BSc 49
AIE no. ISJ19046
Topic: Write reference to infection prevention and control theory critically discuss the challenges of managing surgical site infection in the workplace or the community
Introduction
Surgical site infection refers to the infections which occur after doing surgery, and it occurs in any part of the body in the parts where surgery was done. They have continued to be the most common complication of a surgical procedure despite when there are advances in the practices about infection control. Sometimes these infections are known to be superficial infections because they involve the skin only. Other sites where infections can result from include under the skin, implanted materials, or organs. Infection can be provoked by fungi, bacteria, viruses, or prions that can influence almost all of the body systems. Preventing and controlling infections are disciplined to avoid infectious diseases spread in healthcare facilities or the community. According to the Department of Health, it has been giving a board array of health services and the source of ongoing infectious disease outbreaks to the public. They set policies on infection control issues and standard precautions or transmission-based Precautions to prevent transmission of infectious agents.
In Hong Kong, SSI incidence remains the second most common class of healthcare-associated infections. It accounts for 14% to 16% of nosocomial infections with reported rates ranged from 0.5% to 13%, determined by the kind of surgery and patient traits. The essay will be focused on surgical site infections (SSIs) in which an infection appears after the surgical procedure, bacteria that permeate specific body sites. It can be superficial or more severe infections involving the skin, tissues under the skin, or organs (Kong et al., 2019). SSIs’ chain of infection, the impact of clinical care, risk management, audit, surveillance, polices and guidelines, and recommendations also will be mentioned in this essay. Owing to the number of surgical procedures performed in Hong Kong to rise, the prevention of SSIs is increasingly critical.
Chain of infection
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SSI is caused by microbial interaction in the surroundings, a compromised host, and the chain of transmission (Cheng et al., 2020). Six components consist of the causative agent, susceptible host, a reservoir, portal of exit, a mechanism of transmission, a portal of entry into the host.
For a causative agent, most SSIs are derived internally acquired and generated by bacteria, such as Staphylococcus aureus is the most frequently recognized bacteria. When the skin is broken, Staphylococcus generally on the skin or in the nose permeates a surgical wound. Besides, when the person with a weak immune system, the microorganisms must be able to multiply readily to overwhelm and compromise the host’s defense system. By the way, exogenous SSIs result from the contaminated environment, such as when microorganisms on non-sterile techniques or instruments come in contact with the surgical wound. Besides, viruses also provoke infections that can be contracted during surgery (Kamath et al., 2016). For instance, healthcare staff and patients undergoing surgery whose job places them in danger of contracting Hepatitis B or C Virus when exposed to blood carrying these viruses.
The reservoir can be animate or inanimate, where an infectious agent lives, the place it goes from to the susceptible host. An example of animate reservoirs, including people who carry Staphylococcus aureus on their skin and in their upper respiratory tract, is much more excellent. An example of inanimate reservoirs, including surgical equipment and environmental surfaces because many organisms that lead to SSIs can live for long times on its surface.
Portals of exit are the pathway to how microorganisms leave the body of the host. For instance, organisms responsible for pneumonia exit via the respiratory tract or the gastrointestinal tract in feces or the skins or open wounds.
A mode of transmission is how the exit portal from the reservoir is connected to the entry portal into the host. The transmission can be either direct or indirect. Direct transmission can occur through contaminated surgical devices used on a patient during surgery or hand to hand contact the wound (Ling et al., 2019). Indirect transmission is via an inanimate object like the doctor may apply a stethoscope to hear patients’ abdominal wound to hear bowel sound, then used this contaminated stethoscope to a subsequent patient are at increased risk of SSI.
The portal of entry is the path via which microorganisms enter into the host. Infectious agents may through intravenous puncture or incisions made during surgery. The entry portal can be the same as the exit portal. Additionally, it includes the mucous membranes, the skin, the respiratory, and the gastrointestinal tracts.
The susceptible host can be any person who is a hazard for developing an infection. Indeed, patients with a weak immune system, such as Old aged patients, unhealthy lifestyles, or the presence of underlying chronic diseases, those factors make them more susceptible to infection because they are less competent to fight infection and may delay the wound healing process.
Also, surgical wounds are injuries that can permits bacteria to get into the body and begin to multiply. Health care professionals need to recognize the first signs of wound infection and enable to promptly intervene with treatment (Curcio et al., 2019). The common symptoms such as high fever, feeling of fatigue and increasing pain, malodorous and purulent drainage from wound, redness, and swelling of the wounded area.
The impact of clinical health practice on SSI’s prevention and control
Regarding as Recommendations on Prevention of Surgical Site Infection, the surgical team need to perform preoperative hand scrub and surgical clothing properly, provide surgical drapes to protect the surgical field from contamination, consider an operating theatre ventilation system and the sterilization of surgical equipment as well as the post-operative care of incision site (Hoang et al., 2019). Those core principles of infection control can be minimized pathogen transmission between patients and to staff in a health care setting.
