A commentary on "Surgical site infection prevention through bundled interventions in hip replacement surgery: A systematic review" (Int J Surg 2021;95:106149)

Abstract

Dear Editor Surgical site infections (SSIs) have a substantial clinical and economic burden and are estimated to affect up to nearly 3% of hip replacement procedures [1,2]. Deep SSIs in particular are extremely serious, increasing patient mortality and morbidity as well as hospital costs. Patients affected by deep SSIs after hip replacement procedures require prolonged antibiotic therapy, revision, or removal of prosthesis and are at a higher risk of impaired functional ability. Considering the high volume of hip replacement procedures globally, which is expected to rise due to the aging population, preventing SSIs is extremely important. The bundled approach as theorized by the Institute for Healthcare Improvement (IHI) has shown to be an effective strategy to implement, allowing evidence from research to integrate into routine clinical practice [3]. A bundled intervention consists of systematic and consistent implementation of 3–5 evidence-based practices, which results in increased effectiveness when compared to summation of impact of each single element. Several studies have suggested bundled interventions to be effective in reducing SSI rates in orthopaedic surgery [4,5]. Vicentini et al. [6] performed a systematic review which supported bundled intervention as an effective implementation strategy for infection prevention and control in hip replacement surgery. The traditional model of hip replacement care consists of care of patients who are fully under orthopedic surgeons. The lack of coordination between different medical disciplines using a standardized approach to surgical site care result in management fragmentation and inefficiency. As SSI prevention is complex and there are numerous factors which can increase patients’ risks of SSI during the perioperative period, effective SSI prevention should extend beyond the care of just orthopedic surgeons and should engage other stakeholders across various medical disciplines. Each of these different health-care professionals has a unique role to play in reducing the chance of SSIs which can develop at different perioperative phases. The multifaceted nature of a SSI prevention care bundle makes it difficult to establish which element contributes more than other elements in reducing SSI incidence in any study. The presence of unmeasured confounders could have led to biased results, as other factors could have also contributed to the observed reduction in SSI rates. Additionally, as protocols of bundled interventions are different, this can result in huge heterogeneity among various studies. Most of the included studies are retrospective. Future research should consider employing a prospective design to compare SSI incidences before and after bundle implementation. Additionally, further studies should consider evaluating effectiveness of patient-focused interventions in SSI prevention, such as studying the impact of patient education on SSI for patients after hospital discharge as patients are the primary stakeholders who bear the direct consequences of SSI. Provenance and peer review Commentary, internally reviewed. Ethical approval None. Funding None. Author contribution Yujiang Liu: writing. Junxin Lin: study design. Conflicts of interest None. Research registration unique identifying number (UIN) None. Guarantor Yujiang Liu. Trial registry number – ISRCTN None.