SSIs: the creation of lost opportunities

The presentation ‘No compromise in infection control’ was given by Nigel Braithwaite, global training manager at Mölnlycke Health Care. He began with a brief history of surgical site infection (SSI) measures which have their origins in the middle of the 19th Century, when Ignaz Semmelweis recognised the importance of hygienic hand washing and Joseph Lister pioneered infection control by introducing antiseptic measures during surgery. Before this time, most wounds would became infected. Nigel Braithwaite reminded the audience that even as late as the 1970s hypodermic needles were often reusable devices and even well into the 1980s, reusable gloves were cleaned and run through an autoclave between uses. Nigel Braithwaite explained, to a mostly surprised audience, that today some patients are still being covered during surgery with traditional linen drapes and other drapes that do not help keep the wound clean. “These drapes are not medical devices and do not offer effective barrier protection,” he said. “SSIs are a major contributor to healthcare-acquired infections (HCAI) today and the rate of SSIs is expected to rise in the future,” he warned. “This cannot be avoided unless we take really good steps at the very start of the process. The population is ageing – the proportion of the population that is over 64 gets greater each time a census is published and we know from statistics and reports that the older a patient is, the more likely they are to succumb to SSI. We are also seeing an increase in antibiotic resistance.” Indeed, Professor Dame Sally Davies, the Chief Medical Officer for England, has described the problem of antibiotic resistance as a ‘ticking time bomb,’ warning that routine operations could become deadly in just 20 years if we lose the ability to fight infection, stating that: “The danger posed by growing resistance to antibiotics should be ranked along with terrorism on a list of threats to the nation.” Looking at SSI rates around the world, Nigel Braithwaite explained that, in the UK, between 25% and 50% of infections in the blood – post surgery – are a result of meticillin-resistant Staphylococcus aureus (MRSA). “Scandinavian countries have a much lower rate of MRSA infection,” he said. “This is because they employ a ‘seek and destroy’ policy, with every patient, being screened preoperatively for the presence of MRSA. If it is present the patient will be decolonised before their operation.”

An effective barrier

 He went on to explain that the use of effective impermeable drapes will ensure that bacteria such as MRSA are not able to enter the wound and can therefore provide an effective barrier to infection. Looking at some of the key considerations when choosing drapes. Nigel Braithwaite highlighted the importance of selecting a device that is able to provide an effective barrier to infection. “The primary purpose of drapes and gowns is to provide a barrier to infection so this should always be the first and foremost consideration. Once it has been proved as being fit for purpose the next consideration is usually cost. Other considerations will include ease of use, continuity of supply, comfort, and environmental impact of the product. However, whatever other purchasing considerations there are, they will all be irrelevant if the product does not adequately achieve its primary goal – of providing a reliable barrier to infection.” Nigel Braithwaite advised the audience to always question their suppliers about the continuing adequacy of a reusable product, to ensure it is able to protect the patient and surgical team throughout its stated life. “The Medical Device Directive states that drapes and gowns used for the purpose of infection control are medical devices,” he explained. “This Directive is underpinned by the harmonised series of standards, EN13795 European Standard for surgical gowns, drapes and clean air suits which specifies what the products must be able to do. It identifies performance requirements, manufacturing standards and testing methods for both single use and reusable medical drapes and gowns. “EN13795 states that microbial penetration testing should be performed in both dry and wet conditions; the product has to have no bacteria on it when it is put into use; it must not lint; it must be able to resist liquid penetration to an acceptable standard; and it must not burst or rip.” Nigel Braithwaite went on to discuss the findings of a wet bacterial penetration test undertaken on four different reusable products and one single use product which were waiting to be used in surgery. “Two of the reusable drapes quite clearly showed bacterial penetration,” he said. The use of an electron microscope during the testing procedure also showed evidence of organic debris being retained on the material. Considering these results, Nigel Braithwaite stressed how important it was that anyone specifying such medical devices should ask questions of their suppliers and should be comfortable that they have enough information available to make an informed and considered choice. He then went on to look at the costs associated with SSIs. “An SSI is an adverse consequence of surgery. It has adverse health and financial implications for the patient and it will always result in additional costs for the NHS, especially as Trusts are no longer being reimbursed for the cost of treating SSIs. “SSIs are preventable, and it is the theatre teams that are in the best position to reduce infection rates. It is difficult to estimate the true cost and burden of a SSI, with annual costs, according to Leaper et al (2004),1 being estimated at anything between S1.47 billion and S19.1 billion.” Looking at the reason for this huge variation in cost, Nigel Braithwaite said: “There is not currently sufficient awareness of the information that is available relating to the clinical burden. Because of this, SSI is not given its proper weight, and financial pressures – combined with the lack of information – often results in the purchase of the cheapest available technology to prevent infection. It is important to remember that price does not always equal cost.” Various organisations across Europe have looked at this issue through surveilliance, including Hospitals in Europe Link for Infection Control though Surveillance (HELICS); Improving Patient Safety in Europe (IPSE); and European Centre for Disease Prevention and Control (ECDC).2