Intraoperative aseptic practices and surgical site infections in breast surgery

Teija-Kaisa Aholaakko

Research output: ThesisDoctoral ThesisCollection of Articles

Abstract

Background and aims. Operating theatre (OT) personnel implement intraoperative aseptic practices (AP) to control and prevent surgical site infection (SSI). AP is considered important in both infection control (IC) and prevention (IP), despite the challenges of investigating the causality between APs and SSIs. This study introduces a project regarding co-creating intraoperative APs in the OTs of one university hospital, with another hospital functioning as a comparison setting. Objectives for this study were: 1) to investigate the acceptance of and adherence to APs among OT personnel before and after the co-creation of the evidence-based intraoperative APs and during the follow-up study; 2) to introduce assessment tools for the intraoperative APs for further development and improvement; 3) to explore performance of AP-related clinical situations; and 4) to define risk factors for SSIs in breast operations. Methods. Outcomes of the project were measured as changes in the acceptance of and self-reported adherence to the AP recommendations, and as SSIs in breast surgery. A follow-up study was completed 12 years after the cocreation of the AP recommendations. First, the acceptance of and adherence to the AP recommendations were surveyed among OT personnel before (N=211) and after (N=234) the co-creation of the recommended APs. Twelve years after the co-creation, a follow-up survey was completed only for nurses both in the study and comparison hospital (N=242). An initial literature based intraoperative AP model created to facilitate the AP recommendation cocreation process. Descriptive statistics and summation variables were computed for assessing the AP recommendation acceptance and adherence. Second, using the variables of the aforementioned survey, separate AP assessment tools were created for circulating and scrub nurses. The initial AP model served as a structure for the tools. Clinically relevant assessment criteria were selected to achieve a high internal consistency for the scales. Third, qualitative research was completed in the study hospital. Video recordings of 31 operations served as stimulated recalls during interviews of 31 circulating nurses. The APs were observed and feedback discussions completed at the end of interviews using a criteria-based observation tool. Fourth, all breast operation-related patient documents (N=1042) and SSI statistics from infection register in the two hospitals were reviewed before and after the co-creation of the AP recommendations. After removing contaminated and infected operations descriptive statistics and logistic regression analyses computed to define the SSI risk factors for all breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282). Results. Statistically significant differences in recommendation acceptance were found between professions and genders before and after the recommendation co-creation measured according to establishment, maintenance and disestablishment of the sterile field. Between study and comparison hospitals the differences were significant except not during the disestablishment of the sterile field before co-creation. In self-reported prevention of handborne contamination, differences were found between hospitals, professions and those 52 respondents participated in both measurements. In preventing airborne contamination, differences were found between hospitals and among the 52 respondents. In preventing bloodborne contamination, differences were found between professions, genders and the 52 respondents. The self-reported adherence to preventing bloodborne infections was found to be higher among those respondents with no needlestick injuries from used needles than those reporting a needlestick. After the follow-up survey, a 20-item tool with good scale reliability was constructed for assessing the AP of circulating nurses. The three phases of AP–establishment, maintenance, and disestablishment of the sterile field –structured the tool. In testing the tool, differences were found in AP recommendation acceptance according to education and working experience. Three tools were constructed for scrub nurses. One was for preparing to work, one for working in the sterile field and one for reporting adherence to AP recommendations during maintenance of the sterile field. No differences were found in the acceptance and self-reported AP adherence by demographics among day surgery and OT nurses. The stimulated recall interviews (N=31) of the circulating nurses in the study hospital found variation in adherence to recommended intraoperative APs. The circulating nurses expressed working experience-, time- and equipment-related stress in implementing APs. Also working with demanding persons in OT team, challenges with patients, working morals and power related stress reported regarding implementing the intraoperative AP recommendations. The OT nurses managed the stress by both active and withdrawal behaviour. Reactions were individual and situation specific. No improvement was found in postoperative SSI rates after the co-creation of AP recommendations in the study hospital. A multivariate logistic regression model for all the breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282) was built to explain the risks for postoperative infections (6.7%). In all operations, a contaminated or dirty wound, high American Society of Anaesthesiologists’ score, high patient body mass index, use of surgical drains, and re-operation predicted increased SSI risk. High patient body mass index and use of surgical drains predicted an increased risk in lumpectomies. In mastectomies, the statistically significant predictor was re-operation. Conclusions. The varying acceptance of and adherence to the intraoperative AP recommendations requires improvement. Stress due to the challenges in implementing the AP recommendations is avoidable by co-created evidence-based APs. The SSI risks in breast operations may be managed by considering the use of antimicrobial prophylaxis in re-operations and obese patients. The assessment of intraoperative IP is possible to improve by including the baseline AP model and relevant criteria in the documentation. More carefully planned and implemented projects are necessary for improving the evidence-based recommendations for intraoperative AP to secure the safety of the surgical patients, personnel and environment among anaesthesia personnel also. The expertise of the personnel is important to develop through participative and strategic training and structured follow-up reporting.
Original languageEnglish
Supervisors/Advisors
  • Lyytikäinen, Outi, Supervisor, External person
  • Metsälä, Eija, Supervisor, External person
Award date27 Oct 2018
Place of PublicationHelsinki
Publisher
Print ISBNs978-951-51-4580-2
Electronic ISBNs978-951-51-4581-9
Publication statusPublished - 2018
MoE publication typeG5 Doctoral dissertation (article)

