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This study will present a comprehensive discussion of the background of the National Institute for Care and Excellence (NICE) in relation to making a critical discussion of the NICE guidelines on the surgical site infection [SSI]: treatment and prevention. Here the surveillance had been conducted in the 3, 6 and 8 years during October 2008. Throughout the 8 years surveillance process it had been identified from the finding that the choices for using the preoperative antiseptics needs evidence-based investigation.
The guidelines set by NICE for SSI are considered as the local guidelines that had been chosen to highlight the implementation of these guidelines into practices to prevent the risk of infection at the surgical site. The NICE guidelines for SSI have been used worldwide due to the increased awareness about the important guidelines to prevent the SSI, the impacts of SSI on patient’s health and wellbeing and the financial impacts of the SSI on the healthcare professionals. Moreover, the effective implementation of the NICE guidelines assists the healthcare providers not only in the UK but also across the world to identify the possible risk in the pre, intra and post-surgical condition thereby developing as well as implementing effective infection control strategy to protect the patient from any kind of health risk.
SSI is a healthcare-associated infection that usually develops in post-surgical condition. This infection is associated with severe health risk if left untreated or immediate care is not taken by care professionals. The evidence suggests that SSI accounts for more than 20% of healthcare-associated infection that causes sever inflammation on the patient’s skin. The evidence also suggests that 5% of patients develop the SSI in the post-surgical condition. Usually, the infection develops due to the incision of the microorganism residing in the patient's body while the patient undergoes any surgery
Under the NICE guidelines for SSI, the Operating Department Practitioner (ODP) must have enough expertise as well as professional skill in providing high quality as well as safe care to the patient who undergoes the surgery thereby reducing the risk of SSI. If there is any chances or risk of developing SSI, ODP needs to follow the infection control guidelines set by NICE thereby ensuring the proper control measures and taken and the infection would not deteriorate further
Background of NICE guidelines in relation to SSI: treatment and prevention:
The NICE guidelines set for preventing SSI, is equally applicable for young, adults and children if they undergo any surgical procedure in which there is a cut through the skin. These guidelines have the sets of infection control and infection preventing principles that the care providers need to follow before, during and after the surgery
Before the inception of the NICE guidelines on the SSI, many factors were considered in health care during the period of the early nineties (1960). Cochrane Central Register of Controlled Trials (CENTRAL) has mentioned the risk factors that were associated with the SSI. There was a limited number of reviews between 1960 to 2014, which affect the overall progress of the clinical intervention in relation to the management of SSI. Based on these reviews, it is seen that only 12 numbers control trial studies had been conducted during the times period of 1990, in which the WHO guidelines has been applied in managing SSI in a patient undergoing surgery.
Purpose of NICE guidelines in relation to the management of SSI:
NICE guidelines aim to provide the hug quality and safe care as well as guideline to the patient throughout the pre, intra and post operating stage thereby reducing chances of infection at the surgical site thereby promoting their health and wellbeing in patients. Additionally, NICE guidelines aim to guide the care providers to implement all these guidelines accordingly into practice to ensure patients safety ad protection from any risk of infection throughout the in-patient stage.
Persons or organisations involved in the development of the NICE guidelines:
NICE guidelines are developed by all the laypersons as well as a multi-professional group who are involved in the NHS in Northern Ireland, England and Wales. These multiprocessors and laypersons include the surgeons, GP, nurses, health and social care staffs, ODP, nursing and the tissue viability staffs, all the NHS staffs who are involved in the planning and commissioning healthcare service, caregivers, community care nurses, patients and family members of the patients.
Reason for developing NICE guidelines on SSI:
The NICE guideline for preventing SSI had been first introduced in 2008 to prevent the ever-increasing risks of the patients who undergoes any surgery that involves the cute through on the skin. The NICE guidelines had been developed to provide proper guidance to the care professionals on how to maintain the professional care standard by following a systematic infection control pathway to prevent the risk of SSI in patient throughout the pre, intra and post-surgical condition. Additionally, the NICE guideline was developed to control the rates of infection-related mortality and morbidity. Other potential reasons for developing NICE (2019) guidelines are to reduces the extended hospital stay of patients after the surgery and also reduces the financial, emotional and physical burden of the healthcare providers.
