Implementing surgical site infection surveillance in the context of WHO's implementation cycle – The perspective of one London teaching hospital

Claire Kilpatrick; Lilian Chiwera

doi:10.4103/wjsi.wjsi_5_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 1 | Issue : 1 | Page : 7-14

Implementing surgical site infection surveillance in the context of WHO's implementation cycle – The perspective of one London teaching hospital

Claire Kilpatrick¹, Lilian Chiwera²
¹ World Surgical Infection Society Board Member and Independent Global Health Consultant, UK
² Guy's and Saint Thomas' NHS Foundation Trust, UK

Date of Submission	06-Mar-2022
Date of Decision	10-May-2022
Date of Acceptance	11-May-2022
Date of Web Publication	17-Jun-2022

Correspondence Address:
Claire Kilpatrick
40 Craigiehall Place, Glasgow
UK

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wjsi.wjsi_5_22

Abstract

The role of implementation and improvement science in preventing surgical site infections (SSI) has been recognized as important and the global situation with SSI prevention warrants on-going attention. Monitoring and understanding SSI data, including ensuring the on-going availability of local infection rates is one intervention recommended by the World Health Organization (WHO) and plays a critical part in addressing SSI and overall health care-associated infection prevention and antimicrobial resistance. SSI monitoring, specifically surveillance, can be supported by the use of a WHO-recommended implementation cycle which is aimed at health care facility infection prevention and control (IPC) and patient safety efforts. In order to understand how the five steps in the WHO-recommended implementation cycle are being applied in the context of SSI prevention, as part of an IPC programme, a desk exercise was undertaken to collate one hospital's SSI surveillance experiences and to map these to the steps in the cycle. It was possible to map this one hospital's efforts to the WHO five steps for implementation, despite the program of work not being planned around these from the outset. Throughout all of the steps, it was evident that teamwork and communications are frequently at the core of all actions, as well as engagement, leadership, champions, and standardization to support reliability, credibility, and trust in relation to surveillance data. Sharing the experiences of hospitals in applying a recommended implementation cycle may help to highlight the importance of committing to a systematic approach to SSI prevention in the context of global IPC recommendations.

Keywords: Infection prevention and control, surgical site infections, the London experience

How to cite this article:
Kilpatrick C, Chiwera L. Implementing surgical site infection surveillance in the context of WHO's implementation cycle – The perspective of one London teaching hospital. World J Surg Infect 2022;1:7-14

How to cite this URL:
Kilpatrick C, Chiwera L. Implementing surgical site infection surveillance in the context of WHO's implementation cycle – The perspective of one London teaching hospital. World J Surg Infect [serial online] 2022 [cited 2023 Jun 6];1:7-14. Available from: https://www.worldsurginfect.com/text.asp?2022/1/1/7/347769

Introduction

The role of implementation and improvement science in preventing surgical site infections (SSI) has been recognized as important as the global situation with SSI prevention warrants attention. SSI is cited by the World Health Organization (WHO) as being the most frequent health care-associated infection (HAI) in low- and middle-income countries and the second most frequent HAI in higher income settings. In the most challenged settings,^[1],[2],[3] they can affect up to one-third of surgical patients. SSI rates range from 0.6 to 9.5 per 100 surgical procedures and remain the second most frequent type of HAI in Europe and the USA.^[2],[3] Up to 20% of women in Africa who have a cesarean section develop a postoperative wound infection, compromising their health and their ability to care for their infants (WHO. Updated systematic review-unpublished data, 2017). The risk of acquiring an infection postoperatively is affected by multiple factors, including those determined by the patient's condition, the health-care system and environment, as well as behaviors and actions taken with the health care environment.

Monitoring and understanding SSI data is one intervention recommended by the WHO, as well as other national organizations and plays a critical part in addressing SSI and overall HAI prevention. Hospital infection prevention and control (IPC) programs that feature SSI prevention have the opportunity to promote and implement a number of evidence-based interventions. With respect to WHO tools that support SSI surveillance, data collection forms and a protocol exist to support countries that have not already established this activity and include both outcome and process measures, one example being the administration of surgical antibiotic prophylaxis.^[4] Having an IPC program that implements SSI surveillance and prevention meets a number of global recommendations for both IPC and antimicrobial resistance (AMR).^[5],[6],[7] In Europe and the USA, SSI surveillance and prevention programs are known to exist, additionally recognizing the importance of this topic.