Fields of Science

  • Surgical Wound Infection
  • Intraoperative Complications
  • Reoperation
  • Infection Control
  • Antibiotic Prophylaxis
  • 3141 Health care science

Cite this

Aholaakko, T-K. (2018). Intraoperative aseptic practices and surgical site infections in breast surgery. Helsinki: Helsingin yliopisto.
Aholaakko, Teija-Kaisa. / Intraoperative aseptic practices and surgical site infections in breast surgery. Helsinki : Helsingin yliopisto, 2018. 143 p.
@phdthesis{16ffc0f923d0416495cf27a41d8526ca,
title = "Intraoperative aseptic practices and surgical site infections in breast surgery",
abstract = "Background and aims. Operating theatre (OT) personnel implement intraoperative aseptic practices (AP) to control and prevent surgical site infection (SSI). AP is considered important in both infection control (IC) and prevention (IP), despite the challenges of investigating the causality between APs and SSIs. This study introduces a project regarding co-creating intraoperative APs in the OTs of one university hospital, with another hospital functioning as a comparison setting. Objectives for this study were: 1) to investigate the acceptance of and adherence to APs among OT personnel before and after the co-creation of the evidence-based intraoperative APs and during the follow-up study; 2) to introduce assessment tools for the intraoperative APs for further development and improvement; 3) to explore performance of AP-related clinical situations; and 4) to define risk factors for SSIs in breast operations. Methods. Outcomes of the project were measured as changes in the acceptance of and self-reported adherence to the AP recommendations, and as SSIs in breast surgery. A follow-up study was completed 12 years after the cocreation of the AP recommendations. First, the acceptance of and adherence to the AP recommendations were surveyed among OT personnel before (N=211) and after (N=234) the co-creation of the recommended APs. Twelve years after the co-creation, a follow-up survey was completed only for nurses both in the study and comparison hospital (N=242). An initial literature based intraoperative AP model created to facilitate the AP recommendation cocreation process. Descriptive statistics and summation variables were computed for assessing the AP recommendation acceptance and adherence. Second, using the variables of the aforementioned survey, separate AP assessment tools were created for circulating and scrub nurses. The initial AP model served as a structure for the tools. Clinically relevant assessment criteria were selected to achieve a high internal consistency for the scales. Third, qualitative research was completed in the study hospital. Video recordings of 31 operations served as stimulated recalls during interviews of 31 circulating nurses. The APs were observed and feedback discussions completed at the end of interviews using a criteria-based observation tool. Fourth, all breast operation-related patient documents (N=1042) and SSI statistics from infection register in the two hospitals were reviewed before and after the co-creation of the AP recommendations. After removing contaminated and infected operations descriptive statistics and logistic regression analyses computed to define the SSI risk factors for all breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282). Results. Statistically significant differences in recommendation acceptance were found between professions and genders before and after the recommendation co-creation measured according to establishment, maintenance and disestablishment of the sterile field. Between study and comparison hospitals the differences were