A case for Caesarean Section Surgical Site Infection surveillance
COVID-19 has been taking all the infection prevention and control headlines of late. And yet before the pandemic, there had been an increasing interest in surgical site infection (SSI) monitoring and reporting in the NHS and worldwide due to acknowledgement of the negative consequences of SSIs for patients, antimicrobial resistance and increased healthcare costs. In recent years, there had also been an increased emphasis on patient safety and transparency which tie in nicely with the SSI prevention agenda. Now that the rates of COVID-19 are declining in most countries, a refocus on previous SSI prevention work and other quality improvement work should ideally resume.
Although most elective surgical work reduced significantly or stopped at the peak of the COVID-19 pandemic, it was impossible to stop elective or emergency caesarean section (CS) procedures and other emergency surgery for obvious reasons. It is hoped that SSI prevention and other patient safety strategies continued to be implemented accordingly but the emotional /psychological pressure brought about by the pandemic and the need to minimise COVID-19 transmission through various lockdown measures possibly disrupted all surgical pathways. For example, most of the surgery pre-operative preparation changed from face to face to virtual assessments. It has not been possible to measure the impact of these changes on the overall patient SSI outcomes since SSI surveillance resources were diverted. SSI surveillance and prevention work should now be part of any surgery recovery plans to facilitate adequate scrutiny of SSI prevention measures.
SSI prevention priorities
I have thoroughly enjoyed coordinating SSI surveillance for various surgical specialties including CS over the years, but acknowledge that the focus for most organisations in England for example has mainly been on mandatory orthopaedics and cardiac surgery. Prior to COVID-19, SSI surveillance was starting to gain widespread recognition beyond orthopaedics and cardiac surgery, to other areas covered by the Get It Right First Time programme, spinal surgery, hepatobiliary surgery, etc. A publication from Troughton and colleagues has also raised the profile of SSI, in particular for CS and gastrointestinal surgery. Globally, OneTogetherUK, Surgical Infection Society Europe and World Surgical Infection Society and other emerging groups for example have also been focusing on surgical infections and any associated quality improvement work. With this increasing interest in SSI surveillance, also comes a growing acknowledgement that 'one size doesn’t fit all' surgical specialties. For example, although most SSI prevention measures are generic, some measures are designed to target specialty specific risk factors. Similarly, SSI data collection approaches will depend on existing surgical pathways which may now be different due to COVID-19. There is therefore a need to review each surgical specialty pathways accordingly and introduce tailored SSI surveillance and prevention measures. Given the depth of the CS SSI prevention work that I have already been involved in, I now want to focus more on CS SSI surveillance.
Caesarean section SSI rates & data collection approaches
CS rates have significantly increased worldwide despite the procedure carrying a higher morbidity than vaginal delivery. At least 10% of women in England develop a CS SSI. Other countries also report high CS SSI incidences of up to 24% in Brazil, about 11% in Tanzania and at least 20% in some other African regions. These variations in SSI incidences between hospitals or regions, and internationally between countries can be due to variations in surgical care provision or data collection approaches used to record SSIs at hospital and community level. For example, in a pilot CS SSI study by Wloch and colleagues, although 74% follow up was achieved at 10 days post operatively, data were limited as only 36% of women were followed up to 30 days post-surgery. Sullivan and colleagues from Scotland found that post discharge surveillance for up to 10 days post operatively improved CS SSI data capture. Data from Scotland can therefore be compared with that by Wloch and colleagues only up to the 10th day follow up. These data cannot be fairly compared with that from an acute Trust in London which used very robust post discharge SSI surveillance methods that yielded higher 30 day follow up success. More complete and effective standardised SSI surveillance strategies are needed to facilitate reliable comparisons between organisations and countries and the learning that comes with data sharing. There is no doubt however, that where resources are limited, the tendency is to rely on cheap, often already established data collection approaches, which unfortunately may not always be robust enough and can lead to under-reporting. Utilising telephone surveys and electronic or postal questionnaires can improve SSI data capture post discharge but the issue of subjective data with reported SSI criteria like redness, swelling, pain cannot be ignored and must be carefully addressed. Furthermore, the use of any post discharge SSI surveillance approaches must be coupled with good patient engagement and education. Whitby suggests that patient education on SSI criteria and/or risks can actually lead to SSI over-diagnosis, therefore results must be fully validated. A good cost effective investment in a robust SSI surveillance and prevention strategy yields useful data for informing and improving clinical practice.
Benefits of robust CS SSI surveillance
Engaging with CS SSI surveillance and prevention work is beneficial for mothers who can focus more on looking after their babies and full recovery rather than looking after infected wounds. Furthermore, high SSI rates inevitably result in other poor patient outcomes and significant financial burden to health care organisations. Given the state of the global economy, there is no doubt that most healthcare organisations will start to feel (if not already feeling it) the financial squeeze caused by deleterious effects of this COVID-19 pandemic in due course. Whilst everyone is still in that fluid or change mode, it may be a good opportunity to adopt a whole health economy approach and make lasting positive changes. Creating a seamless surgical pathway from pre-assessment-hospital-community care and review post-surgery whilst incorporating SSI surveillance and prevention measures within already existing governance structures or proposed new surgical pathways is desirable. Although this may seem like a costly intervention, prior work suggests that the National Health Service may be losing millions of pounds annually through extended length of stay, readmissions etc. when patients develop SSIs.
Exciting times ahead
COVID-19 brought about sadness and numerous changes in healthcare but has certainly not changed our desire to continually improve patient safety and experience / continually improve the quality of services provided to all our patients. I am therefore excited and look forward to embracing this moment of considerable change for the good. I will continue the exciting infection prevention SSI prevention and other quality improvement or patient safety work with colleagues in my organisation as well as collaborating with other organisations in the United Kingdom and globally. I hope that through these collaborative working partnerships, all mothers, babies, families, organisations and commissioners can benefit from a robust model of CS SSI surveillance and prevention.