Efforts to prevent healthcare-related infections are one of the highest priorities within quality and patient safety in the Swedish healthcare sector (1). The number of reported MRSA cases is low compared to that in other countries, and is mainly due to the good hygiene routines combined with a restrictive use of antibiotics.
But there is still much room for improvement. Healthcare-related infections are estimated to cost Sweden about SEK 4 billion (€400 million) per year according to the Smittskyddsinstitutet (Swedish Institute for Infectious Disease Control). This money could be used in a more constructive manner.
|
“The time invested in acquiring good hygiene routines is well worth it. A reduction in postoperative infections and other hospital infections improves not only patient safety but also cost effectiveness within healthcare,” comments Margareta Forsell, Hygiene Nurse at Sahlgrenska University Hospital in Gothenburg.
The spread of infection is either exogenous, when bacteria is transmitted from outside, or endogenous when it comes from the patient’s own skin flora (2). In hospitals, the greatest risk of infection is from personnel carrying the infection from one patient to another in the wards, primarily on the hands. These infection pathways must be stopped; first and foremost by scrupulous hand hygiene. The use of fast-acting, alcoholbased disinfectants, before and after contact with each patient, form the basis of hygiene routines intended to reduce the transient, or non-intentional, transmission of bacteria from the hands of healthcare personnel. |
Margareta Forsell |
One other obvious risk is that of surgical wounds becoming infected with bacteria from the patient’s own skin flora, the so-called normal or resident skin flora. The risk for this type of infection can be reduced radically through a preoperative whole body wash with chlorhexidine soap.
|
“The one most important factor in the reduction of the number of hospital infections is that personnel and patients follow the hygiene rules. With regard to the patient’s own preparations prior to surgery, a whole body wash with a soap solution containing 4% chlorhexidine is the best precaution that is available atthe moment”, says Kerstin Mannerquist, Hygiene Nurse at the Swedish Institute for Infectious Disease Control.
The Swedish National Board of Health and Welfare recommends a whole body wash with chlorhexidine for all patients undergoing vascular, orthopaedic, cardiac or other surgery in which the patient’s own skin flora could cause serious infections (2). Normally, these bacteria have a protective function but, if they come in contact with a surgical wound, they can cause major problems. |
Kerstin Mannerquist |
The active substance, chlorhexidine, is a synthetic chemical compound that exhibits a bactericidal effect through interaction with the bacteria’s cell membrane (3). The antimicrobial effect of chlorhexidine was discovered in 1950 (2). Two doctors at Sahlgrenska University Hospital, Åke Brandberg, Consultant in the Laboratory of Infection Hygiene, and Professor Alf Nachemson, of the Orthopaedic Clinic, started testing the substance on orthopaedic patients at Sahlgrenska University Hospital during the 1960s, and it has been used systematically as a skin disinfectant since the end of the 1970s.
There are no European standards for products that are used as preoperative body washes. But in Swedish hospitals, a whole body wash with a soap solution containing 4% chlorhexidine is the accepted number-one method within critical, high infection risk surgery (4),( 5).
“You must complete all the steps in the hygiene procedure. An antiseptic whole body wash prior to critical surgery is paramount for preventing postoperative infections,” says Kerstin Mannerquist.
The effectiveness of a preoperative whole body wash has been proven for high infection risk surgery, partly through a study in the Department of Vascular Surgery at Sahlgrenska that covered 341 patients from 1971–1974. The incidence of postoperative infections dropped from 17.5% to 8% in the group that used a preoperative whole body wash with chlorhexidine (6).
“True, the study was conducted some years ago, but the result is still relevant today. At that time we did not give preoperative antibiotics, which means that the efficacy of the whole body wash method was particularly evident,” comments Margareta Forsell.
At Sahlgrenska University Hospital, the patients have to routinely shower with chlorhexidine soap three times before an operation involving high infection risk surgery. During each shower, the patient must have a double shower, which means that they have to wash themselves all over twice, including their hair, and rinse in between. Then they must put on clean clothes and get into a newly made-up bed. The antibacterial effect of three double showers lasts about seven days, during which time the operation wound has normally healed.
“The first wash removes the loose, epithelial skin cells. At the next wash, the chlorhexidine binds to the younger epithelial cells that are located deeper in the skin. This means that if the skin is prepared properly, the bacteria are rendered harmless for a long time,” explains Margareta Forsell.
If you shower with ordinary soap, the bacteria-bearing skin flakes released to the surroundings increase during the first hour. But when chlorhexidine soap is used instead of ordinary soap, the number of bacteria on the skin drops significantly, resulting in lower amounts of bacteria-bearing skin flakes. After repeated washing with chlorhexidine soap, the effect is amplified.
This has been demonstrated in an American study from 1993 and a UK study from 1990 (7), (8). In the American study, the subject had a full body wash with chlorhexidine every day for five days. The effect was measured after one day, two days and five days.The effect measured after five days was better than that after two days. In the UK study, an optimal effect was achieved after two washes.
