I am always interested in compliance. What makes staff implement an intervention reliably? What makes a patient follow the advice they’ve been given? A new retrospective cohort study purports to look at what factors influence compliance with preoperative regimes aimed at preventing surgical site infection (SSI). The authors were of the opinion that socio-economic group would be a major factor in whether individuals would be compliant with measures that are likely to reduce the risk of SSI, since this has been demonstrated to be the case in chronic health issues such as asthma. Disappointingly the authors stated that the method of determining at adherence is described elsewhere with the accompanying reference to an 4-minute abstract given at a paediatric orthopaedic conference in Toronto in 2013 which, if you weren’t there, you’ve missed it. However they do provide a small amount of detail and of the 2-5 protocol tasks they only mention bathing and decolonisation of those screened.
An interesting finding was that patients who had previously experienced similar surgery (Spinal fusion) the compliance was lower than those you had not had a previous similar surgical procedure. The authors previously had felt that previous experience would make individuals more enthusiastic about reducing the risk however after this finding may suggest that in fact previously successful and uncomplicated procedure may actually reduce a patients perception of risk.
The conclusion of the study was that patients in lower socio-economic groups were less likely to comply with interventions for a number of reasons, including financial aspects where are products may not be purchased, inability to take time off work and possibly poor access to adequate washing facilities. They suggest that socio-economic status should be considered as part of the preoperative assessment process. I suspect this is rarely done and I do wonder if efforts to promote practices such as preoperative Chlorhexidine bathing, which are normally aimed at surgeons and infection prevention and control teams would be better focused on the staff working in preoperative clinics who may need motivating to try and increase patient compliance.
The lack of quality randomised controlled trials has meant that current guidelines cannot recommend antiseptic showers prior to surgery. The most recent Cochrane review (updated in 2015 – no new studies included..) on this subject lists the most recent study (of the seven that were included) as in 1992 however, at that time there was no standardisation of the method of applying skin antiseptics. Compliance was also not mentioned in any of these papers and some used soap and others lotion. It is possible that many trials have failed because of the lack of engagement with the intervention. A number of studies have now looked at patient compliance and in many cases it is poor, however socio-economic group has not to my knowledge been mentioned as a possible factor for non-compliance for pre-surgical interventions up until now. What is certain though is that we consider an intervention worthwhile enough to be invested in and implemented, we have to do more about ensuring that those to whom it really matters follow the protocols.