Intraoperative aseptic practices and surgical site infections in breast surgery

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Title: Intraoperative aseptic practices and surgical site infections in breast surgery
Author: Aholaakko, Teija-Kaisa
Contributor: University of Helsinki, Faculty of Medicine, DEPARTMENT OF GENERAL PRACTICE AND PRIMARY HEALTH CARE
Doctoral Program in Population Health
Publisher: Helsingin yliopisto
Date: 2018-10-27
URI: 978-951-51-4581-9
Thesis level: Doctoral dissertation (article-based)
Abstract: Background and aims. Operating theatre (OT) personnel implement intraoperative aseptic practices (AP) to control and prevent surgical site infection (SSI). AP is considered important in both infection control (IC) and prevention (IP), despite the challenges of investigating the causality between APs and SSIs. This study introduces a project regarding co-creating intraoperative APs in the OTs of one university hospital, with another hospital functioning as a comparison setting. Objectives for this study were: 1) to investigate the acceptance of and adherence to APs among OT personnel before and after the co-creation of the evidence-based intraoperative APs and during the follow-up study; 2) to introduce assessment tools for the intraoperative APs for further development and improvement; 3) to explore performance of AP-related clinical situations; and 4) to define risk factors for SSIs in breast operations. Methods. Outcomes of the project were measured as changes in the acceptance of and self-reported adherence to the AP recommendations, and as SSIs in breast surgery. A follow-up study was completed 12 years after the cocreation of the AP recommendations. First, the acceptance of and adherence to the AP recommendations were surveyed among OT personnel before (N=211) and after (N=234) the co-creation of the recommended APs. Twelve years after the co-creation, a follow-up survey was completed only for nurses both in the study and comparison hospital (N=242). An initial literature based intraoperative AP model created to facilitate the AP recommendation cocreation process. Descriptive statistics and summation variables were computed for assessing the AP recommendation acceptance and adherence. Second, using the variables of the aforementioned survey, separate AP assessment tools were created for circulating and scrub nurses. The initial AP model served as a structure for the tools. Clinically relevant assessment criteria were selected to achieve a high internal consistency for the scales. Third, qualitative research was completed in the study hospital. Video recordings of 31 operations served as stimulated recalls during interviews of 31 circulating nurses. The APs were observed and feedback discussions completed at the end of interviews using a criteria-based observation tool. Fourth, all breast operation-related patient documents (N=1042) and SSI statistics from infection register in the two hospitals were reviewed before and after the co-creation of the AP recommendations. After removing contaminated and infected operations descriptive statistics and logistic regression analyses computed to define the SSI risk factors for all breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282). Results. Statistically significant differences in recommendation acceptance were found between professions and genders before and after the recommendation co-creation measured according to establishment, maintenance and disestablishment of the sterile field. Between study and comparison hospitals the differences were significant except not during the disestablishment of the sterile field before co-creation. In self-reported prevention of handborne contamination, differences were found between hospitals, professions and those 52 respondents participated in both measurements. In preventing airborne contamination, differences were found between hospitals and among the 52 respondents. In preventing bloodborne contamination, differences were found between professions, genders and the 52 respondents. The self-reported adherence to preventing bloodborne infections was found to be higher among those respondents with no needlestick injuries from used needles than those reporting a needlestick. After the follow-up survey, a 20-item tool with good scale reliability was constructed for assessing the AP of circulating nurses. The three phases of AP–establishment, maintenance, and disestablishment of the sterile field –structured the tool. In testing the tool, differences were found in AP recommendation acceptance according to education and working experience. Three tools were constructed for scrub nurses. One was for preparing to work, one for working in the sterile field and one for reporting adherence to AP recommendations during maintenance of the sterile field. No differences were found in the acceptance and self-reported AP adherence by demographics among day surgery and OT nurses. The stimulated recall interviews (N=31) of the circulating nurses in the study hospital found variation in adherence to recommended intraoperative APs. The circulating nurses expressed working experience-, time- and equipment-related stress in implementing APs. Also working with demanding persons in OT team, challenges with patients, working morals and power related stress reported regarding implementing the intraoperative AP