Surgical site infections (SSIs) is a key indicator for measuring the iterator performance of individual surgeons and hospitals, and surveillance data on SSI is a measure of patient safety. With feedback to surgeons, surveillance is effective in reducing rates of wound infection. There are no surveillance systems which monitors SSIs in hospitals in Ghana.
The aim of this study is to describe the epidemiology of Surgical Site Infections and to develop and implement a Surveillance System for control of Surgical Site Infections in a teaching hospital in Ghana. The specific objectives of the study are to pilot and validate an effective surveillance system for Surgical Site Infections in a teaching hospital in Ghana, which will help determine trends of SSI, detect outbreaks with increases in SSI rates, improve infection control practices by raising awareness and determine morbidity and mortality for SSI.
At the end of the first surveillance cycle, an overall SSI rate of 12% of 515 patients was recorded in the general surgical unit of the department of surgery, with SSI rate ranging from 6.2% (7/113) to 43.5% (10/23) for specifics procedures (breast surgeries and colonic surgeries respectively). Most (60% [37/62]) of the SSI was diagnosed after discharge.
The second surveillance cycle recorded an overall SSI rate of 8.9% (48/539), ranging from 3.6% (4/110) in breast surgeries to 30.8% (8/26) in small bowel surgeries.
Feedback to Surgeons, generated a positive response. Based on these initial briefings, the Head of Surgical department decided to establish a committee to look into and recommend policies to help reduce SSI rates.
Background, issue and context of the project and its approach and methodology, highlighting the value added.
Surveillance is the systematic ongoing collection, management, analysis and interpretation of data followed by the dissemination of these data to public health programs to stimulate public health action.
There are no surveillance systems which monitors SSIs in hospitals in Ghana. With feedback of surveillance data to surgeons, surveillance systems are effective in reducing rates of wound infection. The aim of active surveillance of SSIs in the department, is to create awareness of the rates of SSI, pick up outbreaks when they occur, and help modify attitudes to infection prevention at the individual, department and institutional level.
The site for this study is at the surgical department of the Korle Bu Teaching Hospital (KBTH), a 2000-bed capacity tertiary hospital in Ghana, West Africa.
The study comprises three phases. The first phase is a prospective cohort study to pilot and validate a surveillance system for surgical site infections where in-patients will be actively surveilled by direct observation and out-patients during outpatient change of wound dressing and by telephone calls. In the second phase, the surveillance system developed and piloted in phase 1 will be implemented in the various surgical units of the teaching hospital and the third phase a case control study will be done to determine microbial aetiology and risk factors for selected SSIs in the teaching hospital.
Data will be collected within a surveillance period of three months followed by a 30 day follow up for identifying SSIs which may occur. The four surveillance periods are 1st January to 31st March; 1st April to 30th June; 1st July to 30th September and 1st October to 31st December.
Denominator data of eligible patients is collected after surgery. Methods of identifying SSIs include a direct daily observation of patients wounds post-operatively whilst on admission and a post-discharge surveillance. Post-discharge SSI identification strategies include telephone survey of patients using a modified surgical wound healing post-discharge questionnaire and post-discharge healthcare personnel surveys using a post-discharge surgical wound card. Healthcare personnel and research assistants will be trained for the identification of SSIs. After a surveillance period, data will be analysed to study the rate of SSI, type of SSI, rate of SSI by risk index and mortality associated with the SSI and validate the instruments used for surveillance and the completeness and accuracy of data collected.
Feedback of results will be given at timely intervals to the surgical department as well as to the hospital management at the end of each surveillance period, to ensure measures can be put in at regular intervals to help reduce SSI rates.
Results: What did we learn? Which capacity was built? Summary of the facts, easy to understand. Ensure that your research findings are explained in the context of available evidence on the subject.
Sixty-four per cent (64%) of 515 patients completed a 30-day surveillance. Of the 474 patients elligible for post discharge surveillance, 51% returned wound cards that had been issued and 67.9% of patients responded to the 30-day post-operative call.
At the end of the first surveillance cycle (1st July -30th September 2017), an overall SSI rate of 12% (62/515) was recorded in the general surgical unit of the department of surgery, with SSI rate ranging from 6.2% (7/113) to a high 43.5% (10/23) for specifics procedures (Breast surgeries and colonic surgeries respectively).
Sixty percent (37/62) of recorded SSI were diagnosed after discharge when patients came for change of wound dressing at the department, with forty per cent (25/62) diagnosed when patients were on admission.
SSI rate recorded at the end of the second surveillance period (1st October – 31ST December 2017) was 8.9% (48/539), ranging from 3.6% (4/110) in breast surgeries to 30.8% (8/26) in small bowel surgeries. SSI was diagnosed more often in the post discharge setting (52.1% [ 25/48]) than in the in-patient setting. Sixty-nine per cent (68.9 %) of patients (346/539) completed a 30-day surveillance with wound card return rate reducing to 45% (226/502) for patients elligible for post discharge surveillance.
Conclusion: What does it mean? How can it be used?
With regular feedback of surveillance results to surgeons, policies will be drawn and implemented in the department to help reduce SSI rates and hence improve patient safety.
A higher percentage of SSI is diagnosed in the out-patient setting and hence any form of surveillance should include the active follow up the discharged patient, taking advantage of the role the dressing rooms play in picking up SSIs.
Implications: What are the implications of your results and capacity building? Which policy changes do the results point to?
Results from the third surveillance period, 1st January to 30th March 2018, and will help describe the trends in SSI rate over the three periods after feedback to surgeons.
The pediatric surgical unit was included in the surveillance system in January 2018, Urology will be added in April 2018 whilst surveillance in general surgery continues.
Implementing an active surveillance system to monitor SSIs, in the department of surgery, Korle Bu Teaching Hospital will help improve patient safety in terms of reducing SSIs.
Recommendations: Call to action, which precise steps should be taken? (both flowing from conclusions, supported by evidence and feasible and actionable)
The institution, Korle Bu Teaching Hospital, should consider adding SSI surveillance to the list of conditions it surveilles.
Stemming from this surveillance system and the fact that feedback to surgeons had an immediate impact, personnel can be trained who will collect data, analyze and give quarterly feedback to the surgical department and institution.
Antoinette Bediako-Bowan (PhD Student)
Kåre Mølbak (Principal supervisor)
Jørgen Kurtzhals (Primary co-supervisor)
Samuel Debrah (Other supervisor)
Enid Owusu (Postdoc)