Scientific letter
Preventing surgical site infection through patients’ education: Results from the MEDIPINAS medical mission
Prevención de la infección del sitio quirúrgico mediante la educación de los pacientes: resultados de la misión médica MEDIPINAS
Belén Mercka,
, Valentín Henarejos Pérezb, Antonio Villalonga Moralesc, Antonio Barrasa Shawa
Corresponding author
a Departamento de Cirugía, Universidad Cardenal Herrera CEU, Alfara del Patriarca, Valencia, Spain
b Departamento de Cirugía, Universidad Cardenal Herrera CEU, Castellón de la Plana, Castellón, Spain
c Departamento de Anestesiología, Centre Hospitalier Mère et Enfant Monkole, Mont-Ngafula Kinshasa, Democratic Republic of the Congo
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Alfara del Patriarca, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía, Universidad Cardenal Herrera CEU, Castellón de la Plana, Castellón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Anestesiología, Centre Hospitalier Mère et Enfant Monkole, Mont-Ngafula Kinshasa, Democratic Republic of the Congo" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevención de la infección del sitio quirúrgico mediante la educación de los pacientes: resultados de la misión médica MEDIPINAS" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 2508 "Tamanyo" => 172425 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Follow-up of surgical wound healing using the original Apple® Numbers® application. The upper images (code RED) show the evolution of an infected surgical wound, while the lower images (code GREEN) show a case that progressed favorably.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2018, a group of surgeons and students from the Cardenal Herrera CEU University (UCHCEU) organized the MEDIPINAS2018 medical-surgical mission at the Santa Maria Josefa Hospital Foundation for patients without resources in Iriga City, Philippines. Outpatients were briefly instructed in postoperative care, and nursing staff did not provide wound care. A general surgeon visited the cases with complications. however, 25 (28.8%) of the 87 patients developed surgical wound infection (SSI), which is a very high rate compared to the 11% published by the WHO for low- and moderate-income countries<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We reviewed the hospital’s infection prevention and surgical material sterilization protocols, which were correct. We found that the factors involved in the unusual rate of infection included the lack of knowledge of the population to correctly care for wounds, as well as the lack of clean water and basic material for wound care. It seemed necessary to adapt our protocols to the country and its social and sanitary conditions<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. The strategies described in surgical infection prevention guidelines can prevent 60% of SSI<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>; therefore, we created an SSI prophylaxis project to apply in MEDIPINAS2019. The MEDIPINAS2019 surgical mission incorporated the “Recommendations for Zero Surgical Infection”, with the necessary modifications for it to function in a hospital with limited resources. Specifically, these included: intensified handwashing, the use of 2% alcoholic chlorhexidine with a swab to prepare the surgical field, and glycemic control in diabetic patients. Antibiotic prophylaxis was administered in clean-contaminated and contaminated surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We designed a prospective study including patients who agreed to participate after being informed and signing an informed consent from in accordance with the WHO model. We created an information sheet, which was given to each patient after surgery. It explained surgical wound care and the warning signs of SSI. In addition, patients were given material for dressings (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), analgesics (paracetamol, ibuprofen) and antibiotics for the treatment of the infection in those cases in which it was necessary, and healthcare education was provided.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">An Apple® Numbers® spreadsheet application was used to follow the evolution of the surgical wound, which collected the patients’ clinical data as well as photographs of the surgical area before the incision, at the end of the operation and during check-ups. The use of a color code of the final state of the wound completed by Filipino nurses (green: not infected; yellow: resolved infection; red: active infection) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) facilitated the follow-up and treatment of each case. The ability to easily collect patient data and images during the various phases of surgical wound healing has been instrumental in cooperating with our Filipino colleagues. Although the use of the app for surgery and cooperation is not new<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, the MEDIPINAS app stands out for having been created for a specific project, with minimal development cost and complexity. This project was approved by the Ethics Committee of the College of Health Sciences of the UCHCEU.