The Reduction of Surgical Site Infections in Cesarean Section Deliveries by Implementation of a Surgical Care Pathway

Introduction

Caesarean section (CS) deliveries are on the rise not only in high income countries (HIC) but low and middle income countries (LMIC) too. This global trend has now reached “epidemic proportions” according to the 2010 report released by the World Health Organization (WHO) with many countries far exceeding the 15% recommended limit [1]. A cross-sectional survey from 57 LMIC spanning 4 different regions conducted by Benova et al. showed that C-section deliveries accounted for 4% of all deliveries in Sub-Sharan Africa, 23% in North Africa/West Asia/Europe, 10% in South/Southeast Asia and 24% in Latin America & Caribbean [2]. Betran et al. showed that countries with the highest CS rates in each region are as follows: Latin America & Caribbean (Brazil - 55.6% and Dominican Republic - 56.4%), Africa (Egypt -

51.8%), Asia (Iran -47.9% and Turkey - 47.5%), in Europe (Italy - 38.1%), Northern America (United States -32.8%) and Oceania (New Zealand -33.4%) [3]. In both studies it was shown that rate of CS deliveries were significantly higher in the private sector compared to public sector health care facilities. In South Africa, the overall national CS rate is 22.7% in district hospitals [4] however many public hospitals far exceed the national average, with one district hospital even reporting a 42.4% rate of CS deliveries [5]. The figures released by the South African Council for Medical Schemes however show a very different picture in that almost 70% of all births in the private hospital sector are by means of CS deliveries with some hospitals having up to a 90% CS delivery rate [6]. Like many countries across the world these elective CS deliveries are based on convenience rather than medical necessity. Besides the huge cost implications, CS rates are also associated with significant perinatal and maternal morbidity and mortality. A significant portion of maternal morbidity and mortality is attributed to surgical site infections (SSI). Although credible data on SSI associated with CS deliveries are lacking, the 2011 WHO bulletin showed that approximately 38% of obstetrics & gynaecology procedures are complicated by infections in Africa [7]. A multi-country study conducted in Sub-Saharan Africa reported a 7.3% incidence of SSI’s during CS deliveries [8] while Jjuuko and Moodley (2002) showed that abdominal wound sepsis was 11.9% at a district hospital in South Africa [9]. According to the Centers for disease control and prevention (CDC), as surgical site infection is described as an infection that manifests in that part of the body undergoing an invasive surgical procedure and may occur with 30 days post-operatively or up to 1 year later in the case of an implant [10]. The CDC further classifies SSI’s as follows. Superficial SSI’s are when an infection occurs within 30 days of the surgical procedure and is confined to the skin and superficial layers around the incision [10]. A deep SSI either occurs within 30 days if no implant is in situ or within a year with implant related surgery and manifests in the deep tissues of the incision [10]. An organ space SSI also occurs within 30 days if no implant is used or within a year for implant surgery and affects any anatomical site other than the incision which was opened or manipulated during the procedure [10].

The study in Sub-Saharan Africa from Doctors without Borders (Medicine’s Sans Frontiers) reported that the median length of stay in hospital, for women undergoing a CS delivery without SSI was 7 days compared to 21 days for those women that acquired an SSI (p < 0.001) [8]. These extended lengths of stay have significant financial impacts on both the patient and the hospital. In the public sector, most of the cost of an infection is absorbed by the hospital itself and the increased bed-days also means decreased throughput and more pressure on the hospital because of the growing patient base. In the private sector, on the other hand, patients are billed for an infection but medical insurance funders are becoming more reluctant to pay for hospital acquired infections resulting in a rise of medical malpractice lawsuits. All in the entire patient and the hospital faces a huge financial liability with the incidence of an SSI. The purpose of this study was to reduce the burden of SSI at a private hospital in South Africa by implementing a performance improvement project.

Discussion

Caesarean section deliveries are an important surgical procedure that saves millions of lives each year. It is for this reason that it has been recognized by the WHO as one of the 29 recommended surgical procedures that must be accessible to all women irrespective of financial background [1, 8]. Global trends indicate a rise in CS deliveries, with more and more healthy pregnancies opting for elective CS deliveries. Since it is a major, invasive surgical procedure the risk for developing an SSI is great. The incidence of SSI at Louis Pasteur Private Hospital during CS deliveries was on the rise. In light of this, a drastic intervention program was needed to curb the increase. The intervention involved an audit of their existing surgical protocol using a modified checklist as recommended by the CDC (1999). Studies show that the biggest source of microorganisms capable of producing an SSI comes from the patient’s own skin [16]. It was reported that approximately 60% of all SSI’s is caused by the patient’s own skin flora. The next biggest source of microorganisms come from the hospital staff and is responsible for approximately 30% of all SSI’s. Lastly, the contaminant in the air is responsible for approximately 10% of all SSI’s. It is no wonder that most of the interventions aimed at reducing SSI’s as prescribed by the CDC focuses on protecting the patient from their own flora, followed by minimizing bacterial transmission from the medical staff to the patient and finally an emphasis on air quality in the operating room. From the audit 7 areas of the patient’s surgical pathway required intervention. The 7 areas that scored below 50% were as follows: pre-warming the patient (25%), hair removal (35%), verification of instrument sterility (45%), traffic control (45%), patient skin preparation (50%), post-operative glucose control (50%) and post-operative wound management (50%). In most of the elective CS cases observed at Louis Pasteur Private Hospital, the women opted to remove their own pubic hair at home. It is reasonable to assume that many of them removed hair by shaving with a razor blade although others could have possibly used depilatory creams. In the emergency CS cases hair removal was done inside the operating room with the use of a razor blade. Although pubic hair removal is not totally necessary when making a pfannenstiel cut, its close proximity to the incision site often warrants removal. The 2011 Cochrane review of preoperative hair removal reported that patients are at an increased risk for developing a postoperative infection when shaving with a razor [17].