Infection Prevention and Control Evidence-Based Recommendations in the Context of Surgical Site Infections Prevention

The WHO core components for IPC programs are a set of evidence-based recommendations which provide the “roadmap” for health care facilities and countries to successfully implement and improve HAI and AMR prevention.^[5] All eight core components outlined for the use at health care facility level are important. However, there are key synergies between some of these and SSI prevention. [Table 1] highlights these synergies as outlined in a WHO SSI implementation manual where the original text to describe these core components has been modified to apply them to SSI prevention.^[8] These selected core components were in fact informed by SSI prevention studies and are especially relevant when setting up or improving SSI prevention strategies.

Table 1: World Health Organization infection prevention and control core components and the relevance to surgical site infection prevention

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A WHO five-step implementation cycle also exists and aims to maximize the likelihood of overcoming some of the complexity of the IPC core component's implementation.^[10] This implementation approach is recommended^[11] and each of the five steps have indeed been applied to aspects of IPC programs for a number of years, including to the recommendations from the WHO guidelines for hand hygiene in health care, published in 2009,^[12] for the management of antibiotic-resistant organisms^[13] and most recently in 2018, SSI prevention recommendations.^[8] The WHO has featured brief country stories within their implementation manuals related to efforts to achieve the IPC core components and a publication featuring the first WHO global survey on IPC in health care facilities in 2020^[14] outlined use of a recommended assessment tool as one part of the action required to achieve all core components. However, little is known regarding the use of the recommended implementation cycle and each of its five steps as it applies to health facilities in their SSI surveillance efforts.

Understanding The World Health Organization Five-Step Implementation Cycle as it Applies to Surgical Site Infections Surveillance in One London Hospital

In order to understand if the five steps in the WHO implementation cycle are being applied in the context of SSI surveillance as part of an IPC program, an expert in the WHO IPC implementation approach and contributor to WHO SSI documents, collaborated with the surveillance team lead from a London teaching hospital. In June 2021, a desk exercise was undertaken to collate the hospital's experiences to map these to the steps in the cycle. This entailed emails and follow-up discussions using probing questions, in order to obtain a level of detail to be able to consider where actions and reflections fell with the five steps. An iterative process ensued between both, until no new information was available to populate a table outlining the steps alongside the hospital descriptors of activities and other relevant information. The hospital was chosen through convenience as it had demonstrated success in implementing SSI prevention activities. Their program commenced in 2009, and therefore, their experiences are mainly retrospective, especially for step 1.

Results

[Table 2] outlines the descriptions of each of WHO five-steps alongside the SSI surveillance experiences from the London teaching hospital. It describes a range of actions and reflections that informed (1) getting ready to start a program of work, (2) conducting {a baseline} assessments, (3) actions related to the results of the assessment, (4) evidence to detect what had worked for improvement, and (5) taking decisions on how improvements could be sustained; namely the five steps. The information that was collated populated each of the five steps to varying degrees. In addition, themes appeared to emerge from the findings that were perceived as critical to success during implementation, across all five steps; namely, teamwork and communications, engagement, leadership and champions, and standardization to support reliability, credibility, and trust in relation to surveillance data.

Table 2: WHO implementation steps and example actions from the London experience

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In addition, it was possible to summarize a case study from cardiac surgery at the London hospital during the exercise, to try to bring the actions to life as they relate to the five steps. A summary is presented in [Box 1].

Discussion

The aim of this desk exercise was to give one description of applying the WHO five-step implementation approach. It describes just one, large teaching hospital's activities but could serve as a useful example for other hospitals.