significant except not during the disestablishment of the sterile field before co-creation. In self-reported prevention of handborne contamination, differences were found between hospitals, professions and those 52 respondents participated in both measurements. In preventing airborne contamination, differences were found between hospitals and among the 52 respondents. In preventing bloodborne contamination, differences were found between professions, genders and the 52 respondents. The self-reported adherence to preventing bloodborne infections was found to be higher among those respondents with no needlestick injuries from used needles than those reporting a needlestick. After the follow-up survey, a 20-item tool with good scale reliability was constructed for assessing the AP of circulating nurses. The three phases of AP–establishment, maintenance, and disestablishment of the sterile field –structured the tool. In testing the tool, differences were found in AP recommendation acceptance according to education and working experience. Three tools were constructed for scrub nurses. One was for preparing to work, one for working in the sterile field and one for reporting adherence to AP recommendations during maintenance of the sterile field. No differences were found in the acceptance and self-reported AP adherence by demographics among day surgery and OT nurses. The stimulated recall interviews (N=31) of the circulating nurses in the study hospital found variation in adherence to recommended intraoperative APs. The circulating nurses expressed working experience-, time- and equipment-related stress in implementing APs. Also working with demanding persons in OT team, challenges with patients, working morals and power related stress reported regarding implementing the intraoperative AP recommendations. The OT nurses managed the stress by both active and withdrawal behaviour. Reactions were individual and situation specific. No improvement was found in postoperative SSI rates after the co-creation of AP recommendations in the study hospital. A multivariate logistic regression model for all the breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282) was built to explain the risks for postoperative infections (6.7{\%}). In all operations, a contaminated or dirty wound, high American Society of Anaesthesiologists’ score, high patient body mass index, use of surgical drains, and re-operation predicted increased SSI risk. High patient body mass index and use of surgical drains predicted an increased risk in lumpectomies. In mastectomies, the statistically significant predictor was re-operation. Conclusions. The varying acceptance of and adherence to the intraoperative AP recommendations requires improvement. Stress due to the challenges in implementing the AP recommendations is avoidable by co-created evidence-based APs. The SSI risks in breast operations may be managed by considering the use of antimicrobial prophylaxis in re-operations and obese patients. The assessment of intraoperative IP is possible to improve by including the baseline AP model and relevant criteria in the documentation. More carefully planned and implemented projects are necessary for improving the evidence-based recommendations for intraoperative AP to secure the safety of the surgical patients, personnel and environment among anaesthesia personnel also. The expertise of the personnel is important to develop through participative and strategic training and structured follow-up reporting.",
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Intraoperative aseptic practices and surgical site infections in breast surgery. / Aholaakko, Teija-Kaisa.

