agencies had no role in the preparation, review or approval of the manuscript.
Financial support and sponsorship
This work was supported by funding from the European Community (PROHIBIT consortium agreement 2009-241928).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Owens CD, Stoessel K. Surgical site infections: Epidemiology, microbiology and prevention. J Hosp Infect 2008;70 Suppl 2:3-10.
Leaper DJ, van Goor H, Reilly J, Petrosillo N, Geiss HK, Torres AJ, et al.
Surgical site infection – A European perspective of incidence and economic burden. Int Wound J 2004;1:247-73.
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;37:387-97.
Shepard J, Ward W, Milstone A, Carlson T, Frederick J, Hadhazy E, et al.
Financial impact of surgical site infections on hospitals: The hospital management perspective. JAMA Surg 2013;148:907-14.
Jenks PJ, Laurent M, McQuarry S, Watkins R. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect 2014;86:24-33.
Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al.
Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039-46.
Cima R, Dankbar E, Lovely J, Pendlimari R, Aronhalt K, Nehring S, et al.
Colorectal surgery surgical site infection reduction program: A national surgical quality improvement program – Driven multidisciplinary single-institution experience. J Am Coll Surg 2013;216:23-33.
Merollini KM, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: Guideline recommendations and expert opinion. Am J Infect Control 2013;41:221-6.
Uçkay I, Hoffmeyer P, Lew D, Pittet D. Prevention of surgical site infections in orthopaedic surgery and bone trauma: State-of-the-art update. J Hosp Infect 2013;84:5-12.
Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Identifying opportunities for quality improvement in surgical site infection prevention. Am J Infect Control 2009;37:398-402.
Rózanska A, Wójkowska-Mach J, Bulanda M, Heczko PB. Organization and scope of surveillance of infections in Polish hospitals. Results of the project prohibit. Przegl Epidemiol 2014;68:27-32, 117-20.
Garus-Pakowska A, Sobala W, Szatko F. Observance of hand washing procedures performed by the medical personnel before patient contact. Part I. Int J Occup Med Environ Health 2013;26:113-21.
Garus-Pakowska A, Sobala W, Szatko F. Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II. Int J Occup Med Environ Health 2013;26:257-64.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97-132.
Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011;(11):CD004122. doi: 10.1002/14651858.CD004122.pub4.
Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infection rates: A prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol 2009;30:964-71.
Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, Embil JM. Preoperative skin antiseptic preparations for preventing surgical site infections: A systematic review. Infect Control Hosp Epidemiol 2012;33:608-17.
Fukuda H, Morikane K, Kuroki M, Taniguchi S, Shinzato T, Sakamoto F, et al.
Toward the rational use of standardized infection ratios to benchmark surgical site infections. Am J Infect Control 2013;41:810-4.
Mu Y, Edwards JR, Horan TC, Berrios-Torres SI, Fridkin SK. Improving risk-adjusted measures of surgical site infection for the National Healthcare Safety Network. Infect Control Hosp Epidemiol 2011;32:970-86.
Wójkowska-Mach J, Różańska A, Bulanda M, Heczko PB. Post-discharge surveillance of surgical site infections in Polish hospitals. Pol Przegl Chir 2006;78:776-89.
Wójkowska-Mach J, Bulanda M, Kochan P, Heczko PB. Surgical site infections surveillance and quality management in Polish hospitals. Chir Pol 2006;8:136-45.
Walaszek M, Zienczuk W, Wolak Z, Dobros W, Walaszek M. Surgical site infections in patients of orthopedic – Trauma unit in district hospital in 2008-2012. Przegl Epidemiol 2013;67:439-44, 543-6.
Garus-Pakowska A, Szatko F, Pakowski M. Legal aspects of the health care institution liability for nosocomial infections. Med Pr 2009;60:335-43.
[Table 1], [Table 2], [Table 3]