Surgery Process Maps May Reduce Infection Risks in Low Resource Settings

Laird Harrison

October 24, 2017

SAN DIEGO — Process maps can reduce the risk for perioperative infection in low-income countries by pinpointing barriers to good procedures, researchers say.

A process map implemented at a pilot site in Jimma, Ethiopia, significantly improved such measures as hand-washing and the timing of prophylactic antibiotics, said Jared Forrester, MD, a surgical fellow at Stanford Health Care in Palo Alto, California. "This can be a powerful tool," he said.

He presented his findings here at the American College of Surgeons (ACS) 2017 Clinical Congress.

At baseline, about 45% of patients undergoing cesarean section in Jimma suffered from infections, including 16% who suffer from surgical site infections, and 2% died, Dr Forrester reported.

Working through an Ethiopian government effort to reduce these infections, Dr Forrester and colleagues at Lifebox, a global nonprofit organization, developed Clean Cut, a process map. They based the map on a surgical checklist created by Lifebox Chair Atul Gawande, MD, for the World Health Organization.

Surgeons have used formal checklists in the United States for about a decade, and have shown they can cut death rates in half and complications by a third, Dr Forrester said. But such lists do not always translate well to countries with fewer resources.

In contrast, a process map can identify barriers to implementing such guidelines and ways to overcome these barriers.

Dr Forrester compared the approached to brewing beer, in which multiple steps must take place — harvesting hops and barley, mixing with water, fermenting with yeast — for the process to succeed.

The Clean Cut process map included the following infection prevention standards:

  1. Hand and surgical site decontamination

  2. Maintenance of a sterile field (integrity of gowns, drapes, and gloves)

  3. Confirmation of Instrument sterility

  4. Prophylactic antibiotic administration

  5. Surgical gauze tracking

  6. Checklist compliance

In Jimma, Dr Forrester and colleagues closely examined the steps local staff undertook to meet each of these standards.

For example, to analyze the steps involved in prophylactic antibiotic administration, his team traced all the steps, beginning with the decision that a patient requires surgery. After a surgical intern orders an antibiotic, the map notes whether there is any resistance to the procurement of the antibiotic, whether the patient can afford the antibiotic, whether the antibiotic is in stock in the pharmacy, and who retrieves it.

The map continues through the patient's arrival in the hospital, the turnover of a room, the delivery of the antibiotic there, the documentation of the administration of the antibiotic, and so on.

Through the process map, the team found there was a breakdown in communication around antibiotics. Whereas microbiologists had found that about 90% of infections were resistant to the antibiotic most commonly used, that information had not reached the prescribing physicians. When they did receive the information, they switched to a broader-spectrum antibiotic.

Also, in creating the process map, the researchers noted that surgical gauze had been retained in some patients. Investigating, they found that the same nurse in charge of counting the gauze was also in charge of resuscitating newborns in another room. The solution was to make sure someone in the operating room was tracking the gauze.

After implementing the procedures, the researchers documented a 180% improvement in the use of appropriate hand hygiene before surgery, a 92% improvement in proper timing of prophylactic antibiotics, and an increase in the use of sterile indicators to confirm use of sterility of surgical instruments from 7% to 87%, among other improvements.

"It's not overall sexy work, but I think we have been able to make a difference," Dr Forrester told Medscape Medical News.

The researchers are currently analyzing their data on infection rates. "We had some preliminary good results," Dr Forrester said.

He and his colleagues believe the program can be successfully adapted for other low-resource settings. But there are challenges in changing a hospital's environment to implement a checklist program, Dr Forrester said. He estimates that about a third of hospitals will readily try to pick up new changes, another third will need coaching and ongoing mentorship, and the final third will be more resistant to changing current practices.

In Ethiopia, the team has already consolidated and streamlined process maps through site visits to multiple tertiary hospitals.

After Dr Forrester's presentation, session moderator, Ziad C. Sifri, MD, an associate professor of surgery at Rutgers University in Newark, New Jersey, asked how the work would be carried forward when he left Ethiopia. A team in Addis Ababa has taken over the program and plans to roll it out throughout the country, Dr Forrester said. "They'll be the ones carrying it forward, not myself," he said.

"I think this is great work and it requires a lot of effort and perseverance," Dr Sifri told Medscape Medical News.

"When you go into a low-resource environment, you realize that nobody is keeping track of standards that we take for granted."

The "most interesting" data will be the effects on the actual incidence of infection, he said.

Dr Sifri and Dr Forrester have disclosed no relevant financial relationships.

American College of Surgeons 2017 Clinical Congress. Presented October 23, 2017.

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