Preventing surgical site infection

Infection is a common, but often avoidable complication of healthcare, which has a major impact on the patient and healthcare service. Healthcare associated infection (HCAI) continues to dominate the media headlines and the Government has responded in the past decade by implementing various strategies such as the Saving Lives (Department of Health 2005) programme, which aimed to reduce bacteraemia. For Trusts within England infection rates are integral to their performance assessment and can result in external visits and for some improvement notices.
    
The National Audit Office in 2000 estimated that nine per cent of patients have a hospital acquired infection at any one time during their stay and that up to a third of healthcare associated infections could be prevented by improved infection control practice.

Vulnerable patients
Patients enter the perioperative environment relying on the expertise of the entire perioperative team to ensure that they come to no harm. The operating practitioner when making a surgical incision will compromise the patient’s natural defence mechanism - the skin - and the patient will become vulnerable to infection, therefore the prevention of surgical site infection is paramount and strategies and policies must be based on best practice.
    
With the emergence and increasing incidence of blood borne infections such as Hepatitis B and Human Immunodeficiency Virus (HIV), drapes and gowns provide a valuable barrier to protect both the patient and staff. Drapes and gowns used during a surgical procedure reduce the potential for surgical site infection by significantly minimising the transference of micro-organisms from the patient and staff into the open wound.

Fabrics used
Historically the most common fabric used was poly-cotton, an open structure material that provides little or no resistance to microbial penetration, particularly when wet. Such materials are no longer viable since drapes and gowns were classified as medical devices. A medical device is defined as a product used in healthcare for the diagnosis, prevention, monitoring or treatment of illness or disability (MHRA 2005) and this includes surgical instruments and equipment.
    
Drapes and gowns are made from different materials with contrasting properties and specifications. Manufacturers have developed single-use and reusable fabrics that offer greater protection for the patient and the surgical team which should be resistant to liquid and microbial penetration.

European Standard
The new European Standard EN 13795 was approved in 2006 and has three parts. It was developed to standardise requirements for the manufacture and use of both reusable and single-use surgical drapes, gowns and clean air suits. The Standard details the technical requirements for materials to achieve, such as resistance to wet and dry microbial penetration; cleanliness; bursting and tensile strength wet and dry; and resistance to liquid penetration.
    
EN 13795 is becoming a recognised benchmark and purchasers, perioperative users and patients will be able to identify those manufacturers that have met the minimum requirements to ensure that they have greater safety and protection when using a product. The Standard provides the team with the knowledge that if they are using a surgical drape or gown or clean air suit that complies with certain stringent requirements, then they have greater protection not only for themselves but also for their patients, and that professionally they are ensuring the risk of infection is reduced and providing a safer environment for the patient.
    
Complance
Compliance with the EN Standard is, however, not mandatory, and hospitals may continue to purchase and use surgical drapes gowns and clean air suits if they meet the locally agreed requirements.
    
Perioperative practitioners as users and healthcare organisations as purchasers of these products now have guidance via the EN13795 Standard to assist in the decision making process particularly regarding quality assurance and the products standards of performance for surgical drapes and gown products. The standard allows the whole of the perioperative team to influence the usage and purchasing of surgical drapes, gowns and clean air suits to ensure greater safety and protection not only for their patients but also for themselves.
    
Extensive literature and research evidence is available to enable practitioners to consider and evaluate the risk of infection when choosing the materials for drapes and gowns.
    
There are several factors that need to be considered, discussed and agreed by all members of the perioperative team (surgeons, staff, sterile services, infection control team and laundry services) when determining the most appropriate fabric to use in the operating theatre. These include the type of procedure, properties of the fabric, whether it is reusable or for single use, cost and expected life.
    
Benchmarks
The introduction of the Standard benchmarks best practice for the user and the manufacturer with a clear set of minimum requirements to be achieved. The arguments and debates - single use versus reusable - will continue but users and purchasers have guidance to assist in their decision, and manufacturers the need for rigorous quality assurance processes to be established to ensure continuation in this competitive market.

Diane Gilmour is a Trustee of AfPP and is the Association’s Decontamination Lead.

About the AfPP
The Association for Perioperative Practice (AfPP) was established as the National Association of Theatre Nurses, known as NATN, in 1964. It is a registered charity working to enhance skills and knowledge within operating departments, associated areas and sterile services departments.  It aims to enhance the quality of care in the NHS and the independent sector throughout the UK.

AfPP also works to encourage the exchange of professional information between members and co-operation with other professional bodies. These include the Departments of Health, the Perioperative Care Collaborative, the Nursing, Midwifery and Health Visiting Advisory Committee (Scotland), the medical Royal Colleges, CNOs of all four member countries, Skills for Health and many of the British Safety Institution Committees and other groups set up to discuss specific issues.