Hand hygiene before any preoperative surgery is necessary. It is essential because it ensures that it gets rid of any microorganisms. Essential things that should be done include: nails are supposed to be kept short. Rings or watches should be removed, the five moments for hand hygiene which are before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient, and after touching patient surroundings because MRSA can be contracted anywhere, the main route of its transmission is spread by direct person to person contact, in particular through hands (Damani, 2019). Hence, performing surgical hand antiseptic with antimicrobial soap such as 4% chlorhexidine or 7.5% povidone-iodine or an alcohol-based hand rub. Alcoholic Chlorhexidine has been shown to have more excellent residual antimicrobial activity.
Surgical operation theatres have been provided with some form of ventilation equipment. Indeed, periodic and maintenance systems can be monitored and assessed, it is essential to ensure the target pressure gradient and airflow maintained (Kunutsor et al., 2017). Moreover, the theatre’s temperature should be kept at 20-24°C and humidity at 20-60%. Furthermore, microbiological air sampling by the hospital infection control team is initially manipulated before and after any fundamental adjustments that influence airflow patterns in pre-existing theatres but cannot be routinely performed to prevent the decontaminated environment from occurring.
Whether using surgical drapes or personal protective equipment (PPE), these devices used to protect the wearer from transferring microorganisms to maximize the maintenance of sterility of environmental surfaces and surroundings. Moreover, medical staff must wear surgical masks or double gloves if necessary and must remove the surgical gowns if they are soiled by blood or body fluids (Dubinsky-Pertzov et al., 2019). Place sterile drapes to create a barrier between the surgical field and the environment, which is the source of bacteria.
The effective decontamination of reusable medical devices is essential to inhibit the transmission of pathogens between patients, by the equipment being contaminated or by transferring a microorganism from one organ or cavity (Okubo et al., 2018). Disinfection is utilized to inactivate all organisms on the inanimate surface, except resistant bacterial spores. Sterilization depends upon the elimination of all forms of microbial life. Using a dry heat sterilization process to disinfect all surgical instruments, especially laparoscope, arthroscopes, and other scopes with long and narrow lumens, hinges must be cleansed. Besides, monitoring and assessing the reliability of the sterilization process should be maintained and updated for epidemiological tracking. Health care staffs need to monitor and record it appropriately.
Surgical site infection audit and surveillance
Developing active surveillance and audit on SSI are crucial to track patient outcomes and to assess the impact of any prevention or improvement intervention. Surveillance is an organized method that assists in the systemic collection, analysis, interpretation, and evaluation of SSI data (Hoang et al., 2019). Surveillance protocols must be associated with training materials, practical data collection forms, and education pamphlets to assist application, then to examine and measure the effectiveness of prevention for controlling the incidence of SSI.
Hong Kong has various policies which help to prevent the occurrence of surgical site infection from a different site. These policies are being observed thoroughly in multiple facilities in Hong Kong. Various measures are being recommended in Hong Kong. Some of the measures include: preparing the patient for theatre, the preoperative care of the operation site, preoperative surgical hand preparation of the surgical team, antimicrobial prophylaxis and also having the ventilation and environment in the operating theatre amongst other measures.
One of the most successful strategies which help to reduce the surgical; site infection is by doing the surgical site infection surveillance with feedback. Several things should be done when doing an inspection. One of the components of surveillance is to select the categories of operations which exist in the scope based on the risk and also the volume of procedures in the local hospitals (Lai et al., 2017). Standardized methods are used and define data collection and analysis. Case finding should be done by the trained personnel. Consistent post-discharge surveillance of the surgical site infection should be performed to capture the infection incidence, which occurs outside the hospital setting. It is essential because it makes the surveillance data more accurate and complete.
Other strategies include stratifying the operations according to the SSI index, which is being determined by the duration of operation, wound class, and also the ASA score. Then, later on, report the stratified SSI rates periodically to the team, which is responsible. Benchmarking on the surveillance data with the local and the international benchmark is critical (Qasem & Hweidi, 2017). To ensure that there are quality and accuracy, the data and also process of SSI surveillance should be evaluated and validated periodically. Investigation on the outbreak or the abnormal clusters and then make recommendations to the staff. Finally, the SSI surveillance protocol with the relevant materials is later published by a branch of Infection Prevention.
Applying Principles of Risk management
Risk refers to a probability or threat of an injury, damage, and liability loss, which is caused by vulnerabilities that can be avoided through preventive measures.
Risk management refers to the process of analyzing the practices and methods which have been put in place, identification of the risk factors, and also implementing the procedures which address the identified risks. The primary purpose of managing the SSI is to reduce the injury, which most of these patients usually experienced (Lui et al., 2019). The five necessary steps which have been identified for risk management include: the establishment of the context, identification of the risks, analyzing the risks, evaluating the risks, and finally treating or managing the uncertainty which has been identified.
The establishment of the context is essential for identifying risk and management. In this context, the high priority areas which are being referred to include the intensive care unit, emergency room, operation room, medication management, blood transfusion services, and the coronary care unit. These are about the care of the patient in the health facility.
Identification of risks refers to the process in which the healthcare professional and also the healthcare employees are aware of the identified risks in the environment and even the healthcare services.