It was possible to map this one hospital's activities to the WHO five-step implementation cycle, despite the program of work not being planned around these steps from the outset. The approach of someone experienced in the WHO implementation cycle and SSI prevention recommendations collaborating with a surveillance team lead to probe for reflections on hospital activities until a sufficient amount of detail allowed for the mapping was employed. As the application of the steps is intended to be used appropriate to the local setting rather than prescriptively, it is not possible to conclude whether the actions and reflections described for each step are proportionate or not. However, it is possible to say that the activities relate to each of the steps, confirming the usefulness of a systematic, cyclical approach.

As no other publications were found detailing an outline of SSI prevention activities alongside the WHO five-step implementation cycle, a discussion featuring comparisons with other hospital experiences is not possible.

For step 1, “getting ready to start a program of work or strengthen what is already in place to improve SSI prevention in the facility,” an outline of people involved and actions to change attitudes and perceptions is provided. In the London hospital, a range of people were identified and engaged and testing was conducted to ensure the surveillance system was working. In comparison to the WHO suggestions for this step, the examples cover some of the recommendations, likely reflecting the established setting where the surveillance took place, a large London teaching hospital. The engagement of people well reflects WHO recommendations for this step.

For step 2, “conducting an exploratory baseline assessment of the current situation concerning SSI and SSI preventive measures in your facility,” the data collection actions were listed for both process and outcome indicators. Actions that have stemmed from data availability appear to again have focused on people which outline the need for continued reflection on those who can influence the success of an SSI surveillance programme. In comparison to the WHO suggestions for this step, data collection for this hospital was driven by national guidance rather than WHO, while the approach reflects WHO recommendations and again a focus on activities and people that can keep the surveillance alive concurs. What is not clear is the use of other tools besides process and outcome data collection forms. WHO recommends that a peri-operative staff safety assessment tool^[16] which may be worthy of considerations in some settings.

For step 3, “acting on the results of the baseline assessment,” an outline of action planning and again, critically, those who were involved was provided. The approach of focusing on short term wins to address improvements highlighted during the data collection process, as well as recognition for the need to update actions plans on an on-going basis to outline other priority actions was described. In comparison to the WHO suggestions for this step, the activities outlined concur while it is not clear of the actions recommended in the WHO SSI implementation manual^[8] were considered.

For step 4, “collecting evidence to determine what has worked for improvement and the remaining gaps, with the aim to measure the impact and engage critical decision-making for the review of action plans within the timeline already defined,” long-term actions were listed. The schedule for evaluation, as recommended by the WHO for this step, was not however clear.

For step 5, “taking local decisions on how the SSI prevention activities and improvements can be sustained, as well as seriously and realistically addressing gaps hindering SSI prevention,” actions and successes were listed. Engagement of staff through various communication methods was described, and importantly, actions that helped to build on the success of the program were listed, alongside on-going challenges. This again concurs with WHO's recommendations for this step, noting that it is important to avoid fatigue with SSI surveillance programs and on-going evaluation and exploration of new, timely actions is critical to this.

The main challenges drawn from the descriptions in [Table 2] included data collection forms not standardized, poor documentation compliance and incomplete data, feedback to clinical staff not deemed effective, staff perceptions of “We are too busy for this” and “We do not have a problem so we do not need to change,” appear to justify the systematic, cyclical approach taken. They appear in part to have been addressed through the number of the actions described including the standardization of forms informed by those already available at the national level. Similar barriers, including staff not recognizing there is a problem, have been outlined in other studies and most notably and systematically summarized in the WHO guidelines for hand hygiene in health care.^[17] A systematic approach and long-term commitment to implementation can help overcome challenges, while it is likely that staff perceptions of the burden of work from such programs may be an on-going barrier that requires constant and innovative focus. Competence is necessary for IPC professionals to attempt to address implementation barriers.^[18]

The case study outlined in Box 1 implies, to a degree, the timeline required to track both process and outcome improvements. However, information on an exact timeline is not fully evident, nor in the WHO implementation manuals. Further investigation to outline a range of timeline examples would be beneficial and engaging to all health care settings, in committing to a step-wise implementation approach.

