Infection-Control Program Improves Operative Practices in Ethiopia

By Lorraine L. Janeczko

November 22, 2021

NEW YORK (Reuters Health) - The Clean Cut quality-improvement program can help make surgeries safer, a study from Ethiopia suggests.

Lifebox Foundation's checklist-based Clean Cut program aims to improve anesthesia safety, reduce surgical infection rates, and strengthen surgical teamwork.

"The improvements in surgical safety seen as a result of the Lifebox Clean Cut program in Ethiopia were sustained between 6 and 18 months after completion of the intervention, suggesting these changes in surgical culture and practice are long-lasting," said Dr. Nichole Starr of the University of California, San Francisco, who worked on the study.

"The findings of sustainable improvements in surgical safety practices over time are not surprising but are reassuring that our collaborative work is making a lasting impact," she told Reuters Health by email.

Dr. Starr and her colleagues investigated the sustainability of the Clean Cut program introduced at eight hospitals in Ethiopia.

Over four years, surgical teams and hospital management staff in the program engaged in six key practices:

- Skin antisepsis of the surgeon's hands and surgical site

- Sterile-field maintenance of gowns, drapes, and gloves

- Confirmation of instrument sterility

- Appropriate antibiotic prophylaxis

- Gauze count before and after each case

- Adherence to World Health Organization Surgical Safety Checklist

During the program, the research team monitored infection-prevention practices, process mapping, training, and action planning. Then, six to 18 months after the program ended, for 14 days in seven of the hospitals, they observed and evaluated how well the hospitals maintained the program's practices. Evaluators observed all operations in the same operating rooms and used the same Clean Cut data collection tool they had used during the program.

Overall, 738 patients were enrolled before the Clean Cut program began, 2,178 were enrolled after the program began, and 469 took part during the sustainability audit. The case urgency between the groups was similar.

Compared with the program period, the audit period showed increased compliance with surgical-safety-checklist use (50% vs. 58%, respectively), skin antisepsis (58% vs. 75%), antibiotic prophylaxis (59% vs. 66%), and gauze counting (94% vs. 95%).

Compliance decreased over time with surgical-linen integrity and sterility (46% vs. 39%) and instrument sterility (55% vs. 42%), but remained far above baseline (6% and 8%, respectively).

On multivariable analysis, the results were not linked with differences in case volume by hospital, age, or procedure type.

"Ownership creation among hospitals was a strength of the study," co-author Dr. Natnael Gebeyehu of St Peters Specialized Hospital in Addis Ababa told Reuters Health by email. "All solutions were designed by the hospitals' team members themselves."

The authors acknowledge limitations to the study, including the lack of functioning autoclaves and biomedical engineering expertise needed to maintain them.

"Surgical-quality-improvement projects in low-income settings are increasingly commonplace and are gaining more recognition as important interventions to improve surgical care in all types of global settings," Dr. Starr said.

"We do not always have the opportunity to measure impacts over time," she explained. "However, it is important to demonstrate that gains in safety are not transient or reliant on external influences."

"The changes in surgical culture as a result of Clean Cut may have lasting positive effects on patient care, substantially reducing their risk of infections after surgery. We estimate that over 80,000 patients in Ethiopia have been impacted by the Clean Cut program to date." Dr. Starr noted, adding that Clean Cut programs are also operating in Liberia and Madagascar.

SOURCE: JAMA Surgery, online November 3, 2021.