SURGICAL SITE INFECTION PREVENTION ANALYSIS OF COMPLIANCE WITH GUILDELINES

 

ABSTRACT

 

Surgical aseptic technique is the application of those strict principles and procedures aimed at preventing the invasion of surgical sites by micro organisms. Prevention of surgical site infection (SSI) has become a priority worldwide. Approximately 50,000 deaths are estimated to occur annually across Europe, as a consequence of surgical site infection. In some university teaching hospitals in Nigeria, the rate of SSI ranges from 10 to 20%. This was linked to non compliance with standard practice due to poor theatre workers’ attitude to work. Compliance to surgical aseptic standard in this study entails theatre workers’ readiness and obedience to carry out the correct procedure in the area of surgical hand scrub, proper use of personal protective device and maintenance of sterile field during surgery. The purpose of this study is to determine the attitude and compliance of theatre workers towards the practice of surgical aseptic standard in tertiary health institutions in Enugu state. The specific objectives were to: (i) elicit theatre workers’ attitude towards various aspects of surgical aseptic standard, (ii) determine theatre workers’ practice of surgical aseptic standard, (iii) determine the relation between attitude and compliance in the practice of surgical aseptic standard and (iv)compare the practice of standard aseptic technique across tertiary health institution in Enugu State. The study adopted a descriptive cross sectional survey design. It was conducted at the three tertiary health institutions in Enugu State, Nigeria. Using purposive sampling technique and observing the following inclusion criteria: (a) participants must be doctors and nurses working in the operating theatre, (b) must be certified, registered, and licensed to practice in the operating theatre, (c) must be physically fit to operate or assist during surgery and (d) willingness to participate in the study. A total of 272 theatre workers were recruited from the population of 660 theatre worker. Instruments for data collection were the pre tested, 20 item researcher developed questionnaire on attitude of theatre workers and 40 item observational checklist. The instruments were validated by the researcher’s supervisor and two experts in the Department of Nursing in University of Nigeria Enugu Campus. Reliability of the questionnaire was established using test retest method at two weeks interval that yielded Cronbach’s alpha correlation coefficient of 0.88. The observational checklist, inter rater scores showed high degree of agreement. Data collected were subjected to descriptive statistics and analysed using Pearson’s Product Moment Correlation and analysis of variance (ANOVA) at p < 0.05 significant level. The significant means decision point for attitudinal item is >2.5 and >2 for observational checklist. The perceived attitude of theatre workers to surgical aseptic technique was positive with overall mean of  3.40 ± 0.81, while SHS had 3.79 ± 0.18, use of PPD 3.1 ± 0.18, and MSF had 3.43 ± 0.81.Theatre workers’ compliance to surgical standard practices were as follows: surgeons and peri operative nurses consistently had higher mean score, for SHS (2.89 ± 0.19, 2.78 ± 0.18), use of PPD (2.84 ± 0.12, 2.81 ± 0.22) and MSF(2.75 ± 0.20, 2.84 ± 0.19) respectively, than physician and nurse anesthetists score SHS (2.34 ± 0.45, 2.39 ± 0.40), use of PPD (2.43 ± 0.35, 2.71 ± 0.31) and MSF (2.29 ± 0.42, 2.61 ± 0.41) respectively. There were significant relationship (r= 0.86, r= 0.81, r= 083) between attitude and compliance. There were no significant variations (p> 0.05) in the practices across the three health institutions. Surgeon and physician anesthetists showed less compliance to the practice of wearing theatre outfit within the restricted area, with mean score of 1.67 and 1.56 respectively.

 

 

CHAPTER ONE

 

                                                              INTRODUCTION

Background to the Study

Surgical aseptic technique is the application of those strict principles, practices, and procedures aimed at preventing the invasion of surgical sites by microorganisms during intra and post-operative period (Briggs, 2013). This according to Albany, (2010) is achieved by ensuring that only uncontaminated equipment, fluid, and items come in contact with the sterile field during clinical procedures. Albany, (2010) refers to this procedure as Aseptic Non Touch Technique (ANTT). However, ineffective application of these clinical procedures and protocols according to Briggs, (2013) usually result to surgical site infection which in turn gives rise to long periods of hospitalization and high cost of hospital bill to both patient and hospital

