Estimation Of Awareness Of Surgical Site Infections And Their Risk Factors Among Physicians In Surgical Departments In The Hail Region, Kingdom Of Saudi Arabia, 2019-2020

Introduction

According to the Centers for Disease Control and Prevention [1], surgical site infections (SSIs) are acquired by patients during or after surgery and involve the skin; in severe instances, the infection might spread to deeper tissues and organs [2]. SSIs are considered to be a substantial cause of morbidity and mortality worldwide [3]. SSIs are a frequent and worrisome part of postoperative recovery and account for 2% of surgical complications, which is more than 20% of health-care-associated infections (HCAIs) [4].

A study conducted in 2017 argued that SSIs are a preventable complication, as it is estimated that approximately half of SSIs could be prevented by adhering to proper postoperative hygiene, which includes proper sterilization techniques of the operative field [5] . Hand hygiene, use of antibiotics, avoidance of shaving, limiting traffic, controlling crowdedness, employing personal protective equipment (e.g., masks, gowns, hair covers, and gloves) and other strategies as reported by multiple studies [3-6]. Prevention of SSIs is particularly cost-effective as the total number of surgical procedures performed is increasing worldwide [3]. According to a study in 2017, applying preventive measures in a health institute is cost effective and can reduce bad and devastating outcomes [7].

Accurate measurement can be a challenge in patient safety, but the CDC's National Healthcare Safety Network has developed standards for SSI measurement, which are also used by the National Surgical Quality Improvement Program (NSQIP) [1].

In 2019, a study conducted in Jeddah city, reported that 6.7% of physicians had good knowledge of SSIs, while 30.2% had poor knowledge [8]. Therefore, the aim of the present study was to estimate the level of awareness of SSIs among physicians in surgical departments in the Hail Region of the Kingdom of Saudi Arabia.

Materials

Study Design and Participants

This hospital-based cross-sectional study was conducted at the Departments of Surgery at Hail General Hospital, King Khalid Hospital, Maternity and Children Hospital, and King Salman Specialist Hospital in Hail city from October 7 to 27 2019. All surgical consultants, specialists, residents, and medical interns whose doing the internship in surgery departments were invited to participate in the study after gaining a written consent. The participants were divided into four groups:

Group 1: 11 interns.

Group 2: 18 residents.

Group 3: 50 specialists.

Group 4: 18 consultants.

All groups were working at the hospitals at the time of the present study. A questionnaire was distributed to all of the included departments by the departments’ coordinators and secretaries.

A 20-item multiple-choice questionnaire was developed by reviewing the previous literature and consulting with a group of certified surgeons. These steps allowed for the identification of the important factors and knowledge that must be followed to reduce SSIs and also facilitated the development of a valid questionnaire to properly assess the levels of knowledge about SSIs and risks of wound infection among physicians in the city of Hail. The questionnaire was distributed randomly among the included sample.

After recruitment, the participants were asked to specify their position. Then, the questionnaire was distributed among the participants, they were asked to answer the questions according to their knowledge about SSIs and risks of wound infections. Then, the level of knowledge was assessed for all participants.

Method

Statistical Analysis

Data were analyzed on a computer using SPSS version 22.

Ethical Approval

The study was approved by the University of Hail College of Medicine Ethical Committee, approval number: HREC 00114/CM-UOH.04/20 .

Results

With respect to the distribution of the participants by age, the group between 31 and 40 years of age had the highest representation (32%), and the group of those 50 years of age and older had the lowest (16.5%). Males had the highest representation (78.4%), and females comprised 21.6% of the sample. Table 1 shows which position (i.e., specialist) had the highest representation (51.5%), with interns comprising only 11.3% of the sample.

The respondents were categorized as having good knowledge (> 80% correct answers or a ≥ 77 total score), fair knowledge (50% correct answers or a ≥ 48 total score), or poor knowledge (< 50% correct answers or a < 48 total score). The results of the statistical analysis using SPSS version 22.0 are demonstrated in Table 2 and Figure 1, which showed that the level knowledge was between poor and good, and the total score was fair. Table 3 presents the means and standard deviations (SDs) by job position.

A total of 97 doctors were included in this study. Among these respondents, 50 (51%) were specialists, 18 (18%) were residents, 18 (18%) were consultants, and 11 (11%) were interns. It was shown that 52 (54%) of doctors knew the correct definition of an SSI according to the criteria developed by the CDC; this was considered to be indicative of a fair level of knowledge. Further, 43 of the physicians had a poor level of knowledge, as only 44% knew about the most common organism associated with SSIs.

