This week we welcome Dr Jude Robinson as a guest blogger to Reflections to discuss a paper on surgical site infection prevention.

I feel very honored to have been asked to be a guest speaker on the esteemed IPC partners journal club. I love critiquing papers, and I honestly don’t give myself enough time to do this on a regular basis, probably the same position as many of us with our busy clinical roles. I have really enjoyed preparing for this, so I hope you are able to join Register. I have used a recognised critical appraisal framework to support me with this journal review Qualitative Studies Checklist.

I decided to choose a qualitative study that is investigating factors that affect surgical site infection prevention in cardiac surgery in England Article  which was conducted by the awesome Professor Judith Tanner and colleagues. 

This is an ethnographic study, which is the study of culture where the researcher overtly participates in the daily lives of those being explored, over an extended period of time. It involves examining and observing, in real time a specific communities shared behaviours, beliefs and customs. The authors do not go into any detail as to why ethnography was chosen, but it is clear from the definition of ethnography and the aim of the study that this is a suitable design investigating factors that affect SSI prevention.

The methods used for data collection are observations and interviews, which are very common in qualitative research, it is a way of triangulating the data collection.  The researchers do not carry out observation and interviews concurrently. They carry out the observations first, and then conduct interviews remotely.

Ethical approval has been declared, but there is minimal information on how access to the research sites was gained or the consent process. Inclusion to the study were patients undergoing coronary bypass grafting (CABG) procedure.

This study was conducted in 4 cardiac centers across England. Each cardiac site was observed for one week, where observations and interviews were conducted. Patients were followed through from admission to the hospital to discharge from the post-surgical ward. 

The article states that over the 4 sites 32 patients were observed, resulting in 130 hours of observations.16 staff were interviewed in total over the 4 sites, these consisted of 1 surgeon, 2 anaesthetists, 1 OPD, 4 surgical care practitioners, 1 IPC nurse, 7 nurses. Observations ranged from 15 mins to 4.5hrs. 

Findings have been structured into micro, meso and macro level factors affecting SSI prevention.

Micro level factors

Attributes of the intervention

The authors present 2 examples, the first example is referring to ChloraPrep (skin prep) being liked by the end user. The use of ergonomics has made these easy to use. They also give an example where face masks on the other hand are disliked, constantly fiddled with and always being touched and adjusted. 

Evidence, beliefs and perceived risks 

Findings suggest it is complex when evidence, beliefs and perceived risk are continually negotiated and that this is found to drive staff behaviours. The authors describe instances where there are recognised gaps in the evidence, with the example of the well-known betadine and chlorhexidine debate. The authors found in their interviews that evidence guidelines were often overruled, and an example of hair removal was given where decisions had been made in more than one cardiac centre, for hair to be removed the day before surgery rather than on the day. 

Power and hierarchy

It’s interesting that this study found that there was a defined hierarchy which saw surgeons seen as the most powerful professional. The authors describe that other professionals working with the surgeons were not found to challenge surgeons even when there was a need to do so. This study found that the surgeons set the tone of the theatres. However, in another theme detailed by the authors (leadership and culture), the authors suggest that despite surgeons feeling accountable for SSI’s they did not feel they had authority to prevent them, which slightly contradicts the previous theme around power and hierarchy. 

Patient engagement and patient power are suggested as themes, but limited detail provided. It is suggested that providing information to patients was found to be key as well as recognising that patients can initiate change. I would have like to have seen more airtime given to patient empowerment in this article.

Macro level factors

The findings suggest that the impact of the COVID-19 pandemic has resulted in delayed surgery so patients are coming to surgery much sicker, impacting and increasing their SSI risk. It was also felt that since COVID-19, patients are less likely to come back to the surgeon for wound checks, as this is now done in primary. 

Brexit is reported to have effected availability and quality of some supplies (gloves, gowns and drapes).  The war in Ukraine has also had some impact on manufacturing of plastic impacting supply of chest drains, which are crucial for this surgery. 

Workforce shortages are also provided as a macro issue. Reduced staff to patient ratios, gaps in expertise, high turnover of staff are felt to be impacting CABG patient post-op wound hygiene, in particular dressing changes and showering which was felt to be compromised. 

I would like to end with some take home messages from this study. This study has helped confirm the complexity of factors affecting SSI prevention. The national context such as policy does appear to be impacting SSI prevention and suggests implications for implementing interventions should stretch beyond the organisation and even beyond healthcare.

This study should challenge us in considering how we can encourage internal debate for weighing up evidence, SSI risks, outcomes and costs to help with implementation and compliance of interventions to prevent SSIs.

And lastly, the recognition that in this study effective drivers for achieving behavioral compliance were hard physical barriers (locking a theatre door or removing items from stock). Maybe we need to consider what the hard barriers might be for our own organisations.

I really look forward to talking you through this in more detail on Wednesday 7^th August.

You can register for the IPC Partners webinar facilitated by Dr Phil Norville on Wednesday 7th August at 3 PM GMT where Jude will discuss the study here: https://events.teams.microsoft.com/event/c93b3959-6684-497d-9aae-38479a06fd39@880e1cf6-0e66-4ce3-9534-eadf2d5ded15