The prevention of surgical site infection has become a priority worldwide. Approximately 50,000 deaths are estimated to occur annually across Europe as a consequence of surgical site infection (Jones, 2012). In New York, the national infection average per 1000 is 2.7% (National Infection Control, 2010). Albany (2010) in a study in a New York hospital recorded 3.7% infection rate per 1000 in the surgical intensive care unit. If the infection rate is that high in developed economies, the situation may be expected to be worse in developing countries like Nigeria, where challenges to compliance to surgical aseptic standards are definitely more.(Infection

Control Policy (2010) A descriptive study carried out in the University Hospital Lagos by Afolabi, (2012) showed about 15% to 20% infection rate in male surgical ward. This was linked to non- compliance due to poor attitude of theatre workers to surgical aseptic standard in the area of surgical hand scrub, use of personal protective device and maintenance of sterile field during surgery observed by Berkeley (20012).

Compliance in this regard implies the readiness of theatre workers to practice various aspects of surgical aseptic standard in the area of surgical hand scrub, use of personal protective device and maintenance of surgical field during surgery. In other word, it involves willingness of theatre workers to stick firmly in practice to the rules and principles of standard aseptic technique. Previous studies according to Ginasekara (2010) have shown that compliance to the surgical aseptic standard among theatre workers has been generally unstable and increase in compliance has been difficult to sustain. Nevertheless, He noted that poor attitude is responsible for substandard practice as far as compliance to the surgical aseptic practice is concerned. Several reasons for noncompliance have been identified, including staff attitude and lack of interest to work. Relationship among theatre users has also been identified as an important factor in improving compliance (WHO, 2013). Sidon (2011) also stated that the designing and establishment of a practicable evidence-based surgical aseptic standard coupled with a positive attitude to work has been known to improve compliance to surgical aseptic standard practice.                         Macleod, (2010) defines attitude as a predisposition, a tendency or a propensity to respond positively or negatively to a certain idea, object, person or situation.   Attitude is therefore a serious variable in compliance (Leon, 2011).This is precisely because attitude influences individual’s choice of action either positively or negatively. A positive attitude is sure to affect compliance positively with a low rate of surgical site infection as collateral, while poor attitude is associated with noncompliance to the protocol and corresponding increase of rate of surgical site infection.

Despite  application of the standard aseptic technique in recent times as required by WHO (2013) coupled with National and International recommendations for good practice in infection prevention and control in many health institutions, compliance has been low leading to surgical site infection. Surgical site infection has remained the third most common hospital acquired infection responsible for longer hospitalization with increased cost for both the patient and hospital (Briggs, 2013).

This study therefore wishes to assess theatre workers’ attitude and compliance towards various aspects of surgical aseptic standard as practice in the three Tertiary Health Institutions in Enugu State.

 

Statement of problem

Fairchild (2010) and Rowley (2010) identified surgical aseptic practice as an effective technique that can prevent the invasion of wound and surgical sites by micro-organism in pre, intra and post-operative periods. However, despite the important roles this technique play in prevention of pre and post-operative invasion of surgical sites by microorganisms, cases of this invasion and complications of surgical sites by infection still exist in our health institutions. For instance, in the three tertiary hospitals in Enugu State where this study will be undertaken, surgical site infections account for 10% – 20% of all hospital acquired infections (Infection Control Unit, University of Nigeria Teaching Hospital (UNTH), Enugu, 2010). According to

Microbiology Unit, Enugu State University Teaching Hospital (ESUTH)/National Orthopedic

Hospital, Enugu (2011), the rate of surgical site infection ranges between 15% – 20%. Ugamma (2009) also noted that in UNTH, Enugu, most surgical wounds do not heal by first intention leading to the administration of high doses of antibiotics which most of the times are unaffordable. The researcher therefore wondered what could account for these high rates of surgical site infections (SSI) in these hospitals. Do theatre users have the desired attitude? Or a problem of noncompliance to surgical aseptic standard practice, Or is it as a result of complete nonexistence of surgical aseptic standard technique policy or compliance in the tertiary health institutions in Enugu State? To arrive at the answers to these questions is the purpose of this

study.