Regarding the knowledge of physicians about the most common pre-operative antibiotics and the best time for administrating prophylactic antibiotics, 82 (85%) had knowledge of these factors (good level of knowledge). More than half of the doctors (52%) had knowledge about the risk factors of SSI (fair level of knowledge). The physicians did not have any knowledge regarding the most effective method to prevent SSIs (0%), but 42 (43%) doctors knew the best method to remove hair from surgical patients (poor level of knowledge). A total of 24 (25%) doctors knew the proper hand hygiene techniques, including surgical scrubbing, and their purpose (poor level of knowledge).

It was found that 81 (83.5%) physicians knew the classification and definition of superficial SSIs (good level of knowledge). Less than half provided a correct answer to a question on the chances of developing SSIs (26.8%) (poor level of knowledge). Only 35 (36.1%) answered a question about the antibiotics used in the pre-operative stage correctly (poor level of knowledge). Most of the respondents, or 86 (88.7%), had a good level of knowledge regarding the complications of SSIs, and 83 (85.6%) had a good level of knowledge about the presentation of infected wounds. However, only 39 (40.2%) knew the appropriate time to discontinue a prophylactic antibiotic (poor level of knowledge).

A total of 67 (69.1%) of the respondents answered correctly about the best time to remove the body hair before the operation (fair level of knowledge). More than half (77, or 79.4%) had a good level of knowledge about the factors that impair wound healing, and 59 (60.8%) knew how to assess the nutritional status of a surgical patient (fair level of knowledge). Less than half (45, or 46.4%) correctly answered a question about the first step in surgical scrubbing (poor level of knowledge), but 85 (87.6%) knew the purpose of pre-operative skin cleansing (good level of knowledge). A score of 55% (53.5) was the mean level of knowledge and risk assessment of wound infection among physicians in the surgical departments in the Hail region (fair level of knowledge).

The study correlates the experience and qualifications with the total knowledge. Surprisingly, the total knowledge for consultant was 53%, specialist was 57.2%, resident was 56.6% and interns was 45%.

Discussion

The focus on SSI prevention is growing worldwide, and this process requires appropriate strategies since SSIs cause serious morbidity and mortality [9-10]. SSIs are associated with common risk factors mentioned in various studies, such as old age (>55), diabetes mellitus, and immunocompromised status [11-12]. SSIs account for approximately 2–20% of surgical procedures, depending on the procedure, and they can cause a significant economic burden and heavy demand on health care resources [7-12-13].

In the present study, the authors examined and analyzed the total knowledge scores among doctors regarding SSIs information and practice. The present work found that most of the doctors had a fair level of knowledge regarding the definition of SSIs, as 54% knew the correct definition of an SSI according to the CDC. This was similar to another study conducted in Jeddah in 2019, Saudi Arabia which showed that 55.5% of respondents knew the definition [8].

The present study showed that most of the doctors had a good level of knowledge regarding the classification of SSIs and the difference between each type (83.5%). Knowing the appropriate classification is crucial to respond and treat SSIs appropriately. There are two defined systems worldwide regarding wound assessment: the ASEPSIS scoring system and the Southampton Wound Assessment Scale, both of which help with assessment, grading, and identifying any complications, such as SSIs, postoperatively [11].

In the present study, most of the region’s doctors were shown to have a fair level of knowledge about the most common type of SSIs, as 63.9% of the respondents knew that superficial incisional SSIs accounted for more than half of all SSIs. A lower percentage (58.8%) was reported in a study in a neighboring city, according to which only 9.3% of doctors knew that deep incisional SSIs were more common than superficial incisional and organ/space SSIs [8].

It was also revealed that 44% of the doctors had fair levels of knowledge regarding the most common organisms causing SSIs, which are Staphylococcus aureus and Escherichia coli. The most common group of microorganisms to cause an SSI is gram-positive cocci, mainly Staphylococcus aureus [12]. The incidence of SSIs in Nigeria was shown to be 38% [13], while India reported a lower incidence of 12% [14]. This was 15 times higher in non-developed countries than in developed countries. Moreover, a previous study conducted in India 2016 reported that the perception of health care staff about SSIs was good enough (94%) [11]. However, the practices were inadequate (47%) [15]. Further, an international survey sponsored by the WHO demonstrated that the prevalence of nosocomial infections ranged from three to 21%, and wound infection percentages were surprisingly 5–34% [12].

