Skip to main content

Lund University Publications

LUND UNIVERSITY LIBRARIES

Prevention of surgical site infections after lower extremity bypass procedures

Rezk, Francis LU orcid (2024) In Lund University, Faculty of Medicine Doctoral Dissertation Series
Abstract
Abstract: Surgical site infections (SSIs) are a common cause of morbidity following open vascular surgery. Numerous randomized controlled trials (RCTs), along with systematic reviews and meta-analyses of RCTs, have been conducted to compare incisional negative pressure wound therapy (iNPWT) with standard wound dressings above sutured incisions in the inguinal region. These meta-analyses consistently demonstrate that iNPWT leads to a significant reduction in SSIs. However, there has been a lack of similar studies focusing on all leg incisions for arterial exposure in lower extremity bypass surgery. Hence, it is imperative to investigate the impact of iNPWT on reducing SSIs in leg incisions following lower extremity bypass. Implementation of... (More)
Abstract: Surgical site infections (SSIs) are a common cause of morbidity following open vascular surgery. Numerous randomized controlled trials (RCTs), along with systematic reviews and meta-analyses of RCTs, have been conducted to compare incisional negative pressure wound therapy (iNPWT) with standard wound dressings above sutured incisions in the inguinal region. These meta-analyses consistently demonstrate that iNPWT leads to a significant reduction in SSIs. However, there has been a lack of similar studies focusing on all leg incisions for arterial exposure in lower extremity bypass surgery. Hence, it is imperative to investigate the impact of iNPWT on reducing SSIs in leg incisions following lower extremity bypass. Implementation of existing wound care bundles and the role of a mediated Hawthorne Effect (HE) in prevention of SSI has been demonstrated in many studies.
The aims:
- To examine the effect of iNPWT compared to standard dressings on SSI and other wound complications in leg incisions following elective lower extremity bypass except incisions at separate vein harvest sites.
- To investigate the Hawthorne Effect and its influence on how healthcare professionals (HCPs) perceive observations related to hygiene routines and standard precautions during an ongoing RCT.
- To explore patients’ experiences of wearing the PICO™ dressing after lower extremity vascular surgery.
Materials and methods: The multi-center RCT was registered in Clinical Trials (NCT01913132) and eligible patients were randomized to iNPWT or standard dressing, or in case of bilateral incisions iNPWT on one side and the alternative on the other side. The rationale and design were published as a study protocol in a peer-review journal. Eligible patients were enrolled between 2017 and 2023. Forty-four HCPs from all units involved in the care of vascular surgical patients participated in a multi-professional focus group interview. Inductive content analysis was done to investigate the HE and its impact on staff adherence to standard precautions, and their compliance. Fifteen individual and semi-structured telephone interviews were conducted with patients from all centers participating in the ongoing RCT.
Results: The power calculation for the RCT resulted in that 110 leg incisions needed to be included and analyzed to demonstrate the expected difference in SSI between iNPWT and standard dressings. The RCT results showed that there was no reduction of SSI rates in leg incisions with iNPWT compared to standard dressings in patients undergoing elective lower extremity bypass (34.9% versus 40.4% in the unilateral group (n=100), p=0.68), whereas iNPWT reduced the incidence of wound dehiscence (23.3% versus 43.9% in the unilateral group p= 0.0366). Communication and addressing hierarchical issues were crucial. Healthcare professionals expressed a preference for more personal and direct feedback. The analysis revealed four themes and 12 subthemes. Communication and hindering hierarchy were found to be crucial. The study also identified the need to empower observers with a clear mandate and support for their work. Importantly, both the ongoing RCT, checklist and direct observations had mediated HE. The PICO™ dressing system was well accepted by most patients. Most prominent problems were fear of dropping the pump on the floor and lack of information.
Conclusion: SSI rate in leg incisions after elective lower extremity bypass is high. There was no difference in SSI rate between patients receiving iNPWT and standard dressings, whereas iNPWT reduced the wound dehiscence rate. This RCT identified that there is a need for development of longer iNPWT dressings than the available 40 cm to cover long uninterrupted incisions. Managers within the healthcare system must put into place improved and sustainable hygiene care, to reduce the rate of SSIs after vascular surgery. The communication and the direct and indirect observations of how well hygiene routines are followed are considered important in HCPs adherence to standard precautions. The PICO™ dressing can be used with little discomfort to most patients.


(Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Wahlgren, Carl-Magnus, Department of Vascular Surgery, Karolinska University Hospital, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Antibiotic prophylaxis, surgical site infection, vascular surgery, lower extremity bypass, wound dehiscence, compliance, incisional negative pressure wound therapy, Hawthorne effect, healthcare professionals, observation, hygiene, adherence, patient experience, PICO-dressing
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
issue
2024:14
pages
110 pages
publisher
Lund University, Faculty of Medicine
defense location
Agardh föreläsningssal, CRC, Jan Waldenströms gata 35, Skånes Universitetssjukhus i Malmö. Join by Zoom: https://lu-se.zoom.us/j/67316282128
defense date
2024-02-02 09:00:00
ISSN
1652-8220
ISBN
978-91-8021-507-7
language
English
LU publication?
yes
id
87a4680a-c8c1-4640-a498-506e3311f8cb
date added to LUP
2024-01-14 13:03:39
date last changed
2024-01-16 12:21:37
@phdthesis{87a4680a-c8c1-4640-a498-506e3311f8cb,
  abstract     = {{Abstract: Surgical site infections (SSIs) are a common cause of morbidity following open vascular surgery. Numerous randomized controlled trials (RCTs), along with systematic reviews and meta-analyses of RCTs, have been conducted to compare incisional negative pressure wound therapy (iNPWT) with standard wound dressings above sutured incisions in the inguinal region. These meta-analyses consistently demonstrate that iNPWT leads to a significant reduction in SSIs. However, there has been a lack of similar studies focusing on all leg incisions for arterial exposure in lower extremity bypass surgery. Hence, it is imperative to investigate the impact of iNPWT on reducing SSIs in leg incisions following lower extremity bypass. Implementation of existing wound care bundles and the role of a mediated Hawthorne Effect (HE) in prevention of SSI has been demonstrated in many studies. <br/>The aims: <br/>- To examine the effect of iNPWT compared to standard dressings on SSI and other wound complications in leg incisions following elective lower extremity bypass except incisions at separate vein harvest sites. <br/>- To investigate the Hawthorne Effect and its influence on how healthcare professionals (HCPs) perceive observations related to hygiene routines and standard precautions during an ongoing RCT.<br/>- To explore patients’ experiences of wearing the PICO™ dressing after lower extremity vascular surgery.<br/>Materials and methods: The multi-center RCT was registered in Clinical Trials (NCT01913132) and eligible patients were randomized to iNPWT or standard dressing, or in case of bilateral incisions iNPWT on one side and the alternative on the other side. The rationale and design were published as a study protocol in a peer-review journal. Eligible patients were enrolled between 2017 and 2023. Forty-four HCPs from all units involved in the care of vascular surgical patients participated in a multi-professional focus group interview. Inductive content analysis was done to investigate the HE and its impact on staff adherence to standard precautions, and their compliance. Fifteen individual and semi-structured telephone interviews were conducted with patients from all centers participating in the ongoing RCT.<br/> Results: The power calculation for the RCT resulted in that 110 leg incisions needed to be included and analyzed to demonstrate the expected difference in SSI between iNPWT and standard dressings. The RCT results showed that there was no reduction of SSI rates in leg incisions with iNPWT compared to standard dressings in patients undergoing elective lower extremity bypass (34.9% versus 40.4% in the unilateral group (n=100), p=0.68), whereas iNPWT reduced the incidence of wound dehiscence (23.3% versus 43.9% in the unilateral group p= 0.0366). Communication and addressing hierarchical issues were crucial. Healthcare professionals expressed a preference for more personal and direct feedback. The analysis revealed four themes and 12 subthemes. Communication and hindering hierarchy were found to be crucial. The study also identified the need to empower observers with a clear mandate and support for their work. Importantly, both the ongoing RCT, checklist and direct observations had mediated HE. The PICO™ dressing system was well accepted by most patients. Most prominent problems were fear of dropping the pump on the floor and lack of information.<br/>Conclusion: SSI rate in leg incisions after elective lower extremity bypass is high. There was no difference in SSI rate between patients receiving iNPWT and standard dressings, whereas iNPWT reduced the wound dehiscence rate. This RCT identified that there is a need for development of longer iNPWT dressings than the available 40 cm to cover long uninterrupted incisions. Managers within the healthcare system must put into place improved and sustainable hygiene care, to reduce the rate of SSIs after vascular surgery. The communication and the direct and indirect observations of how well hygiene routines are followed are considered important in HCPs adherence to standard precautions. The PICO™ dressing can be used with little discomfort to most patients. <br/><br/><br/>}},
  author       = {{Rezk, Francis}},
  isbn         = {{978-91-8021-507-7}},
  issn         = {{1652-8220}},
  keywords     = {{Antibiotic prophylaxis; surgical site infection; vascular surgery; lower extremity bypass; wound dehiscence; compliance; incisional negative pressure wound therapy; Hawthorne effect; healthcare professionals; observation; hygiene; adherence; patient experience; PICO-dressing}},
  language     = {{eng}},
  number       = {{2024:14}},
  publisher    = {{Lund University, Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{Prevention of surgical site infections after lower extremity bypass procedures}},
  url          = {{https://lup.lub.lu.se/search/files/169482906/Francis_Rezk_-_WEBB._Dissertation.pdf}},
  year         = {{2024}},
}