An Adaptive Surgical Infection Prevention Program in Ethiopia Improves Quality and Reduces Postoperative Infections

Author(s):
Jared Forrester; Tihitina Negussie; Diego Schaps; Andualem Beyene; Seifu Alemu; Nichole Starr; Mohammed Adem; Abebe Bekele; Thomas Weiser

Background:

Surgical infections cause major morbidity and mortality post-operatively, particularly in resource-constrained settings. Improved compliance with infection prevention standards embedded in the WHO Surgical Safety Checklist could reduce this burden.

Hypothesis:

We developed Clean Cut, a multimodal, adaptive, checklist-based infection prevention program to improve compliance with best practices and reduce complications from surgery.

Methods:

We introduced our program at three tertiary surgical hospitals in Ethiopia from July 2016-August 2018. We collected data prospectively on operating room infection prevention practices, assembled process maps to understand barriers to complying with best practices, and identified improvement opportunities through a locally-driven multidisciplinary team collaborative focused on six infection prevention standards: appropriate skin preparation, sterile field maintenance, proper selection & timing of antibiotics, instrument sterility verification, routine gauze counting, and appropriate surgical checklist use. We tracked outcomes for all patients for whom intraoperative compliance information was collected. Approval was obtained from appropriate hospital administrative bodies; as this was a quality improvement initiative, patient consent was not obtained.

Results:

A total of 1409 operations were prospectively collected (276 during baseline assessment & 1133 following process improvement implementation). Adherence to all standards increased significantly, except skin preparation which was already performed at the standard. At baseline, perioperative teams only complied with an average of 2.8 of the six infection prevention standards; following process improvement changes, compliance rose to 4.6/6 (p<0.0001) [Figure 1]. The relative risk of infection following the process improvements was 0.59 (p=0.0433); overall surgical infections decreased from 8.52% to 6.70% (p=0.2993).

Conclusions:

An adaptive, multimodal checklist-based infection prevention program relying on process mapping coupled with locally-led improvement solutions significantly reduced postoperative infection risk. This was accomplished without significant investments in new infrastructure or resources. A larger, more rigorous trial is necessary to determine whether this can be replicated to reduce postoperative complications and improve compliance with critical perioperative infection prevention standards on a larger scale.