The third step is analyzing the risks. Analysis of risk includes the development of an understanding of the dangers which have been identified. The following include the underlying causes, level of the risk or risk score, and also the existing control measures. When examining the control measures which are existing, considerations are usually given with a lot of adequacy, implementation method, and effectiveness level in minimizing risk to the lowest level as much as possible (Razavi et al., 2018). All measures have been put in place to eliminate and reduce the risk. These measures include policies, guidelines, protocols, engineering controls, code teams, emergency arrangements, alarms and beeps, and preventive maintenance controls.
The fourth step is to evaluate the risks. The purpose of assessing risk is to prioritize the risks based on a risk analysis score and then decide the risks that require medications and also the mode of treatment.
Guidelines and policies in Hong Kong
Surgical site infections have been ranked amongst the most frequent infections, which causes morbidity and mortality in Hong Kong. For instance, in a particular local setting in about 100 patients who have undergone surgery and an estimate of 6 had the SSI. When these infections occur to a patient or client, then it increases the cost of healthcare a patient incurs, and also it prolongs the length of hospital stay. SSI has accounted for more than 20% of all healthcare-associated infections among surgical patients. An estimate of about 2 to 5% of the surgical patients in the world usually develops this infection. SSI risk factors correlated with environmental factors, such as the growth of fungi and bacterial infection, temperature and humidity, air regeneration, and differential atmospheric pressure in the operative theatre. Also, it related to the characteristic of the patient, including age, sex, comorbidity, nutrition level, and medical history. Hong Kong hospital authorities have followed the guidance and policies of the preoperative, intraoperative, and post-operative phases of care. Health care professionals play an essential role in the surgical care process to make a treatment plan or strategies to diminish factors that may negatively impair surgical wound healing.
The preoperative remedy can decrease the risk of an SSI, and all health care professionals play a role in patient education about glycaemic control, nutritional screening, and advice on dressing care. During the preoperative phase, patients should be advised to shave hair and take a shower or give the patient a bed bath with antisepsis soap on the day before or the day of surgery in preventing surgical site infections from being uncertain (Cheng et al., 2018). Some patients need to receive antibiotics prophylaxis in antimicrobial coverage.
Intra-operative techniques are necessary to minimize the transmission of microorganisms during the operative procedure by following best practice in hand hygiene. Also, antiseptic skin should be prepared at the surgical site instantly before performing the incision. Moreover, due to patients undergoing surgery under anesthesia, maintaining a body temperature of 37°C and providing supplemental oxygen is essential during the operation.
For the sake of preventing the development of SSIs, appropriate post-surgical wound care is essential. All surgical wounds should be kept clean or postoperatively kept it intact for 24-48 hours. While changing or removing dressings, health care staff must make use of an aseptic, non-touch technique (Yousufuddin et al., 2018). To improve the management of surgical wounds, consult wound care services if necessary to introduce advanced wound care management. If signs or symptoms of SSIs occur, consider the patient’s microbiology test results and select prophylactic antibiotics that can cover the causative organisms.
Recommendations
Apart from the above mentioned of the prevention of SSIs, other recommendations also can do better in Hong Kong. For the medication part, some patients are on immunosuppressive medications. They should discontinue it before surgery, although these are prophylactic drugs used to prevent the transplantation of organs or inflammatory diseases, it causes affect wound healing and an enhanced risk of infection in patients taking these medicines. Comparing the difference between the patient discontinue and also continue on immunosuppressive medication before the peri-operation, the survey described that the patient who stops immunosuppression drugs might induce disease activity flares and the formation of anti-drug antibodies as well as no effect on SSI (Zhang et al., 2019). Nevertheless, according to the Centre for Health center in Hong Kong, the dosage modification and time administration of antimicrobial prophylaxis must be crucial for the patient, such as the patient who undergoes elective colorectal surgery. The use of oral antibiotics has been combined with mechanical bowel preparation further to reduce the bacteria load in the intestinal lumen.
For the nutritional part, early nutritional support in the different dietary status of patients who undergo major surgery is crucial because it can improve the consequence of major surgery and reduce infection associated with surgical complications. WHO determine to set up the development of evidence-based recommendations for SSIs prevention, the researchers believe multiple nutrient enhanced formulas can decrease the incidence of SSIs and related morbidity. Moreover, when considering a priority assessment approach, resources, and product availability of nutritional support for the SSI intervention, requiring further work for clinical workers, involving dietitians and pharmacists, should be carefully assessed to lessen the risk of SSI.
Conclusion
In conclusion, based on above mentioned of the guidance and recommendations, serve as advice for the hospital staff in applying strategies, programs, and plans for the prevention of SSIs to diminish those patients’ morbidity, mortality, and length of inpatient days. Besides, they should have a clear understanding of their role in the surgical care process and be educated on the risk and preventive measures in SSIs. Thus, controlling the risk is relatively straightforward can be useful even though infections can spread quickly. This is so because the prevention of surgical site infections is better than curing diseases themselves. This is a collective responsibility among healthcare professionals together with the patient. By doing so, then cases of surgical site infections are drastically reduced.
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