PREVENTING SURGICAL SITE INFECTIONS: …

1 PREVENTING SURGICAL site infections : IMPLEMENTATION APPROACHES FOR EVIDENCE-BASED RECOMMENDATIONS PREVENTING SURGICAL site infections : implementation approaches for evidence-based recommendationsISBN 978-92-4-151438-5 world health organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-Non-Commercial-ShareAlike IGO licence (CC BY-NC-SA IGO; ). Under the terms of this licence, you may copy, redistribute and adapt the work for non-com-mercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization , products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence.

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3 If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

4 The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the ma-terial lies with the reader. In no event shall WHO be liable for damages arising from its use. Graphic design by CommonSense, in CONTENTSACKNOWLEDGEMENTS ..4 ABBREVIATIONS AND ACRONYMS ..51. INTRODUCTION ..62. PURPOSE OF THE DOCUMENT.

5 123. SECTION I: THE WHO SURGICAL SAFETY CHECKLIST AN EXAMPLE OF BRINGING GUIDELINES TO LIFE IN THE SERVICE OF PATIENT SAFETY .. Introduction .. Background .. Developing the WHO SURGICAL Safety Checklist: building implementation and dissemination from the start .. Launching the Checklist: a multifaceted approach to early engagement and dissemination .. Testing the Checklist: the importance of testing, collecting feedback and adapting .. Creation of an online community for additional feedback and engagement .. Engagement of key influencers to ensure successful uptake and implementation .. Creating the right culture for implementation: the Checklist journey (at national/subnational and facility level) .. General lessons from large-scale mandated implementation efforts .. General lessons from large-scale voluntary implementation efforts.

6 Learning from national and facility voluntary implementation .. The challenge of bringing the WHO SURGICAL Safety Checklist to low- and middle-income countries .. Spreading knowledge of the Checklist .. Addressing resources .. The Checklist is difficult to implement in its entirety .. Summary of general lessons from the WHO SURGICAL Safety Checklist to consider for the scale-up of other interventions ..254. SECTION II: IMPROVEMENT INTERVENTION EXAMPLES FOR SURGICAL site INFECTION REDUCTION .. A review of the evidence framed around the Four E s model .. Introduction .. Facilitating successful improvement using engagement, education, execution and evaluation .. Summary of success factors and barriers to improvement .. Use of a multimodal infection control and patient safety intervention in four African countries.

7 Introduction .. Background to the SUSP-Africa multimodal intervention approach .. Actions carried out to improve on the SURGICAL site infection prevention process and outcome measures .. Key lessons from the SUSP-Africa experience ..375. SECTION III: THE WHO MULTIMODAL APPROACH AS A PROVEN AND SUCCESSFUL WAY TO IMPLEMENT SURGICAL site INFECTION PREVENTION RECOMMENDATIONS INTO PRACTICE .. Introduction .. Background .. The multimodal approach explained in detail .. Applying the multimodal approach to SSI prevention to achieve improvement ..44 REFERENCES ..584 PREVENTING SURGICAL site infections : IMPLEMENTATION APPROACHES FOR EVIDENCE-BASED RECOMMENDATIONSThe Department of Service Delivery and Safety of the world health organization (WHO) gratefully acknowledges the contributions that many individuals and organizations have made to the development of this practical manual.

8 Overall coordination and writing of the documentBenedetta Allegranzi (Department of Service Delivery and Safety, WHO) coordinated the development of this document and contributed to its writing. Claire Kilpatrick (Department of Service Delivery and Safety, WHO) led the writing of the document; Lizabeth Edmonson (Ariadne Labs, United States of America [USA]), Willian R Berry (Ariadne Labs, Harvard TH Chan School of Public health , United States of America [USA]) and Tom Weiser (Stanford University School of Medicine, United States of America [USA]) led the writing of section I (The WHO SURGICAL Safety Checklist - an example of bringing guidelines to life in the service of patient safety); Bassim Zayed (Division of Communicable Disease, WHO Eastern Mediterranean Region Office) and Giulio Toccafondi (Patient Safety Centre and Risk Management Tuscany Region, Italy) made contributions to section II (Improvement intervention examples for SURGICAL site infection reduction) and section III (The WHO multimodal approach as a proven and successful way to implement SURGICAL site infection prevention recommendations into practice), respectively.

9 Rosemary Sudan provided professional editing to the development of the reportThe following experts provided original content contributing to the development of section II: Promise Ariyo, Blair Anton (Johns Hopkins University School of Medicine, United States of America [USA]), Asad Latif (The Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, United States of America [USA]), Sean Berenholtz (The Armstrong Institute for Patient Safety and Quality, Johns Hopkins University Schools of Medicine and Bloomberg School of Public health , United States of America [USA]).Expert review group The following experts contributed to the review of the manual: Alex Aitken (London School of Hygiene and Tropical Medicine, United Kingdom [UK]); An Caluwaerts (M decins Sans Fronti res/Doctors Without Borders, Belgium); Asad Latif (Johns Hopkins Hospital and University Schools of Medicine, United States of America [USA]); Paul Malpiedi (Centers for Disease Control and Prevention, United States of America [USA]); Anna Maruta (WHO Country Office, Sierra Leone); Shaheen Mehtar (Infection Control Network Africa, Republic of South Africa); Peter Nthumba (AIC Kijabe Hospital, Kenya); Joseph S Solomkin (University of Cincinnati College of Medicine and world SURGICAL Infection Society, United States of America [USA]); Julie Storr (Department of Service Delivery and Safety, WHO).

10 Giulio Toccafondi (Patient Safety Centre and Risk Management Tuscany Region, Italy); Akeau Unahalekhaka (Chiang Mai University, Thailand); Tom Weiser (Stanford University School of Medicine, United States of America [USA]).Photograph contributionsCourtesy of Didier Pittet, MD (University of Geneva Hospitals, Switzerland); courtesy of Juliana Cusack (Patrick Okao, MD, Surgeon, Butaro District Hospital, Rwanda, and James Cusack, MD, Visiting Surgeon from Massachusetts General Hospital and Harvard Medical School, United States of America [USA]).Acknowledgement of financial supportFunding for the development of this document was provided by ABBREVIATIONS AND ACRONYMSCCiSC Clean Care is Safer CareCUSP Comprehensive Unit-based Safety ProgramFour E s engage, educate, execute and evaluateHAI health care-associated infectionIHI Institute of Healthcare ImprovementIPC infection prevention and controlLMICs low- and middle-income countriesOR operating roomPDSA plan, do, study, actSAP SURGICAL antibiotic prophylaxisSBAR situation, background, assessment, and recommendationSSI SURGICAL site infectionSUSP SURGICAL Unit-based SURGICAL ProgramUK United KingdomUSA United States of AmericaWHO world health OrganizationABBREVIATIONS AND ACRONYMS6 PREVENTING SURGICAL site infections .