Purpose of the study

The main purpose of this study is to investigate the attitude and compliance of theatre workers towards surgical aseptic standards in tertiary health institutions in Enugu State.

 

Objective of the study include to:

• Elicit theatre workers’ attitude towards various aspects of surgical aseptic standard in tertiary health institutions in Enugu State.
• Determine theatre workers’ practice of surgical aseptic standard in tertiary health institutions in Enugu state.
• Determine the relationship between attitude and compliance in the practice of selected aspects of surgical aseptic standard.
• Compare the practices of standard aseptic technique across tertiary health institutions in Enugu State used in the study.

 

Hypotheses

• There is no significant relationship between theatre workers’ attitude towards standard aseptic techniques and their compliance to surgical aseptic standard.
• There are no significant variations in the practice of surgical aseptic standard across tertiary health institutions in Enugu State.
• There are no significant variations in the compliance of theatre workers with surgical aseptic standard practices.

 

 

Significance of the study

Findings from this study will add to the existing knowledge on the extent of theatre workers’ attitude and compliance to surgical aseptic standard. This knowledge will help theatre users and policy makers to realize if ineffective implementation and noncompliance are affecting the practice of surgical aseptic standard. It will also help theatre workers to know the intervening variables that affect their attitude and how attitude influences compliance. If noncompliance to surgical aseptic standard is identified, this could assist theatre managers to plan and execute corrective measures such as seminars, workshops, proper supervision, etc. that will improve attitude and enhance compliance. At the same time it will help theatre workers to be knowledgeable on the need for positive attitude and adequate compliance to surgical aseptic standard. This will help to reduce the rate of surgical site infection, leading to better surgical outcome. Finally, the study will be useful for other academic purposes especially to theatre workers, through the provision of data base from which information could be obtained for future research in related areas of study and policy guidelines on infection control.

 

Scope of the study

The study was delimited to surgeons, Anesthetic Physicians, Registered Peri-operative Nurses and Nurse Anesthetists working in the operating theatre in three tertiary health institutions (UNTH, Enugu; National Orthopedic Hospital, Enugu and ESUTH, Enugu) in Enugu Urban, Enugu State. It is also delimited to determining their attitude and compliance to various aspects of surgical aseptic standard namely, surgical hand scrub, use of personal protective device, and maintaining of sterile field during surgery.

 

Operational definition of terms

Theatre workers– they are Surgeons, Anesthetic Physicians, Registered Peri- operative Nurses and Nurse Anesthetists working in the operating theatres in the three tertiary health institutions

under study.

Attitude of theatre workers – overall or general opinion, feelings, and behaviours of theatre workers towards the application of surgical aseptic standard technique. These  include  ritualistic method of practice in theatre techniques which include surgical hand scrub eg  application of anti- microbial agent during surgical hand scrub , use of personal protective device in the areas of theatre attire/cap and mask glove, and drapes, and maintaining of sterile field during surgery which includes placing only sterile items within the sterile field , opening and recognizing that the edges of package containing a sterile item are considered unsterile, recognizing that a sterile barrier that has been penetrated (wet, cut, or torn) is considered contaminated. According to Albany (2010) this technique is referred to as Aseptic Non Touch Technique. This was measured using likert rating scaled questionnaire.

Surgical Aseptic Standard – this refers to application of the strict principles, practices and procedures aimed at preventing surgical site infection. It is a lay down rule or protocol which every theatre user must follow in order to maintain uniformity in practice. These include- practice of surgical hand scrub, use of personal protective device, and maintaining sterile field during surgery.

Compliance to surgical aseptic standard – entails theatre workers’ readiness and obedience to carry out the correct procedure in the area of surgical hand scrub, proper use of personal protective device and maintaining sterile field during surgery. This will be measured using 3 point scaled observational checklist.

Tertiary Health Institutions – Federal owned hospitals in Enugu urban that provide highly specialized surgical health services to patients and training for students and other health professionals. These are University of Nigeria Teaching Hospital Enugu, Enugu State Teaching Hospital and National Orthopedic Hospital Enugu.

 

SURGICAL SITE INFECTION PREVENTION ANALYSIS OF COMPLIANCE WITH GUILDELINES

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