Helsinki : Helsingin yliopisto, 2018. 143 p.

Research output: ThesisDoctoral ThesisCollection of Articles

TY - THES

T1 - Intraoperative aseptic practices and surgical site infections in breast surgery

AU - Aholaakko, Teija-Kaisa

N1 - M1 - 143 s. + liitteet

PY - 2018

Y1 - 2018

N2 - Background and aims. Operating theatre (OT) personnel implement intraoperative aseptic practices (AP) to control and prevent surgical site infection (SSI). AP is considered important in both infection control (IC) and prevention (IP), despite the challenges of investigating the causality between APs and SSIs. This study introduces a project regarding co-creating intraoperative APs in the OTs of one university hospital, with another hospital functioning as a comparison setting. Objectives for this study were: 1) to investigate the acceptance of and adherence to APs among OT personnel before and after the co-creation of the evidence-based intraoperative APs and during the follow-up study; 2) to introduce assessment tools for the intraoperative APs for further development and improvement; 3) to explore performance of AP-related clinical situations; and 4) to define risk factors for SSIs in breast operations. Methods. Outcomes of the project were measured as changes in the acceptance of and self-reported adherence to the AP recommendations, and as SSIs in breast surgery. A follow-up study was completed 12 years after the cocreation of the AP recommendations. First, the acceptance of and adherence to the AP recommendations were surveyed among OT personnel before (N=211) and after (N=234) the co-creation of the recommended APs. Twelve years after the co-creation, a follow-up survey was completed only for nurses both in the study and comparison hospital (N=242). An initial literature based intraoperative AP model created to facilitate the AP recommendation cocreation process. Descriptive statistics and summation variables were computed for assessing the AP recommendation acceptance and adherence. Second, using the variables of the aforementioned survey, separate AP assessment tools were created for circulating and scrub nurses. The initial AP model served as a structure for the tools. Clinically relevant assessment criteria were selected to achieve a high internal consistency for the scales. Third, qualitative research was completed in the study hospital. Video recordings of 31 operations served as stimulated recalls during interviews of 31 circulating nurses. The APs were observed and feedback discussions completed at the end of interviews using a criteria-based observation tool. Fourth, all breast operation-related patient documents (N=1042) and SSI statistics from infection register in the two hospitals were reviewed before and after the co-creation of the AP recommendations. After removing contaminated and infected operations descriptive statistics and logistic regression analyses computed to define the SSI risk factors for all breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282). Results. Statistically significant differences in recommendation acceptance were found between professions and genders before and after the recommendation co-creation measured according to establishment, maintenance and disestablishment of the sterile field. Between study and comparison hospitals the differences were significant except not during the disestablishment of the sterile field before co-creation. In self-reported prevention of handborne contamination, differences were found between hospitals, professions and those 52 respondents participated in both measurements. In preventing airborne contamination, differences were found between hospitals and among the 52 respondents. In preventing bloodborne contamination, differences were found between professions, genders and the 52 respondents. The self-reported adherence to preventing bloodborne infections was found to be higher among those respondents with no needlestick injuries from used needles than those reporting a needlestick. After the follow-up survey, a 20-item tool with good scale reliability was constructed for assessing the AP of circulating nurses. The three phases of AP–establishment, maintenance, and disestablishment of the sterile field –structured the tool. In testing the tool, differences were found in AP recommendation acceptance according to education and working experience. Three tools were constructed for scrub nurses. One was for preparing to work, one for working in the sterile field and one for reporting adherence to AP recommendations during maintenance of the sterile field. No differences were found in the acceptance and self-reported AP adherence by demographics among day surgery and OT nurses. The stimulated recall interviews (N=31) of the circulating nurses in the study hospital found variation in adherence to recommended intraoperative APs. The circulating nurses expressed working experience-, time- and equipment-related stress in implementing APs. Also working with demanding persons in OT team, challenges with patients, working morals and power related stress reported regarding implementing the intraoperative AP recommendations. The OT nurses managed the stress by both active and withdrawal behaviour. Reactions were individual and situation specific. No improvement was found in postoperative SSI rates after the co-creation of AP recommendations in the study hospital. A multivariate logistic regression model for all the breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282) was built to explain the risks for postoperative infections (6.7%). In all operations, a contaminated or dirty wound, high American Society of Anaesthesiologists’ score, high patient body mass index, use of surgical drains, and re-operation predicted increased SSI risk. High patient body mass index and use of surgical drains predicted an increased risk in lumpectomies. In mastectomies, the statistically significant predictor was re-operation. Conclusions. The varying acceptance of and adherence to the intraoperative AP recommendations requires improvement. Stress due to the challenges in implementing the AP recommendations is avoidable by co-created evidence-based APs. The SSI risks in breast operations may be managed by considering the use of antimicrobial prophylaxis in re-operations and obese patients. The assessment of intraoperative IP is possible to improve by including the baseline AP model and relevant criteria in the documentation. More carefully planned and implemented projects are necessary for improving the evidence-based recommendations for intraoperative AP to secure the safety of the surgical patients, personnel and environment among anaesthesia personnel also. The expertise of the personnel is important to develop through participative and strategic training and structured follow-up reporting.