recommendations. The OT nurses managed the stress by both active and withdrawal behaviour. Reactions were individual and situation specific. No improvement was found in postoperative SSI rates after the co-creation of AP recommendations in the study hospital. A multivariate logistic regression model for all the breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282) was built to explain the risks for postoperative infections (6.7%). In all operations, a contaminated or dirty wound, high American Society of Anaesthesiologists’ score, high patient body mass index, use of surgical drains, and re-operation predicted increased SSI risk. High patient body mass index and use of surgical drains predicted an increased risk in lumpectomies. In mastectomies, the statistically significant predictor was re-operation. Conclusions. The varying acceptance of and adherence to the intraoperative AP recommendations requires improvement. Stress due to the challenges in implementing the AP recommendations is avoidable by co-created evidence-based APs. The SSI risks in breast operations may be managed by considering the use of antimicrobial prophylaxis in re-operations and obese patients. The assessment of intraoperative IP is possible to improve by including the baseline AP model and relevant criteria in the documentation. More carefully planned and implemented projects are necessary for improving the evidence-based recommendations for intraoperative AP to secure the safety of the surgical patients, personnel and environment among anaesthesia personnel also. The expertise of the personnel is important to develop through participative and strategic training and structured follow-up reporting.Tämän tutkimuksen tarkoituksena oli kehittää leikkauksenaikaista aseptista toimintaa yhden suomalaisen yliopistosairaalan leikkausosastolla toisen osaston toimiessa vertailuosastona. Tutkimusprojektin tavoitteina oli: 1) tutkia leikkausosaston henkilökunnan raportoimaa aseptiseen toimintaan liittyvien suositusten hyväksyntää ja suosituksiin sitoutumista, 2) rakentaa arviontityökaluja leikkauksenaikaisen aseptisen toiminnan arviointiin; 3) tutkia aseptisen toiminnan toteutumista rintaleikkausten aikana, sekä 4) määritellä riskitekijöitä rintaleikkauksen jälkeiselle leikkausalueen infektioille. Projektissa dokumentoitiin tutkimukseen perustuvat leikkauksen aikaisen aseptisen toiminnan suositukset sekä laadittiin kirjallisuuteen perustuva malli. Tuloksia mitattiin muutoksina suositusten hyväksymisessä ja noudattamisessa sekä leikkausalueen infektioiden määrässä ennen ja jälkeen suositusten laatimisen. Seurantatutkimuksen jälkeen laadittiin työkalut sekä valvovan hoitajan että steriilillä leikkausalueella työskentelevien toiminnan arvioimiseen. Stimulated recall interview -menetelmällä haastateltiin 31 leikkausta valvovaa sairaanhoitajaa heidän kokemuksistaan aseptisen toiminnan toteuttamisesta rintaleikkauksissa. Aseptisen toiminnan toteutumista ja leikkausalueen infektioiden esiintymistä rintaleikkauksissa (N=1042) arvioitiin kaikista leikkauksiin liittyvistä asiakirjoista. Logistisen regressioanalyysin avulla määritettiin rintaleikkausten jälkeisiä infektioriskejä kaikissa leikkauksissa (N=982), rintakyhmyn- (n=700) ja rinnanpoistoleikkauksissa (n=282). Tilastollisesti merkitseviä eroja suositusten hyväksymisessä havaittiin eri ammattiryhmien, ja sukupuolten välillä ennen ja jälkeen suositusten laatimisen steriilin alueen luomisen, ylläpitämisen ja purkamisen aikana. Seurantatutkimuksen jälkeen eroja havaittiin suositusten hyväksynnässä koulutuksen ja työkokemuksen suhteen. Päiväkirurgisten ja leikkausosastolla työskentelevien sairaanhoitajien välillä eroja ei havaittu. Sairaanhoitajat (N=31) havaitsivat vaihtelua toteuttamassaan aseptisessa toiminnassa. He kokivat leikkauksen aikaisen aseptisen toiminnan stressaavaksi. Stressi liittyi omaan tai leikkausosastolla työskentelevien työkokemukseen, rajalliseen aikaan, työskentelyvälineisiin, työskentelyyn vaativien henkilöiden kanssa, potilaaseen liittyviin haasteisiin sekä työmoraaliin ja vallankäyttöön. Valvovat sairaanhoitajat käyttivät sekä vetäytyviä että aktiivisia keinoja selviytyäkseen stressistä. Projektin jälkeen leikkausalueen infektioiden määrässä (6.7%) ei havaittu vähenemistä. Logistisen regressioanalyysin avulla tunnistettiin leikkausalueen infektioita ennustavia tekijöitä. Kaikissa rintaleikkauksissa (N=982) infektioriskiä lisäsivät kontaminoitunut (3) tai likainen (4) leikkausalue, korkea anestesiariskiä kuvaava (ASA) pistemäärä, korkea painoindeksi (body mass index), kirurgisten laskuputkien käyttö, ja uusintaleikkaus. Korkea painoindeksi ja leikkausalueen dreeni ennustivat infektioriskiä myös rintapatin poiston (n=700) yhteydessä. Rinnanpoisto-leikkauksissa (n=282) uusintaleikkaus lisäsi leikkausalueen infektioriskiä. Vaihtelevuus leikkauksen aikaisessa aseptisessa toiminnassa ja suositusten hyväksynnässä edellyttävät toiminnan parantamista ja kehittämistä. Suositusten toteuttamiseen liittyvä stressi on vähennettävissä moniammatillisesti laadittujen suositusten toimeenpanon avulla. Infektioita voitaneen vähentää harkitsemalla antibiootti-profylaksia uusintaleikkauksissa ja ylipainoisilla. Suositusten ja laaditun mallin avuilla kehittämistyötä voidaan jatkaa.
aseptic practices
surgical site infection
breast operation
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