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In MEDIPINAS2019, 108 patients were included, and 10 (9.7%) developed SSI. When we compared the results with MEDIPINAS2018, there were no significant differences in mean age, gender or type of interventions, but there were differences (<span class="elsevierStyleItalic">P</span> < .001) for SSI infection with a decrease of 19.1% in MEDIPINAS2019.</p><p id="par0030" class="elsevierStylePara elsevierViewall">MEDIPINAS was created in 2016 to provide surgical treatment for patients who do not have access to surgery due to lack of resources or surgical specialists<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. For the collaboration to succeed, one must avoid creating problems, as otherwise ‘the remedy is worse than the disease’<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. Therefore, surgeries must be planned with consideration of the limitations in the area. In these rural areas, it is customary to consult with a healer for medical problems, which is cheaper than going to a doctor or a pharmacy. In the past, the use of hot infusions of leaves or herbs was shown to be detrimental to the surgical wounds of patients treated by our group. Medical professionals who participate in volunteer projects in other countries must be very respectful of local customs but must also provide patients with timely education<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. We emphasized hand hygiene and wound cleaning, and it was essential to provide our patients with the material since most could not afford it. With this approach, we managed to reduce the SSI rate to less than 11%, which was our objective<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. The app, which is very easy to use, contributed towards the collaboration with our Filipino colleagues.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In short, the application of the “Recommendations for Zero Surgical Infection” and the education of patients regarding how to clean the wound, providing material to treat the wound, together with the follow-up of nursing staff through visits and wound care when necessary, as well as the distant follow-up through the app, have all contributed to the lower rate of SSI in our series.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">The MEDIPINAS Project was financed in 2019 with the Collaboration Grant from the <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Association of Surgeons</span> (no ID, therefore not included on the platform), with contributions from the <span class="elsevierStyleGrantSponsor" id="gs0010">Universidad Cardenal Herrera CEU</span> and, especially, many small contributions from individuals.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Merck B, Henarejos Pérez V, Villalonga Morales A, Barrasa Shaw A. Prevención de la infección del sitio quirúrgico mediante la educación de los pacientes: resultados de la misión médica MEDIPINAS. Cir Esp. 2022;100:247–249.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1605 "Ancho" => 2341 "Tamanyo" => 758759 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Material for surgical wound care, treatment, informed consent, and information sheet that were given to patients after explaining how to use it.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 2508 "Tamanyo" => 172425 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Follow-up of surgical wound healing using the original Apple® Numbers® application. The upper images (code RED) show the evolution of an infected surgical wound, while the lower images (code GREEN) show a case that progressed favorably.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Global guidelines on the prevention of surgical site infection. [Accessed 1 August 2018]. Available from: <a target="_blank" href="https://www.who.int/infection-prevention/publications/ssi-guidelines/en/">https://www.who.int/infection-prevention/publications/ssi-guidelines/en/</a>." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treating surgical infections in low- and middle-income countries: source control, then what?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 0 | 10 |
| 2024 October | 37 | 3 | 40 |
| 2024 September | 64 | 5 | 69 |
| 2024 August | 57 | 6 | 63 |
| 2024 July | 39 | 10 | 49 |
| 2024 June | 37 | 4 | 41 |
| 2024 May | 46 | 9 | 55 |
| 2024 April | 49 | 6 | 55 |
| 2024 March | 87 | 10 | 97 |
| 2024 February | 125 | 8 | 133 |
| 2024 January | 75 | 10 | 85 |
| 2023 December | 89 | 12 | 101 |
| 2023 November | 138 | 4 | 142 |
| 2023 October | 164 | 6 | 170 |
| 2023 September | 120 | 8 | 128 |
| 2023 August | 62 | 5 | 67 |
| 2023 July | 21 | 3 | 24 |
| 2023 June | 10 | 4 | 14 |
| 2023 May | 21 | 7 | 28 |
| 2023 April | 21 | 2 | 23 |
| 2023 March | 2 | 0 | 2 |
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