New Consensus statement to prevent surgical site infections after major gynecological surgery released.

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Surgical site infections are the most common complications following surgery in United States. A recent prevalence study found that SSIs were the most common healthcare-associated infection, accounting for 31% of all HAIs among hospitalized patients.[1] The Estimated cost is $3.5 – 10 billion per year.[2]

Hysterectomy is the most common surgery performed in women, second to Cesarean section. A study by Uppal S et al, published in Journal of Obstetrics and Gynecology concluded that rate of SSI after gynecological surgery varies between 1.4 to 3.9%.

Implementation of recommendations provided by patient safety bundle can reduce the incidence of SSI by about 40-60% in any surgical environment.[3] Care Bundles are a set of evidence based practices that when performed collectively and reliably improves standard of care and patient outcome.[4]

Council on Patient Safety in Women's Health released a new consensus statement ‘the safety bundle’ that emphasizes good communication, standardization, maintaining a checklist and cooperation among team members to decrease the surgical site infection after major gynecological surgeries.[5]

The council’s working group include many major groups notably Society for Maternal Fetal Medicine, Society of Gynecologic Oncology and American College of Obstetricians and Gynecologists.

Published on line on December 2, 2016 and January 2017 issue of Obstetrics & Gynecology the consensus bundle mainly consists of four main domains readiness, recognition and prevention, response, and reporting and systems learning. 

Besides the usual recommendations and encouraging standardization of institutions the bundle emphasizes very good communications and spirit of teamwork between the surgical team members in each of its domain.

The main recommendations are:

• Establishing standard for maintaining ambient operating room temperature and patient’s temperature. ( Normothermia)
• Standardizing the time, choice and discontinuation of prophylactic antibiotics with proper records.
• Uniformity in skin preparations preoperatively and postoperatively.
• Each patients risk for SSI should be assessed before surgery based on BMI, Blood Glucose, smoking habits, nutritional status, methicillin resistant staphylococcus aureus (MRSA) and immunodeficiency status. Members of the surgical unit huddling to identify patients that are high risk for SSIs.
• Continue to assess patient risk for SSI during operation based on blood loss, duration of surgery and contamination of surgical field.
• Allocation of specific time during surgery to discuss antibiotic dose, prophylaxis and other specific issues pertaining to the patient.
• Education of the patient and other family members regarding postoperative care especially in patients undergoing hysterectomy.
• Developing a sound reporting system to collect, analyze and share infection data among different physician as a part of ongoing learning process.

A study conducted at Mayo clinic reported a significant and sustained reduction in SSI after implementation of the evidence based bundle in gynecological cancer surgeries. The rate for SSI before and after the intervention was 6.0%  and  1.1% (P = .01)[6]

The WHO also released first ever Global guidelines for the prevention of surgical site infection on 3 November 2016. They include a list of 29 concrete recommendations distilled by 20 of the world’s leading experts from 26 reviews of the latest evidence. The recommendations have also been published in The Lancet Infectious Diseases. [7] [8]

[1] Magill, S.S., et al., "Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida". Infection Control Hospital Epidemiology, 33(3): (2012): 283-91

[2] Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control and Hospital Epidemiology. 1999;20:725-30.

[3] https://www.mnhospitals.org/Portals/0/Documents/patientsafety/SSI/Handout-Slashing-SSI-Raising-the-Bar-to-Lower-the-Rate.pdf

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218985/

[5] http://safehealthcareforeverywoman.org/wp-content/uploads/2016/09/Surgical-Site-Infections-Bundle-01-04-16.pdf

[6] http://journals.lww.com/greenjournal/Citation/2016/06000/Using_Bundled_Interventions_to_Reduce_Surgical.22.aspx

[7] http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30402-9/fulltext

[8] http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30398-X/fulltext