Are Surgical Site Infection (SSI) prevention campaigns sustainable during outbreaks like COVID-19?

… and everyone now knows about the new novel coronavirus (COVID-19). Globally, the World Health Organisation (WHO) has been keeping us all appraised of the current COVID-19 situation which was recently declared a global pandemic. All countries are required to take measures that minimise spread and loss of life. An outbreak which started in December 2019 in the Wuhan, Hubei province in China had spread to at least 127 countries, leading to more than 133 000 cases and causing more than 4900 deaths worldwide as of the 13th March 2020. This new virus is getting all the attention and of course there is now a rush to produce a new vaccine against COVID-19. I personally wonder whether this experience with COVID-19 will improve future vaccine uptake given that some healthcare organisations currently struggle to vaccinate more than 75% of their workforce against seasonal flu each year; uptake of other vaccines has declined. The full impact of COVID-19 on current infection prevention and control (IPC) and other health promotion campaigns is yet to be established.

The UK Prime Minister, Mr Boris Johnson and other Public Health Chiefs have been reiterating on the importance of good hand washing whilst singing ‘Happy Birthday’ twice and supporting the Department of Health COVID-19 updates and development of respective guidelines. Similarly, the WHO Chief, Dr Tedros Adhanom Ghebreyesu and teams have been providing daily COVID-19 updates via the WHO website and live broadcasts; more recently participating in the #SafeHands challenge on Twitter. Furthermore, Public Health England (PHE), Health Protection Scotland (HPS), Public Health Wales, Infection Prevention Society (IPS), Hospital Infection Society (HIS), European Centres for Disease Control (ECDC), Association for Professionals in Infection Control and Epidemiology (APIC), Australasian college of Infection Prevention & Control Ltd (ACIPC), Infection Prevention & Control Canada (IPAC) etc. are all doing a sterling job, keeping everyone updated whilst promoting best IPC principles to minimise the spread of COVID-19. Of course we very much appreciate top IPC experts like Dr Jon Otter and team for excellent IPC & COVID-19 reflections. Some leading global scientists/virologists are now giving us detail of how and why soap works so well on viruses (Palli Thordarson) to encourage us all to wash our hands properly, and of course some upload useful Twitter posts (Ian Mackay) &regular Twitter updates (Susan Hopkins) on a fast evolving & ‘fluid’ COVID-19 situation. The current Hand Hygiene campaign is probably one of the most terrific of all time, if not of our generation in my own opinion and I am keen to hear what one great hand hygiene champion, Professor Didier Pittet thinks. Healthcare professionals and the general public should however be mindful of misinformation or ‘fake news’ too around Hand Hygiene techniques etc. which can cause confusion and panic. That said, current campaigns highlight the magnitude of the COVID-19 threat to humankind and the importance of countries working together to tackle this global pandemic.

Despite current pressures on healthcare settings, all healthcare professionals and the media under the advice of IPC, Infectious Diseases (ID) experts, epidemiologists, scientists, critical care consultants, respiratory specialists etc. are doing a fantastic job spreading the right key messages and also caring for affected patients with the aim of protect further loss of life from COVID-19. Not forgetting organisational leadership who always do a fantastic job of making everything appear business as usual even under intense pressure. For those who work in critical care areas, we know that a lot of patients can get admitted to those settings already very ‘poorly’ and teams have to learn to be calm under pressure to provide patients with the best possible care so as to optimise their chances of survival. I am optimistic that with everyone working well together, this pandemic can be beaten. I even imagine that perhaps by the end of this outbreak, hand washing campaigns and regular hand hygiene audits may no longer be needed as ‘people will have good #HandHygiene mindsets!’. I may well be overoptimistic and certainly look forward to an IPS conference debate on the continued need for regular hand hygiene audits in September 2020. (If we survive COVID-19!)

So imagine, if the WHO and local governments took at least a month each year to do huge public health campaigns of this magnitude focusing on other areas within IPC e.g. surgical site infection (SSI) prevention, antimicrobial stewardship, Hospital Acquired Pneumonia (HAP) prevention, Catheter Associated Urinary Tract Infection (CAUTI) prevention etc.; perhaps we would make huge strides in minimising avoidable hospital acquired infections in general. So why is it difficult to give these other infections, particularly SSIs the same level of response and attention? Well, the impact of SSIs may be under-reported due to a lack of standardised SSI surveillance activities within healthcare facilities, a useful reference here and here. Furthermore, consequences of surgical site infection on patients are perhaps not as magnified because often cases are seen as ‘just one SSI’ in hospital or community settings unless there is a cluster of SSIs which may trigger a short lived enhanced response. Sometimes, patients don’t even know they developed an avoidable SSI and often don’t feel it’s the hospital’s fault. An excellent publication from Professor Judith Tanner highlights some of these points and explores patients’ experience of SSI in more detail which should hopefully help us to see SSI from a different perspective.

I am inclined to ask another question - whilst all the focus is now on COVID-19, who is paying attention on SSIs? Are SSIs important during a global pandemic? Perhaps not as important as COVID-19 because they don’t tend to impact operational activities to the same extent. However, SSI patients still suffer unnecessarily and there is a huge human and economic burden for organisations and patients who may lose their income or completely change their way of life, delay further treatments for chemotherapy, radiotherapy etc. cancellations of other vital operations and blockage of hospital or critical care beds. I think SSI prevention and other branches of IPC dealing with CAUTI reduction, avoidable HAP reduction and antimicrobial stewardship should still be a main priority even during serious outbreaks. But how can we prioritise these other IPC aspects and where do we get resources from at a time when most IPC teams are stretched, most elective work is being cancelled (NB – it is impossible to cancel emergency caesarean sections!) and services are being redirected? Of course this can only be possible in teams with already inbuilt resilience and capacity to manage unprecedented challenges posed by emerging global infectious diseases.

Another question – how many organisations currently have a dedicated SSI surveillance team with a surveillance system that is led from the frontline as well as a fully staffed IPC team with enough nurses to manage current COVID-19 pressures? Perhaps it’s time for a deeper rethink on the current and future IPC and SSI surveillance staffing models. I certainly look forward to outcomes of work, being championed by Jude Robinson & Emma Burnett on behalf of IPS. This work explores/ examines current components of IPC teams in the UK. Hopefully this and other similar work will stimulate further debate on the subject and perhaps now may be a good time for governments to also consider additional funding for IPC & ID teams to provide the much needed resilience that promote continual reduction in all avoidable healthcare acquired infections including SSIs.

With due consideration for COVID-19, patients having surgery should still continue to have optimum care, i.e. good preoperative preparation, excellent inpatient care along patient’s surgical pathways as well as good post- operative wound care and information. Never before has timely provision of SSI prevention patient information for patients been more critical as it enables patients to make an important contribution to safe surgery, promote early discharges which in turn will free up beds to ease the current hospital bed pressures or capacity issues.

In as much as COVID-19 is taking all the headlines, SSI prevention interventions should ideally also continue as usual in order to get it right the first time, promote safe surgery and patient recovery at home, thus not extending length of stay and increasing patients’ risk of acquiring COVID-19 and other hospital acquired infections. Clinicians should also continue to be diligent around antimicrobial stewardship in order to continue supporting the UK and global antimicrobial resistance action plans. I therefore think that SSI prevention and other IPC aspects should not be negated during other IPC outbreaks and perhaps this is a good time to consider appropriate resourcing of SSI surveillance teams to support already existing IPC & ID teams.