Besides adding to the SSI team, overall resources were not the focus of review for this exercise, in comparison to, for example, a setting where even laboratory resources might be lacking to conduct surveillance. This is noted to be a commonly encountered challenge reported from low- and middle-income countries and as such the drive behind the WHO SSI surveillance process and outcome data collection forms and protocol.^[4],[19]

This exercise also garnered themes that appeared to emerge from the systematic, five-step cyclical approach. Importantly, a focus on on-going team work, engagement, and communications transpired. This concurs with Ariyo et al.^[20] in their systematic review when they described the role of multidisciplinary teams, formed of a range of disciplines found across a range of studies, in identifying opportunities for improvement, developing interventions and measuring progress against SSI prevention. These activities were categorised under the “engagement” heading of the framework used for this review. Ariyo et al. also describe the role of champions, from seven reviewed studies, and label these “champions leaders” who coach team members, facilitate meetings, and again monitor progress. The London hospital's implementation experiences included ensuring that identified champions were empowered through active support and information provision by the SSI team as a core part of IPC programmatic work. The role of local champions, engaged from outside of the IPC/surveillance team, concurred with the description of champions/role models in support of aspects of IPC improvement programs in IPC competencies published in 2020.^[18]

In addition, the power of leaders is also implied through the London hospital experience by referring to the role of the surveillance team lead and their sustained passion for engagement and improvement. IPC competencies importantly outline a range of attributes necessary for successful leaders.^[18]

An additional theme appeared to be the range of communication approaches used, as described in [Table 2], which reiterate the need for exploring ways in which to engage staff and avoid fatigue. This will likely depend on the local situation but the role of leaders again appears to be prominent, for example, the involvement of hospital committees and the chief nurse.

Finally, standardization of approaches to surveillance, and the communication of this, was used to engage and ensure that all staff in the London hospital had confidence in the surveillance activities, including data and other information being feedback. Feedback is an important part of surveillance, as per its definition,^[21] and Ariyo et al.^[20] described that in 74 of 125 studies in their systematic review had a general focus on giving feedback to key stakeholders to support improvement efforts. This is reiterated by the WHO in their SSI surveillance protocol which takes account of surveillance feedback activities from a range of countries.^[19]

Publications by health care facilities using the step-wise implementation cycle prospectively could help facilitate deeper understanding on the application of this approach. There is recognition that health care facilities starting their journey at a different point, for example, without the infrastructure or other resources in place, would have a very different experience when applying the step-wise cycle. This article presents only one high income country hosptial example.

Conclusion

There is no doubt that surveillance activities as one part of an IPC program that includes SSI prevention is known to drive improvement, especially when targeted feedback of data and engagement of clinicians, managers and others depending on the setting is achieved. Actions taken within a step-wise approach including; preparing to act, acting on results, collecting evidence on what has worked and taking local decisions on what will continue to drive sustained improvement using a systematic approach can help to achieve success. While a step-wise process can seem overly prescriptive, it is being adhered to as outlined in this one example and has supported and helped articulate actions and reflections over time.