The present study reported that 85% of the doctors had a good level of knowledge regarding the best time for administering prophylactic antibiotics, which was within 60 minutes prior to surgery. This number was higher than that of a study conducted in Jeddah in 2019, which showed that 78.2% of doctors had this knowledge [8]. Further, in this study, it was found that only 26.8% of doctors knew about the incidence of SSIs, which was 1–3%. This was similar to the previous study conducted in Jeddah, for which 25.2% of doctors knew the same fact [8].

The present study found that most of the doctors (88.7%) had good levels of knowledge regarding the complications of surgical site infection, while only 11 of the respondents had no understanding of such complications. This was similar to the findings of a study conducted in 2019, which showed that 84.0% of the doctors knew about the complications of SSIs [8].

Regarding the question about the CDC recommendations for the prevention of SSI, none of the doctors were able to answer this correctly (0%). However, a more positive response rate was observed in a study conducted in Ethiopia among doctors and nurses to assess their knowledge of infection control practices and associated factors toward infection prevention (84.7%) [16]. Nevertheless, the results of the present study indicated that most of the doctors had a good level of knowledge regarding the presentation of infected wounds. The majority of doctors answered that infected wounds can exhibit purulent pus (85.6%), which was similar to the result of the previous study in Jeddah that reported a rate of 89.1% [8].

In the present study, 40.2% of respondents chose the correct time to discontinue prophylactic antibiotics as per the WHO SSI prevention guidelines [17]. Six of the respondents were consultants, 24 were specialists, seven were residents, and two were interns. This reflected a poor level of knowledge that could be associated with a fear of malpractice lawsuits and the rising number of defensive medical practices, according to an international survey [18] . In a Korean study conducted in 2020, it was reported that 15 out of 1,895 patients had had antibiotics appropriately discontinued [19]. In addition, in a 2005 study done in the United States, it was concluded that merely 40.7% of patients discontinued with antibiotics at the recommended time [10].

The World Health Organization (WHO) has recommended clipping as a hair removal technique only if necessary [20], and only 43.3% of participants in the present study answered this question correctly. Further, only 4.1% of them correctly answered the preferred timing of hair removal. There was no correct answer associated with the CDC guidelines that recommended clipping be done shortly prior to incision. However, the NICE guidelines recommend that the removal—if needed—should be on the day of surgery [21].

Participants had a good level of knowledge (79.3%) that steroid use was associated with SSIs, but in another study, 83.2% of respondents had this knowledge [8]. Further, in a King Abdulaziz University Hospital study, 69.7% of the doctors answered that serum albumin was the most commonly used marker to assess nutritional status for a surgical patient [8]. However, in the present study, 60.8% of the respondents in all groups, and just half of the consultants, answered this question correctly.

In the present research, less than half of the doctors (46.39%) knew that the first step in surgical scrubbing was the removal of any watches and rings from their hands, which indicated a poor level of knowledge. However, in another study in Jedda, most doctors knew about this first step (69.7%) [8]. Moreover, the fourth step in hand hygiene was correctly stated by a relatively small number of doctors (24\97), which reflected an even lower level of knowledge in the surgical scrubbing process. In comparison, another study showed similar results (20.4%) [8].

Finally, the doctors in the present study showed a good level of knowledge regarding the purpose of pre-operative skin cleaning (87.6%), which was similar to the finding in the study at KAUH (80.7%) [8].

Conclusion

The present study has clarified that the overall knowledge about SSIs among doctors was fair but insufficient. Therefore, it is recommended that the WHO recommendations be implemented during the pre-operative period to ensure high-quality care for every patient, thereby eliminating the risk of relapsing and unnecessary readmissions. It is also highly recommended that more training programs be initiated for health care professionals. It is important for medical professionals to improve their knowledge and evidence-based practices to maintain the patient experience at a higher level of safety after surgery.

Conflict of Interest

The authors declare that they have no competing interests.

Acknowledgment

The authors would like to acknowledge the effort of the data collectors: Sami Mamdouh Ibrahim Alrashidi , Noura Hamad Rasheed Alshurtan. They would also like to thank the hospital staff for facilitating the data collection.

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