AB - Background and aims. Operating theatre (OT) personnel implement intraoperative aseptic practices (AP) to control and prevent surgical site infection (SSI). AP is considered important in both infection control (IC) and prevention (IP), despite the challenges of investigating the causality between APs and SSIs. This study introduces a project regarding co-creating intraoperative APs in the OTs of one university hospital, with another hospital functioning as a comparison setting. Objectives for this study were: 1) to investigate the acceptance of and adherence to APs among OT personnel before and after the co-creation of the evidence-based intraoperative APs and during the follow-up study; 2) to introduce assessment tools for the intraoperative APs for further development and improvement; 3) to explore performance of AP-related clinical situations; and 4) to define risk factors for SSIs in breast operations. Methods. Outcomes of the project were measured as changes in the acceptance of and self-reported adherence to the AP recommendations, and as SSIs in breast surgery. A follow-up study was completed 12 years after the cocreation of the AP recommendations. First, the acceptance of and adherence to the AP recommendations were surveyed among OT personnel before (N=211) and after (N=234) the co-creation of the recommended APs. Twelve years after the co-creation, a follow-up survey was completed only for nurses both in the study and comparison hospital (N=242). An initial literature based intraoperative AP model created to facilitate the AP recommendation cocreation process. Descriptive statistics and summation variables were computed for assessing the AP recommendation acceptance and adherence. Second, using the variables of the aforementioned survey, separate AP assessment tools were created for circulating and scrub nurses. The initial AP model served as a structure for the tools. Clinically relevant assessment criteria were selected to achieve a high internal consistency for the scales. Third, qualitative research was completed in the study hospital. Video recordings of 31 operations served as stimulated recalls during interviews of 31 circulating nurses. The APs were observed and feedback discussions completed at the end of interviews using a criteria-based observation tool. Fourth, all breast operation-related patient documents (N=1042) and SSI statistics from infection register in the two hospitals were reviewed before and after the co-creation of the AP recommendations. After removing contaminated and infected operations descriptive statistics and logistic regression analyses computed to define the SSI risk factors for all breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282). Results. Statistically significant differences in recommendation acceptance were found between professions and genders before and after the recommendation co-creation measured according to establishment, maintenance and disestablishment of the sterile field. Between study and comparison hospitals the differences were significant except not during the disestablishment of the sterile field before co-creation. In self-reported prevention of handborne contamination, differences were found between hospitals, professions and those 52 respondents participated in both measurements. In preventing airborne contamination, differences were found between hospitals and among the 52 respondents. In preventing bloodborne contamination, differences were found between professions, genders and the 52 respondents. The self-reported adherence to preventing bloodborne infections was found to be higher among those respondents with no needlestick injuries from used needles than those reporting a needlestick. After the follow-up survey, a 20-item tool with good scale reliability was constructed for assessing the AP of circulating nurses. The three phases of AP–establishment, maintenance, and disestablishment of the sterile field –structured the tool. In testing the tool, differences were found in AP recommendation acceptance according to education and working experience. Three tools were constructed for scrub nurses. One was for preparing to work, one for working in the sterile field and one for reporting adherence to AP recommendations during maintenance of the sterile field. No differences were found in the acceptance and self-reported AP adherence by demographics among day surgery and OT nurses. The stimulated recall interviews (N=31) of the circulating nurses in the study hospital found variation in adherence to recommended intraoperative APs. The circulating nurses expressed working experience-, time- and equipment-related stress in implementing APs. Also working with demanding persons in OT team, challenges with patients, working morals and power related stress reported regarding implementing the intraoperative AP recommendations. The OT nurses managed the stress by both active and withdrawal behaviour. Reactions were individual and situation specific. No improvement was found in postoperative SSI rates after the co-creation of AP recommendations in the study hospital. A multivariate logistic regression model for all the breast operations (N=982), lumpectomies (n=700) and mastectomies (n=282) was built to explain the risks for postoperative infections (6.7%). In all operations, a contaminated or dirty wound, high American Society of Anaesthesiologists’ score, high patient body mass index, use of surgical drains, and re-operation predicted increased SSI risk. High patient body mass index and use of surgical drains predicted an increased risk in lumpectomies. In mastectomies, the statistically significant predictor was re-operation. Conclusions. The varying acceptance of and adherence to the intraoperative AP recommendations requires improvement. Stress due to the challenges in implementing the AP recommendations is avoidable by co-created evidence-based APs. The SSI risks in breast operations may be managed by considering the use of antimicrobial prophylaxis in re-operations and obese patients. The assessment of intraoperative IP is possible to improve by including the baseline AP model and relevant criteria in the documentation. More carefully planned and implemented projects are necessary for improving the evidence-based recommendations for intraoperative AP to secure the safety of the surgical patients, personnel and environment among anaesthesia personnel also. The expertise of the personnel is important to develop through participative and strategic training and structured follow-up reporting.

KW - Surgical Wound Infection

KW - Intraoperative Complications

KW - Reoperation

KW - Infection Control

KW - Antibiotic Prophylaxis

KW - 3141 Health care science

M3 - Doctoral Thesis

SN - 978-951-51-4580-2

T3 - Dissertationes Scholae Doctoralis Ad Sanitatem Investigandam Universitatis Helsinkiensis

PB - Helsingin yliopisto

CY - Helsinki

ER -

Aholaakko T-K. Intraoperative aseptic practices and surgical site infections in breast surgery. Helsinki: Helsingin yliopisto, 2018. 143 p. ( Dissertationes Scholae Doctoralis Ad Sanitatem Investigandam Universitatis Helsinkiensis ; 74/2018 ).