Critical Appraisal of Research on Surgical Site Infections

Introduction: The Global Burden of Surgical Site Infections

Surgical site infections (SSIs) are a serious source of concern worldwide. They are not only a health risk to patients but also pose a significant threat in terms of increasing antibiotic-resistant bacterial infections. Yet there remains a gap between theoretical knowledge of how to prevent such infections and how providers actually implement preventive measures. The issue of SSIs has been quantitatively identified as a serious problem — and is especially disheartening given that it is largely preventable: an estimated 60% of all SSIs are preventable if providers follow established guidelines (Mengesha et al., 2020).

This failure of compliance is not limited to underserved or low-resource medical systems. The prevalence of SSIs is approximately 19.6% in Europe, 20% in the United States, and in Africa ranges from as low as 12% in Algeria to as high as 31% in Nigeria (Mengesha et al., 2020). Within Ethiopia alone, infection rates across different regions vary widely, from 10.9% to 19.1% (Mengesha et al., 2020). In resource-poor countries, SSIs impose an even more considerable financial drain through unnecessary costs. There is also significant concern about the spread of antibiotic-resistant bacteria, with multidrug resistance as high as 82.9% in countries where antibiotic shortages are common and treatment options are limited (Mengesha et al., 2020). This paper reviews SSI prevalence quantitatively and then examines two qualitative studies that attempt to address the issue through meaningful, practitioner-centered approaches.

In one study conducted by Mengesha et al. (2020) surveying nurses in Addis Ababa, Ethiopia, fewer than half of the 409 participants (48.9%) observed evidence-based guidelines to prevent SSIs. The study found that being male, having a higher level of education, and having more extensive work experience were all correlated with greater adherence to infection prevention guidelines (Mengesha et al., 2020). This suggested that raising educational standards for providers may result in lower infection rates. A 25-item list of best practices, scored on a 1–4 Likert scale, assessed compliance in a strictly quantitative fashion, spanning questions about handwashing, the use of preoperative shaving, and the appropriate use of antimicrobial agents (Mengesha et al., 2020).

Quantitative Evidence: Nurse Compliance in Addis Ababa

Nurses were the focus of the study not to shift responsibility away from physicians, but because nurses typically play the most significant roles in pre- and postoperative patient care, and thus can have the greatest impact on care improvement. Proper implementation of surgical safety checklists by nurses has been linked to a reduced risk of infection, suggesting that hospitals can play a significant role in creating standard operating procedures that make compliance the default rather than something nurses must consciously strive to achieve.

The study authors also note the importance of the surgical team in creating an environment that reduces infection risk — including minimizing unnecessary personnel and conversations in the operating room, maintaining closed doors, ensuring appropriate ventilation, and adequately preparing both the patient and the hands of the surgical team (Mengesha et al., 2020). Compliance, in short, is a team effort.

The study offered useful insights and a perspective on Ethiopia in particular that was welcome given the relative lack of SSI research specific to that nation. However, one weakness of the study was that while it pointed to deficits in practice and, to a lesser extent, in knowledge and training, it did not solicit input from practitioners about why they did not comply. Providers are not necessarily willfully noncompliant, nor do they necessarily discount the importance of appropriate hygiene. Factors such as time pressure, lack of supplies, and perceived pressure from physicians or supervisors to rush may all contribute to incomplete adherence to surgical checklists. Because the study was quantitative in nature, providers had no opportunity to offer that kind of contextual input.

The Role of Surgical Teams and Institutional Standards

An important corrective, therefore, is to review qualitative studies alongside quantitative ones. While quantitative studies can confirm that practitioners are not always observing necessary procedures and can identify demographic correlates of compliance, qualitative studies allow providers to offer experiential input in an open-ended fashion.

In a study by Qvistgaard, Lovebo, and Almerud-Österberg (2019), using the qualitative Reflective Lifeworld Research (RLR) phenomenological approach, 15 operating room nurses were asked to discuss constructively how and why they took precautions regarding SSIs. Rather than being subjected to a questionnaire, nurses were asked what SSI prevention meant to them personally, followed by open-ended questions about a typical workday, how they took precautions, and what made those precautions difficult to follow.

The disadvantage of qualitative research is that it is highly subjective and personal. But this can also be one of its strengths. For example, one nurse noted that surgeons can be quite intimidating and tend to rush them, which leads to errors and mistakes. Physicians, the study found, tended to defer to medical professional standards, while nurses were more inclined to follow hospital-specific guidelines such as institution-based checklists. Nurses also expressed concerns about being understaffed in the operating room, which can lead to fatigue and burnout (Qvistgaard et al., 2019). These are precisely the types of responses that a quantitative study focused solely on outputs would be unlikely to capture.