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Before any surgery, there must be trust: Trust in the expertise and experience of doctors and OR staff, but also in the hospital’s hygiene standards. Because even in routine procedures, wound infections – which can be avoided – unfortunately continue to occur. Today, with growing competition for patients, clinics can position themselves as hygiene leaders, for example by using disposable surgical materials, and by installing effective practices. This also improves patient safety.
Christiane Auras is in the operating room twice a week. There she assists during operations on ligaments, joints, and other orthopaedic conditions. Auras is clinical practice manager for Sporthomedic, a sports orthopaedic clinic in Cologne. “Our patients assume that their surgery will be performed to the highest possible standards. And here, that is true – also because we use disposable surgical textiles.” The materials protect patients, as well as the clinic staff from infections. “Single-use ensures that potentially contaminated, infectious products are directly disposed of, without having to be touched again,” explains Auras.
Yet this is not common practice everywhere. According to the European Centre for Disease Prevention and Control (ECDC), some 3.2 million people annually contract nosocomial infections in Europe. Every year, approximately 37,000 patients die from infections acquired during or after surgery – surgical site infections (SSI) account for almost one-fifth of all infections. The ECDC estimates that 20 to 30 percent of all hospital infections could be avoided through intensive hygiene management and control programs.
The consequences of poor hygiene are often life threatening for patients. In addition – from the point of view of clinics and doctors – these are also relevant under liability law. “Public awareness is increasing, and complaints and damage claims are likely to increase,” explained Dr. Monika Ploier at an event of the “Safety in the OR” initiative, which took place in Vienna in November 2017. Ploier is a lawyer with HLMK-Attorneys in Vienna and a medical-law expert. “Until now, nosocomial infections were regarded as an unavoidable eventuality of hospitalization,” she says. “But this view is changing – not least because numerous studies have shown that such infections often can be prevented.”
For example, current studies suggest that single-use surgical gowns* and single-use surgical drapes keep the infection rate lower than the corresponding reusable products, especially in operations that carry a high risk of infection. This applies in particular to cardiac surgery, implant-based breast reconstruction, and surgical procedures with implants.
The reasons are clear: disposable medical devices have never been used before, so there can be no possible residues from previous applications. Unlike reusable materials, disposable surgical drapes* and gowns do not wear out. To ensure an optimal germ barrier, the materials must be impermeable to microbes, free of microorganisms and organic residues, lint-free, liquid-impermeable, tear-, tensile- and pressure-resistant. Despite regular impregnation and sterilisation, cotton used for reusable products cannot always guarantee all of this 100 percent.
A study published in the ‘Journal of Cardiothoracic Surgery’ found that the frequency of infections in the study group with disposable surgical drapes was 68 percent lower than in the group using reusables. The authors of the study conclude “a more generous use of disposable surgical drapes can reduce post-operative infections caused by lack of hygiene”.
“Of course, hygiene mistakes aren’t based on evil intentions,” says Ploier. Often it is simply a brief moment of thoughtlessness. The growing burden arising from facilities reducing their staff numbers certainly plays a role here. “To the hospital, however, this is not an excuse that would be relevant in a court case. In such a case, the clinic is always liable.” If it can be proven that treatment errors were caused by negligence, or by not adhering to existing hygiene regulations, Ploier explains that from a criminal-law point of view, is considered a negligent bodily injury, in the worst case, even a negligent homicide.
To make sure that such scenarios don’t occur, many practices are turning to disposable materials. The orthopaedic clinic Sporthomedic has been using disposable textiles during its operations for many years. “With the abundance of germs today, just the thought of reprocessing surgical textiles worries me,” says clinical practice manager Auras.
However, there are also advocates of reusable surgical gowns, as a survey conducted by the TU Dresden in a total of 865 clinics has shown. The reasons listed for the reusable textiles were, above all, comfort when wearing, and ecological aspects.
However, Auras finds these reasons difficult to understand: She has never noticed any lack of comfort nor breathability in disposable textiles. And when in doubt, she believes that hygiene is always more important than comfort, anyway. “For us, disposables are the better products. Fabrics always contains dust. And dust is a killer in the OR.” Auras is convinced that disposable textiles will become standard in the future, because these can reduce infection rates.
Another key to this topic is education, says medical-law expert Ploier. Hygiene is an issue often still neglected in everyday medical routine. “Clinics should receive regular training on hygiene regulations,” recommends Ploier. “Hygiene experts should know the policies, and adhere to the relevant guidelines. And patients should ask about hygiene standards before any operation. Because informing patients builds trust and gives them a feeling of security – even before surgery.
Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study, Cassini A et al., PLOS
Utilization of single-use gowns reduces the incidence of postoperative infections, Nedić M et al., J Cardiothoracic Surg.
The effect of reusable versus disposable draping material on infection rates in implant-based breast reconstruction: a prospective randomized trial, Showalter BM et al., Ann Plast Surg.
Glove and gown effects on intraoperative bacterial contamination, Ward WG et al., Annals of surgery