Forrester Jared A, Koritsanszky Luca, Parsons Benjamin D, Hailu Menbere, Amenu Demisew, Alemu Seifu, Jiru Fekadu, Weiser Thomas G
1 Department of Surgery, Stanford University , Stanford, California.
2 Lifebox Foundation , Boston, Massachusetts/London, United Kingdom .
Surg Infect (Larchmt). 2018 Jan;19(1):25-32. doi: 10.1089/sur.2017.136. Epub 2017 Nov 14.
Surgical site infections (SSIs) are a leading cause of post-operative morbidity and mortality. We developed Clean Cut, a surgical infection prevention program, with two goals: (1) Increase adherence to evidence-based peri-operative infection prevention standards and (2) establish sustainable surgical infection surveillance. Here we describe our infection surveillance strategy.
Clean Cut was piloted and evaluated at a 523 bed tertiary hospital in Ethiopia. Infection prevention standards included: (1) Hand and surgical site decontamination; (2) integrity of gowns, drapes, and gloves; (3) instrument sterility; (4) prophylactic antibiotic administration; (5) surgical gauze tracking; and (6) checklist compliance. Primary outcome measure was SSI, with secondary outcomes including other infection, re-operation, and length of stay. We prospectively observed all post-surgical wounds in obstetrics over a 12 day period and separately recorded post-operative complications using chart review. Simultaneously, we reviewed the written hospital charts after patient discharge for all patients whose peri-operative adherence to infection prevention standards was captured.
Fifty obstetric patients were followed prospectively with recorded rates of SSI 14%, re-operation 6%, and death 2%. Compared with direct observation, chart review alone had a high loss to follow-up (28%) and decreased capture of infectious complications (SSI [n = 2], endometritis [n = 3], re-operations [n = 2], death [n = 1]); further, documentation inconsistencies failed to capture two complications (SSI [n = 1], mastitis [n = 1]). Concurrently, 137 patients were observed for peri-operative infection prevention standard adherence. Of these, we were able to successfully review 95 (69%) patient charts with recorded rates of SSI 5%, re-operation 1%, and death 1%.
Patient loss to follow-up and poor documentation of infections underestimated overall infectious complications. Direct, prospective follow-up is possible but requires increased time, clinical skill, and training. For accurate surgical infection surveillance, direct follow-up of patients during hospitalization is essential, because chart review does not accurately reflect post-operative complications.
手术部位感染（SSIs）是术后发病和死亡的主要原因。我们制定了“清洁切口”这一手术感染预防项目，有两个目标：（1）提高对循证围手术期感染预防标准的依从性；（2）建立可持续的手术感染监测。在此我们描述我们的感染监测策略。
“清洁切口”在埃塞俄比亚一家拥有523张床位的三级医院进行试点和评估。感染预防标准包括：（1）手部及手术部位去污；（2）手术衣、手术单和手套的完整性；（3）器械无菌；（4）预防性抗生素给药；（5）手术纱布追踪；（6）检查表依从性。主要结局指标是手术部位感染，次要结局包括其他感染、再次手术和住院时间。我们前瞻性观察了产科12天内所有术后伤口，并通过病历审查分别记录术后并发症。同时，我们在患者出院后复查了所有围手术期依从感染预防标准患者的书面病历。
对50例产科患者进行了前瞻性随访，记录的手术部位感染率为14%，再次手术率为6%，死亡率为2%。与直接观察相比，仅病历审查有较高的失访率（28%），且感染并发症的记录减少（手术部位感染[n = 2]；子宫内膜炎[n = 3]；再次手术[n = 2]；死亡[n = 1]）；此外，记录不一致导致未记录到两种并发症（手术部位感染[n = 1]；乳腺炎[n = 1]）。同时，对137例患者进行了围手术期感染预防标准依从性观察。其中，我们成功复查了95例（69%）患者的病历，记录的手术部位感染率为5%，再次手术率为1%，死亡率为1%。
患者失访和感染记录不佳低估了总体感染并发症。直接的前瞻性随访是可行的，但需要更多时间、临床技能和培训。为了准确进行手术感染监测，住院期间对患者进行直接随访至关重要，因为病历审查不能准确反映术后并发症。
