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  • Writer's pictureLilian Chiwera

Improving surgical patient safety with 6Ss during COVID-19

The consequences of acquiring COVID-19 disease are dire, and so are the negative implications of surgical site infection (SSI). And yet in both cases, measures can be introduced to mitigate risk. In the case of the COVID-19 pandemic, various interventions and/or lock down measures were introduced to control and minimise spread of the virus. These measures which are nicely summarised in a COVID acronym by Holly Slyne & colleagues from Kettering General Hospital NHS Foundation include: Clean your hands often, Observe social distancing, Ventilate your area, Increased cleaning of surfaces and Don a mask or face covering. It is acknowledged that measures implemented to manage COVID-19 infection can also have high social, psychological and economic costs. A constant review and adjustment or easing of restrictions in accordance with levels of circulating virus in the general population is therefore preferable and is currently done by most governments throughout the world. Alongside easing down of lock down measures, is an urgent need for governments to safely restart the economy. In the United Kingdom (UK), various settings including healthcare, are beginning to reschedule services that had been temporarily paused in a phased ‘new normal’ that minimises the risk of a second wave of infections. Resuming full elective surgical activities is now without a doubt every surgeon’s priority. The desire to resume surgery should be equally matched by a desire to minimise avoidable harm through implementation of evidence based SSI prevention measures.

In my previous blog, I wrote passionately about my concerns for the psychological well-being of individuals or families of those who were having surgery cancelled. My heartfelt thanks go to private sector organisations who continued to facilitate safe surgery on some of our National Health Service (NHS) semi-elective and cancer pathway patients during this pandemic. I’m pleased to see NHS and other organisations now adopting phased approach returns to the ‘new normal’ surgical activities. Adopting a phased approach allows organisations to test ‘new normal’ surgical pathways and adjust them accordingly to assure patient and staff safety.

In the current climate, a positive COVID-19 screen result may preclude organ donation or delay surgery until symptoms are resolved to minimise risk of unintended consequences. Furthermore, there is a requirement in England, for prospective surgical patients to shield for at least 14 days in line with set shielding guidelines which are constantly being reviewed. Personal Protective Equipment (PPE), staffing, together with how patients are anesthetized and recovered after surgery are being planned carefully to minimise the risk of COVID-19 transmission from asymptomatic staff or patients with false negatives or those with confirmed COVID-19. The primary aim is to protect patients and staff and keep services gradually running efficiently towards a ‘new normal’.

I’m delighted to see that surgical activities are being planned with COVID-19 in mind. Depending on COVID-19 status, patients can be managed under risk managed or protected pathways. Although it’s good to see emphasis being placed on thorough COVID-19 risk assessments, for someone who is very passionate about SSI prevention, I’m inclined to ask a question I previously posed in a previous blog: ‘who’s paying attention on surgical site infection (SSI)’ during and after this COVID-19 pandemic? Of course a multidisciplinary team (MDT) approach must be adopted to ensure thorough scrutiny of surgical pathways. MDTs should include at least the following: Anaesthetist, Surgeon, Critical Care Team, Theatre Manager, Virology Doctor, Microbiologist, Infection Control Team, Ward Manager / Bed Manager, Preoperative Assessment representative, Clinical Nurse Specialists, Infectious Diseases (ID) Pharmacist, ID Doctor, Clinical Director /Head of service, Clinical Governance representatives. I however wonder if MDTs are reviewing evidence based SSI prevention care-bundle-implementation strategies accordingly as they design new COVID-19 surgical pathways. Furthermore, it remains to be seen if organisations will attempt to seize this moment of constant change to establish effective SSI surveillance programmes that will not only capture all SSIs, but can also be utilised to identify patients who develop COVID-19 after surgery. Following on from the acronym trend set by Kettering General Hospital NHS Foundation Trust of fighting COVID with COVID, I came up with the 6Ss for promoting safe surgery during COVID-19 and beyond. I hope these 6Ss can trigger further internal dialogue on SSI surveillance and prevention strategies in all organisations.

Improving surgical safety with 6Ss during COVID-19

The order in which the 6Ss are used can be changed accordingly to suit local needs. 

It is a good opportunity to harness digital innovation / revolution or IT technology and improve preoperative preparation, post-operative wound care and follow up surveillance. This will not only enable us to deliver seamless, safe services that protect patients and staff, but will also improve outcomes monitoring and data collection. A Photo At Discharge (PAD) initiative led by Rochon et al. is good innovation to consider for remote multidisciplinary wound review. Other forms of virtual or online communication that can potentially significantly improve continuity of care and bridge the gap between acute and community settings must also take precedence. Patients and carer engagement is key as it will not only improve safety but can alleviate pandemic related anxieties.


If all staff and/or patients fight COVID with COVID and effectively use the 6Ss for promoting safe surgery, together we could potentially reduce the risk of undesirable consequences of COVID-19 and other healthcare associated infections.

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