Claire Kilpatrick

IPC Global Unit

SDS, HIS, WHO HQ

Translating recommendations into

practice for surgical site infection

prevention

XXVIIIe Congrès National de la Société Française d’Hygiène Hospitalière 7 June 2017

WHO Infection Prevention and Control

Global Unit

Protecting patient and health worker lives across the world through excellence in

infection prevention and control

IPC occupies a unique position in the field of patient safety and quality of

care, as it is universally relevant to every health worker and patient, at

every health care interaction

Without effective IPC it is impossible to achieve quality health care

delivery and strong health systems

Why IPC is so important for global health

http://who.int/infection-prevention/en/

SSI burden worldwide About 80 000 hospitalised patients in Europe have at least one

HAI on any given day

In Europe, SSI are the second most frequent type of HAI

(19.6%) – 543 149 (298 167-1 062 673) SSI episodes/year

(HAI prevalence survey 2011)

In the US, the overall SSI rate was 0.9% in 2014 (data from

3654 hospitals over 2 417 933 surgical procedures)

SSI are the most frequent type of HAI on admission (67% in

US, 33% in Europe)

Surgical sepsis accounts for approximately 30% of all patients

with sepsis

SSI are the most frequent type of HAIs in LMICs and rates are

significantly higher than in HICs (11%, on average)

http://who.int/infection-prevention/publications/ssi-guidelines/en/

3 November 2016

Patients with known nasal carriage of S. aureus should receive

perioperative intranasal applications of mupirocin 2% ointment with or

without a combination of CHG body wash.

MBP alone (without the administration of oral antibiotics) should NOT

be used in adult patients undergoing elective colorectal surgery.

In patients undergoing any surgical procedure, hair should either NOT

be removed or, if absolutely necessary, should only be removed with a

clipper. Shaving is strongly discouraged at all times, whether

preoperatively or in the operating room.

Surgical antibiotic prophylaxis (SAP) should be administered before the

surgical incision, when indicated.

Nine strong recommendations –

preoperative measures (1)

SAP should be administered within 120 min before

incision, while considering the half-life of the antibiotic.

Surgical hand preparation should be performed either

by scrubbing with a suitable antimicrobial soap and

water or using a suitable alcohol-based handrub before

donning sterile gloves.

Alcohol-based antiseptic solutions based on CHG for

surgical site skin preparation should be used in patients

undergoing surgical procedures.

Nine strong recommendations –

preoperative measures (2)

Adult patients undergoing general anaesthesia with

endotracheal intubation for surgical procedures should

receive 80% fraction of inspired oxygen intraoperatively

and, if feasible, in the immediate postoperative period for

2–6 h.

Surgical antibiotic prophylaxis administration should not

be prolonged after completion of the operation

Nine strong recommendations –

intra & postoperative measures

But all guidelines need

dissemination, adoption and

implementation strategies

Strategies to improve SSI prevention

A systematic review

Focus - quality improvement initiatives designed to

improve adherence with evidence based processes for SSI

prevention

Search - 1990-2015

Pubmed, Embase, CINAHL, Cochrane library, WHO

regional database, Afro-Lib and Africa-Wide

English, French or Spanish

118 studies included

Important - 84% used multi-faceted interventions

Ariyo P et al. ICPIC 2017

• A multimodal strategy comprises several elements or components (3 or more;

usually 5) implemented in an integrated way with the aim of improving an

outcome and changing behaviour. It includes tools, such as bundles and

checklists, developed by multidisciplinary teams that take into account local

conditions.

• The 5 most common components: (i) system change (availability of the

appropriate infrastructure and supplies to enable IPC recommendations

implementation); (ii) education and training of health care workers and key

players; (iii) monitoring infrastructures, practices, processes, outcomes and

providing data feedback; (iv) reminders in the workplace/communications; and

(v) culture change within the establishment or the strengthening of a safety

climate.

National level: national IPC programmes should coordinate

and facilitate the implementation of IPC activities through

multimodal strategies on a nationwide or subnational level.

Facility level: IPC activities using multimodal strategies

should be implemented to improve practices and reduce HAI

and AMR

WHO Core Component 5 for effective IPC

Strong Recommendation: Multimodal Strategies

In other words…

WHO Interim Practical Manual for the Implementation of the IPC Core

Components at the National Level http://who.int/infection-prevention/en/

Mapping two implementation strategies1

SYSTEM CHANGE*

TRAINING &

EDUCATION

EVALUATION &

FEEDBACK

REMINDERS &

COMMUNICATION

INSTITUTIONAL

SAFETY CLIMATE

ENGAGE

EDUCATE

EXECUTE

EVALUATE

1.WHO HAND HYGIENE MULTIMODAL IMPROVEMENT STRATEGY & The 4 E's: An action-oriented

implementation model (Pronovost et al)

Kilpatrick et al. ICPIC 2017

Is achieved by all noted

components among other actions

The overall aim is to embed SSI evidence based recommendations

as an integral part of the culture in the health care facility on the

continuum of the surgical patient’s journey

Technical Work

Evidence-based

interventions

Adaptive Work

Safety culture

TECHNICAL WORK ADAPTIVE WORK

Work that we know we should do,

like appropriate antibiotic dosing

and skin preparation

The intangible components of

work, like ensuring team members

speak up with concerns and hold

each other accountable

Work that lends itself to

standardization (e.g., checklists

and protocols)

Work that shapes the attitudes,

beliefs, and values of clinicians,

so they consistently perform tasks

the way they know they should

Evidence-based interventions Safety culture, including teamwork

The Surgical Unit-based Safety Program

(SUSP) approach – to be published soon

Patient safety culture improvement (CUSP):

• Science of safety education

• Staff safety assessment

• Leadership

• Learning from defects

• Team work & communications

Infection prevention

best practices identified according to local staff assessment

Improvement of the patient

safety climate

+

Reduction of:

Surgical site infections

Surgical complications

In other words…

WHO Interim Practical Manual for the Implementation of the IPC Core

Components at the National Level http://who.int/infection-prevention/en/

Surgical team: OR, ward, and outpatient services

Infection prevention & control

Anaesthetists

Sterilization services

Pharmacists

Senior managers

Trainers

Creating a safe culture - engagement

Peri-operative form Post-operative form

WHO Collaborating Centre

on Patient Safety

Infection Control & Improving Practices University of Geneva Hospitals

and Faculty of Medicine, Geneva, Switzerland

Known barriers Organisational ‘constipators’

Significant workload

Building the trust of staff in

the institution

Staff turnover

Absence of patient safety

culture

Theatre discipline difficult to

change

Dedicated resources (surv)

Data collection and local

interpretation to allow for

feedback

Availability and quality control

of locally produced products

Producing local SAP policies

according to drug availabilities

– by far most challenging

measure to implement (SUSP

Africa project)

Understanding the multimodal strategy for

successful SSI prevention

A new WHO document featuring learning and

recommendations from:

– Surgical Unit-based Safety Program work

– Evidence based strategies to improve SSI

prevention

– Implementing the WHO surgical checklist and

the ‘CleanCut’ project

Advanced IPC training modules inc SSI

Coming next from WHO

WHO guidelines & implementation

WHO Infection Prevention and Control

Global Unit

Merci

Learn more at: http://who.int/infection-prevention/en/

http://who.int/infection-prevention/publications/ssi-guidelines/en/