IPC programs, including active surveillance, keep patients and health workers safe from HAI and AMR. Implementing the WHO core components for IPC programs continues to be of the utmost importance including for SSI prevention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet 2011;377:228-41.
2.	European Centre for Disease Prevention and Control. Point prevalence Survey of Healthcare- Associated Infections and Antimicrobial use in European Acute Care Hospitals. 2013; Available from: http://ecdc.europa.eu/en/publications/Publications/healthcare-associated-infections-antimicrobial- use-PPS.pdf, 18. [Last accessed on 27 Nov 2018].
3.	Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198-208.
4.	World Health Organization. Surgical site Infection Surveillance: Perioperative Data Collection Form. 2018; Available from: http://www.who.int/infection-prevention/tools/surgical/SSS-pre- op-form.pdf?ua=1. [Last accessed on 2022 Jan 1].
5.	World Health Organization. Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. 2016; Available from: http://www. who.int/infection-prevention/publications/ipc-components-guidelines/en/. [Last accessed on 2022 Jan 1].
6.	Storr J, Twyman A, Zingg W, Damani N, Kilpatrick C, Reilly J, et al. Core components for effective infection prevention and control programmes: New WHO evidence-based recommendations. Antimicrob Resist Infect Control 2017;6:6.
7.	World Health Organization. Global Action Plan on Antimicrobial Resistance. 2015; Available from: https://www.who.int/antimicrobial-resistance/global- action-plan/en/. [Last accessed on 2022 Jan 1].
8.	World Health Organization. Implementation Manual to Support the Prevention of Surgical Site Infections at the Facility Level - Turning Recommendations into Practice (Interim version). 2018; https://www.who.int/publications/i/item/WHO-HIS-SDS-2018-18. [Last accessed on 2022 Jan 1].
9.	World Health Organization. Global guidelines on the Prevention of Surgical Site Infection. 2016; Available from: http://apps.who.int/iris/bitstream/10665/250680/1/9789241549882-eng. pdf?ua=1. [Last accessed on 2022 Jan 1].
10.	World Health Organization. Improving Infection Prevention and Control at the Health Facility: Interim Practical Manual Supporting Implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes. 2018; https://www.who.int/publications/i/item/WHO-HIS-SDS-2018.10?msclkid=46706ba4cfd111ecbe898c0fa026f4c5. [Last accessed on 2022 Jan 1].
11.	World Health Organization. Global Report on Infection Prevention and Control: Executive Summary. 2022; https://www.who.int/publications/m/item/global-report-on-infection-prevention-and-control. [Last accessed on 2022 May 6].
12.	World Health Organization. Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. 2009; Available from: https://www.who.int/publications/i/item/a-guide-to-the-implementation-of-the-who-multimodal-hand-hygiene-improvement-strategy. [Last accessed on 2022 Jan 1].
13.	World Health Organization. Implementation Manual to Prevent and Control the Spread of Carbapenem-Resistant Organisms at the National and Health Care Facility Level. 2019; Available from: https://www.who.int/publications/i/item/WHO-UHC-SDS-2019-6. [Last accessed on 2022 Jan 1].
14.	Tomczyk S, Twyman A, de Kraker MEA, Coutinho Rehse AP, Tartari E, Toledo JP, et al. The first WHO global survey on infection prevention and control in health-care facilities. Lancet Infect Dis. 2022 Feb 21:S1473-3099(21)00809-4.
15.	Chiwera L, Wigglesworth N, McCoskery C, Lucchese G, Newsholme W. Reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration. J Hosp Infect 2018;100:428-36.
16.	Agency for Healthcare Research and Quality. Perioperative Staff Safety Assessment. 2017; Available from: https://www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/perioperative-asst.html?msclkid=165ed81bcfd311ec89d2b913f23e461a. [Last accessed on 2022 Jan 01].
17.	World Health Organization. Guidelines on Hand Hygiene in Health Care. 2009; Available from: https://www.who.int/publications/i/item/9789241597906. [Last accessed on 2022 Jan 1].
18.	World Health Organization. Core Competencies for Infection Prevention and Control Professionals. 2020; Available from: https://www.who.int/publications/i/item/9789240011656. [Last accessed on 2022 Jan 1].
19.	World Health Organization. Protocol for Surgical Site Infection Surveillance with a Focus on Settings with Limited Resources. 2018; Available from: http://www.who.int/infection-prevention/tools/surgical/SSI-surveillance-protocol. pdf?ua=1. [Last accessed on 2022 Jan 1].
20.	Ariyo P, Zayed B, Riese V, Anton B, Latif A, Kilpatrick C, et al. Implementation strategies to reduce surgical site infections: A systematic review. Infect Control Hosp Epidemiol 2019;40:287-300.
21.	World Health Organization. Communicable Disease Surveillance and Response Systems, Guide to Monitoring and Evaluation. 2006; https://www.who.int/csr/resources/publications/surveillance/WHO_CDS_EPR_LYO_2006_2.pdf#:~:text=Communicable%20disease%20surveillance%20and%20response%20systems.%20Communicable%20disease, implementing%20and%20evaluating%20public%20health%20policies%20and%20practices. [Last accessed on 2022 Jan 1].