In a Swedish open, consecutive study in vascular surgery, a significant drop in the number of surface wound infections after surgery was observed when patients had washed 3–8 times with chlorhexidine soap prior to surgery (9).
Even though scientific evidence is not yet available supporting the efficacy of a preoperative whole body wash regarding normal infection risk surgery, the general consensus at Sahlgrenska University Hospital is that all patients who are undergo a surgical intervention should prepare themselves in the same way as for high infection risk surgery.
“There is absolutely no disadvantage to having the same procedures for all operations”, comments Margareta Forsell.
In a pamphlet issued by the Swedish National Board of Health and Welfare, Göran Hedin, a consultant in Clinical Bacteriology at Falu Hospital, states that patients must be given clear instructions on how to carry out a whole body wash if it is to be effective (2). The entire body must be made wet and then the shower must be turned off while the body is carefully soaped all over. There is no benefit if the skin is not thoroughly soaped, and it also takes a certain amount of time before the chlorhexidine has an effect, which improves every minute for up to six minutes (10).
One challenge with regard to preparatory whole body washing within the healthcare service is the increasing use of day surgery. This places a greater requirement on the patient’s understanding of what to do and the importance of following instructions to the letter.
|
Ann Folin |
“You have to reach every inch of your back, for example. In many cases, the patients may need help with this”, says Ann Folin, Theatre Nurse and Clinical Coordinator for Mölnlycke Health Care. “The problem is that the microorganisms are not visible. If they were, it would, of course, be easier for patients to understand the importance of removing them.”
One study, involving 24 patients who underwent general or orthopaedic surgery at a day unit at one of Sweden’s regional hospitals has shown that they thought the instructions for the preoperative whole body wash were easy to understand and that they believed they had followed them correctly. In spite of this, it became clear in followup conversations that only one of the 24 patients had actually followed the instructions to the letter (11). |
The conclusion to be drawn is that both the written and oral information given to the patients must be consistent and easy to understand. Important information should also be followed up before the operation in order to ensure the patient has understood the content properly and that the instructions are actually followed (11).
References
1. Sveriges kommuner och Landsting. Ren vård är säkrare vård II. Erfarenheter från andra omgången av genombrottsprojektet VRISS (Vårdrelaterade infektioner ska stoppas), 2007. (Sweden’s municipalities and county councils. Clean care is safer care II. Experiences from the second phase of the breakthrough project VRISS (Healthcare-related infections must be stopped), 2007).
2. Socialstyrelsen. Att förebygga vårdrelaterade infektioner. Ett kunskapsunderlag, 2006. (The Swedish National Board of Heath and Welfare. Preventing healthcare-related infections. A knowledge base, 2006)
3. Denton GW. Chlorhexidine. In: Block SS, editor. Disinfection, sterilization and preservation. Fifth ed. Philadelphia: Lippincott Williams & Wilkins; 2001:321–336.
4. PM preoperativ helkroppsdesinfektion från Sahlgrenska universitetssjukhuset, Västra Götalandsregionen, 2008. (PM Preoperative whole body wash disinfection from Sahlgrenska University Hospital, West Götaland region, 2008)
5. PM preoperativa hudförberedelser från Akademiska sjukhuset, Landstinget i Uppsala län, 2009. (PM preoperative skin preparations from the Academic Hospital, County Council in Uppsala county, 2009)
6. Brandberg Å, Andersson I. Preoperative whole body disinfection by shower bath with chlorhexidine soap: Effect on transmission of bacteria from skin flora. Skin Microbiology: Relevance to Clinical Infection, New York Springer-Verlag 92–96, 1987. Chapter 12, based on the San Francisco Symp 1979.
7. Paulson DS, Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J InfectControl 1993;21(4):205–9.
8. Byrne DJ, Napier A, Cuschieri A. Rationalizingwhole body disinfection. J Hosp Infect 1990;15(2):183–7.
9. Brandberg Å, Holm J, Hammarsten J, Scherstén T. Postoperative wound infections in vascular surgery – effect of preoperative whole body disinfection by shower-bath with chlorhexidine soap. In: Academic Press Inc (London) and the Royal Society of Medicine; 1979:71–75.
10. Furuhashi M, Miyamae T. Effect of pre-operative hand scrubbing and influence of pinholes appearing in surgical rubber gloves during operation. Bull Tokyo Med Dent Univ. 1979;26(2):73–80.
11. Lindskog K, Idvall E. Preoperativ huddesinfektion inför dagkirurgi – patienters följsamhet. (Preoperative skin disinfection in day surgery – patient compliance) Vård i Norden 2004; Vol 24: No.2:41–43.
*Preoperative body washing is an approved product claim for Hibiscrub in UK, Belgium, Ireland, Italy, Kenya, Luxemburg, Malta, Norway, Spain, Sri Lanka, Sweden, Switzerland and Zimbabwe.