Abstract:
Background: Surgical site infections (SSIs) are a leading cause of post-operative morbidity and mortality.
We developed Clean Cut, a surgical infection prevention program, with two goals: (1) Increase adherence to
evidence-based peri-operative infection prevention standards and (2) establish sustainable surgical infection
surveillance. Here we describe our infection surveillance strategy.
Patients and Methods: Clean Cut was piloted and evaluated at a 523 bed tertiary hospital in Ethiopia. Infection
prevention standards included: (1) Hand and surgical site decontamination; (2) integrity of gowns, drapes, and
gloves; (3) instrument sterility; (4) prophylactic antibiotic administration; (5) surgical gauze tracking; and (6)
checklist compliance. Primary outcome measure was SSI, with secondary outcomes including other infection,
re-operation, and length of stay. We prospectively observed all post-surgical wounds in obstetrics over a 12 day
period and separately recorded post-operative complications using chart review. Simultaneously, we reviewed
the written hospital charts after patient discharge for all patients whose peri-operative adherence to infection
prevention standards was captured.
Results: Fifty obstetric patients were followed prospectively with recorded rates of SSI 14%, re-operation 6%, and
death 2%. Compared with direct observation, chart review alone had a high loss to follow-up (28%) and decreased
capture of infectious complications (SSI [n = 2], endometritis [n = 3], re-operations [n = 2], death [n = 1]); further,
documentation inconsistencies failed to capture two complications (SSI [n = 1], mastitis [n = 1]). Concurrently,
137 patients were observed for peri-operative infection prevention standard adherence. Of these, we were able to
successfully review 95 (69%) patient charts with recorded rates of SSI 5%, re-operation 1%, and death 1%.
Conclusion: Patient loss to follow-up and poor documentation of infections underestimated overall infectious
complications. Direct, prospective follow-up is possible but requires increased time, clinical skill, and training.
For accurate surgical infection surveillance, direct follow-up of patients during hospitalization is essential,
because chart review does not accurately reflect post-operative complications.