Critical Appraisal of Research Studies: Surgical Site Infections (SSI)

Surgical site infections (SSIs) are a serious source of concern worldwide. They are not only a health risk to patients but also pose a significant risk in terms of an increase in antibiotic-resistant bacteria infections. Yet, there is a gap between theoretical knowledge of how to prevent such infections and how providers implement them. The issue of SSIs has been quantitatively identified as a serious issue and is especially disheartening, given it is a preventable one: an estimated 60% of all SSIs are preventable, if providers follow guidelines (Mengesha et al., 2020).

This failure of compliance, however, is not particularly to underserved or low-resource medical systems. Prevalence of SSIs is around 19.6% in Europe, 20% in the U.S., and in Africa as low as 12% in Algeria and as high as 31% in Nigeria (Mengesha et al., 2020). Within Ethiopia alone, infection rates in different regions vary widely from 10.9%-19.1% (Mengesha et al., 2020). In resource-poor countries, SSIs pose an even more considerable drain in terms of unnecessary costs. There is also the concern for increasing the spread of antibiotic-resistant bacteria, with multidrug resistance as high as 82.9%, in countries where antibiotic shortages are rife and options are limited (Mengesha et al., 2020). This article will review the prevalence of SSIs quantitatively and then review two qualitative studies that attempt to address the issue through meaningful approaches.

In one study conducted by Mengesha (et al., 2020) surveying nurses in Addis Ababa, Ethiopia, less than half of the 409 participants observed evidence-based guidelines (48.9%) to prevent SSIs. The study found that male nurses, greater education of providers, and more extensive work experience were all correlated with greater adherence to infection prevention guidelines (Mengesha et al., 2020). This suggested that greater education and setting higher educational standards for provider may result in lower rates of infection. A 25-item list of best practices, scored on a 1-4 Likert scale assessed compliance in a strictly quantitative fashion, spanning from questions about handwashing to the use of preoperative shaving and the use of appropriate antimicrobial agents (Mengesha et al., 2020).

Nurses were the focus of the study not to shift the focus away from physicians but because nurses often have the most significant roles in pre-and postoperative patient care after surgery, according to the study authors, and thus can have the greatest impact upon potential care improvement. Proper implementation of surgical safety checklists by nurses has been linked to reducing risk of infection; this also suggests that hospitals can have a significant role in creating standard operating procedures to make compliance the default, rather than something that nurses must consciously strive to fulfill....…address noncompliance in some of the issues identified by Mengesha (et al., 2020). The Clean-Cut intervention strove to reduce SSI through handwashing and disinfecting, surgical gown and draping, antibiotics, sterilization, gauze counts, and using WHO checklists (Mattingly et al., 2019). Nurses were interviewed afterward to determine issues that prevented compliance, with responses focusing on a lack of resources, obstacles from hospital administration and staff, as well as their personal beliefs and education (Mattingly et al., 2019). Although in this instance only 20 participants were interviewed, the results suggested a more holistic approach to address noncompliance than focusing on education alone.

The qualitative study by Mattingly (et al., 2019) versus the qualitative study by Qvistgaard (et al., 2019) was structured after a specific improvement intervention, versus soliciting general information about nurses perceptions about why deviations from practice occurred. Viewed in conjunction, however, they are useful in providing a very specific window of personal insight through the lenses of nurses themselves. A lack of compliance with best practices is not solely due to ignorance, but rather arises because of a complex constellation of personal, institutional, and material pressures upon nurses. Reducing SSIs thus does not mean targeting nurses, but working with nurses so they can provide input about how institutions can do better, and create a better way to move forward to improve patient health in…