The report included three trials which all conclusively showed an increased risk of SSI when hair was shaved as opposed to clipped (RR 2.09; 95% CI, 1.15-3.80) [17]. The risk for infection is attributed to microscopic epidermal injuries that are caused by shaving which either acts as a portal of entry for transient skin flora or serve as an ideal incubator for bacterial growth. For this reason, if hair removal is deemed necessary immediately prior to surgery, the use of clippers is preferred over’s having. Since there is compelling evidence to suggest an increased risk of SSI when shaving with a razor, in all elective CS cases, the women were advised not to remove pubic hair at home. They were reassured that there are qualified nursing personnel trained for proper hair removal with electrical clippers (3M Surgical Clippers, St Paul, MN). Human skin is densely populated with bacteria. It is documented that skin bacterial density can range anywhere from 100 to 100000 microorganisms per square centimeter. Skin bacterial density has been shown to be the highest in the axilla, inguinal fold and the perineum. Patient skin preparation is therefore an age old technique for reducing the incidence of infections by reducing skin bacterial density. The FDA recommends that any prepping solution must cause a 2-3 log reduction in skin flora in order to be effective. Unfortunately most skin preparations cannot resist fluid wash-off nor do they have a persistent antimicrobial activity. Since logarithmic reduction of bacteria is a time-related event, the decreased contact time between the solution and the skin minimizes the antimicrobial effect. Recent reports show that pooling of CHG-alcohol solutions is associated with perineal chemical burns and is not recommended for prepping epithelial linings. Hence iodine based solutions are preferred for C-Section deliveries [12, 13]. Unfortunately not all iodine based solutions are the same. Both aqueous and alcoholic preparations are easily washed off especially if they are not allowed the maximum drying time. Iodine povacrylex however, is a unique polymer coupled to iodine which optimizes its effect by drying up to form a water-insoluble on the surface of the patient’s skin. This film resists fluid wash-off and therefore provides antimicrobial protection for the duration of the surgical procedure and even up to 48 hours under a suitable dressing. Due to the nature of a CS procedure especially with the large amount of fluids, either amniotic or irrigation solutions and the incisions site’s close proximity to the inguinal folds and perineum which are densely populated with microorganisms, this ranked as one of the greatest improvements to their protocol. Contaminated instruments are a major risk factor for SSI. Even if the surgical team adheres to all the recommended protocols with strict compliance, if the instruments used for the procedure is contaminated then the patients risk for an SSI escalates exponentially. Instrument decontamination and device reprocessing has therefore been identified as a major arm of the infection prevention pathway. International infection prevention organizations emphasize the need for a scientific approach towards sterilization of medical equipment with strict measures to ensure quality assurance of these instruments. During the time-out phase of the WHO Surgical Safety Checklist there is a question addressed to the nursing team regarding whether the sterility of the instruments have been verified by means of a chemical indicator. A “passed” chemical indicator provides the surgical team with confidence that the instruments are sterile and therefore eliminates a major component from the root causes of an SSI. Preoperative hypoglycemia and postoperative hyperglycemia are both associated with increased risk for developing SSI during surgery. Hypoglycemia is associated with decreased immunity whereas hyperglycemia has been shown to cause inflammation, oxidative stress, endothelial dysfunction and tissue ischemia [18]. The postoperative range for blood glucose in a non-diabetic patient is 6-10 mM (108 -180 mg/dl) [15]. Since there is strong evidence pointing towards a correlation between postoperative hyperglycemia and SSI, patient’s blood glucose levels were taken every hour post-surgery for the first 12 hours and every 3 hours thereafter for the next 12 hours. Hyperglycemic patients were given metformin as per the doctor’s instruction when blood glucose levels exceeded the tolerable limit. Post-operative wound management also contributes to SSI reduction. The less interference with the wound post operatively the less likelihood there is of infection. It is therefore imperative that an appropriate wound dressing be applied to the wound after suturing. The makings of a good dressing are that they are hypoallergenic, non-toxic and breathable. It must also allow for the quick evaporation of moisture, the absorption of exudates and most importantly have good adhesion to the skin. This will allow the dressing to remain on the skin for 7-10 days post incision. In South Africa, traditional herbal remedies still form an integral part of the indigenous culture and often herbal decoctions are applied to the wound to “accelerate” healing. The disadvantage is that if they are not prepared aseptically, then it too can be a source of infection. Patient education and the use of superior wound dressings played a huge role towards minimizing this threat of infection. The performance improvement project caused the infection rate to decrease from 5.12 ± 0.82 % to 0.23 ± 0.15 % (p<0.0001). It is interesting to note that the 2 infections reported post PIP were a hematoma and the other was as a result of secondary suturing. In essence they are not classified as SSI’s. These results may be slightly obscured as not all patients were able to be contacted 30 days post-surgery however this number is rather miniscule.

Conclusion

The significant decrease in SSI’s during CS deliveries at Louis Pasteur Private Hospital as a result of implementing a surgical care pathway bares testimony to the fact the HAI’s can be reduced through a conscious effort made by the hospital and its staff. The exceptional result obtained from this performance improvement project certainly warrants the investigation of implementing similar surgical care pathways in other disciplines of surgery to help reduce the incidence of SSI’s.