Raising the profile of paediatric surgery SSIs in South London
I attended my first ever South London Paediatric surgery quadripartite meeting on the 7th February 2020, thank you to organisers of these meetings for inviting me. Of course, I do love anything surgical site infection (SSI) prevention and get excited when SSI discussions are being led from the frontline not just infection control, but this was a meeting with a difference.
Firstly, each centre presented their own SSI data for paediatric enterostomy closure procedures, after which the coordinator presented a summary of the findings. It was interesting to see similarities and slight variations in the data presented, case mix (neonates & non-neonates), diagnosis, weight etc. The discussion on skin preparation agent was rather fascinating with a general consensus to agreeing with evidence based recommendations from NICE, CDC& WHO SSI guidelines albeit acknowledging that risk of fires and skin reactions among neonatal populations does exist. Therefore, best practice guidelines must always be closely adhered to. The centres took it in turns again to discuss SSI prevention evidence base, i.e. scoping preoperative, intraoperative, post-operative and surgical antibiotic prophylaxis.
Some interesting points I picked up from the presentations and discussions below:
1. There should be a high index of suspicion of SSI for patients with fever. I could not agree with this more as most organ space infections, from my experience often presented with fever before definitive diagnosis was made. I also think that it’s not unreasonable to thoroughly review patients who develop fever post operatively, more so prior to hospital discharge.
2. The importance of using similar case finding methods was discussed. By utilising the same methods to identify SSIs, centres are better positioned to make meaningful comparisons. I was however unclear as to whether an anastomotic leak should be reported as an SSI or just a complication of surgery? Would be interesting to hear what others think.
3. The importance of using standardised skin preparation agents and accurate documentation was discussed. Certainly, there is a need to ‘move away’ from using skin preparation agents that aren’t evidence based ‘because it’s a surgeon preference’. Perhaps, centres should consider a baseline audit to help establish current skin preparation practices to get baseline data and gain an understanding of surgeon preferences before standardising practice. In summary, I think it’s fair to say that there shouldn’t be any excuse for anyone using a skin preparation agent that isn’t evidence based.
4. Surgeon practice was also highlighted as an important factor in SSI, so was the practice of leaving junior doctors to close wounds without adequate supervision. It was suggested that closure time needs to be treated with respect, i.e. the whole team including scrub nurses should be ‘alert’ to ensure all SSI prevention processes are thoroughly observed until after a wound dressing has been applied to the surgical incision. See evidence here in cardiac sternal closure which places emphasis on operating surgeon experience playing a key role in patient outcomes, same principles apply for other surgical specialties.
5. An interesting question was posed ‘do junior doctors feel confident to challenge senior colleagues when they are making potential mistakes?’ Acknowledging that human factors play a big part in patient safety, this is a very important question to ask and applies to all healthcare professionals not just surgeons.
6. Methods of skin closure and/or techniques involved were discussed; and what an important discussion too among peers in an open and friendly atmosphere where individual surgeon preferences were explored. I will leave you all to ponder on this – ‘to purse string or to interrupt subcuticular sutures is the question? Interestingly, Neena et al proposed a tailored decisional algorithm for sternal closure and I think such an approach should be adopted in other surgical specialties to achieve consensus &/standardise practice.
7. Hyperthermia was highlighted as possibly linked with higher SSI incidences in one paper when compared to hypothermia especially in the paediatric population; an already existing large body of evidence including this one has so far focused on preventing hypothermia (especially temperatures below 35 degrees Celsius) and maintaining normothermia intraoperatively. I will certainly investigate this further and will be interested to hear what others think. A lack of evidence around hyperglycaemia was reported in this group of patients.
8. Our Paediatric Infectious Diseases Consultant reiterated on the importance of giving patients only one dose of surgical antibiotic prophylaxis unless an operation exceeded 4 hours or in the event of excessive blood loss in line with evidence based recommendations and local guidelines. The whole group agreed, and I fully support this stance and certainly gone are the days when antibiotics were given as per surgeon preference, even without good evidence basis.