Evaluating the NICE guidelines to SSI: treatment and prevention:
NICE guidelines to SSI consist of sets of highly relevant and local up to date guidelines that enabled the NHS to ensure safe and high-quality care to the patient who undergoes a piece of surgery evidence suggest prevention and control of surgical infection are the complex processes that need systematic implementation of ranges of effective measures that will not only cure the infection but also improve the overall quality of care delivery to the patient thereby promoting patient’ holistic wellbeing. The NICE guidelines provide clear information regarding all the necessary aspects in relation to the prevention ad control of the surgical infection such as what is the surgical infection, how it develops, what are the associated risk of surgical infection and how these infections can be controlled effectively [NICE, 2019].
Several organisations are involved in setting effective guidelines for preventing managing SSI. These organisations are the National Institute for Care and Excellence [NICE], the World Health Organisation [WHO], Society for Healthcare Epidemiology of America (SHEA) and Centre for Disease Control and Prevention. Unlike the NICE guidelines for SSI prevention, the guidelines set by the WHO are the global guidelines that are applicable in any of the healthcare context across the world. The WHO infection control guidelines are the first global guidelines that are developed in 2016. However, both the WHO and the NICE guidelines have similar content and the presentation regarding the control, treatment and prevention of SSI. The guidelines set by WHO and CDC are associated with presenting the well-constructed infection control principles that assist the care providers globally to prevent the risk of SSI in patient throughout the pre, intra and post-surgical condition. Both the CDC and the WHO guidelines for SSI are not against or do not recommend the usage of chlorhexidine body wash to prevent the colonisation of the bacteria in the surgical site. Additionally, these guidelines also do not make any recommendation regarding using the pro-operative screening of Staphylococcus aureus.
Although the NICE guidelines for SSI control were first introduced in 2008, there had been carried out many scrutinies to make the effective reformation of policies and principles under the guidelines during 2019. This reformation had been reviewed to analyse the effectiveness of the implementation of these changes in policies in relation to SSI decolonisation, the antiseptic and antimicrobial procedure before the surgery, the reparation of aseptic skin preparation and the process of the safe wound closure. Evidence suggests that these changes in the NICE guidelines were highly important to improve the overall infection control and prevention standard in healthcare which enables the care providers to easily determine the associated risk of SSI and eliminate these risk accordingly [NICE 2019]. Below there are mentioned regarding the updates of NICE infection control guidelines for SSI that develop four effective recommendation that assists care providers to provide high quality and safe pre, intra and post-operative care to patients thereby eliminating the risk of SSI. Many randomised controlled trial and the meta-analysis have been carried out that reviews the effectiveness of these recommendations in terms of preventing and controlling the risk of SSI in patients who undergoes any surgery.
Generally, the SSI is developed on the infection site due to the bacteria, Staphylococcus aureus. NICE (2008) guidelines for the SSI prevention and control recommend the use of nasal decontaminants along with the appropriate topical antimicrobial agents that eliminate the chances of contamination of the open wound with the Staphylococcus aureus thereby eliminating the risk of the SSI
Antiseptic skin preparation:
Under NICE (2008) guidelines for SSI prevention and control, the operation department practitioners are recommended to apply the antiseptic preparation along with povidone-iodine and chlorhexidine on the skin before the incision procedure. The guidelines also recommend that diathermy can also be used as an effective antiseptic before the skin incision to prevent the attack of any bacteria to the open wound after the surgery. The NICE (2017), recommend that the ODP must ensure that the antiseptic preparation is applied on the skin are dried and they must avoid the pooling of the antiseptic preparation of the skin
Antibiotic and antiseptic before the wound closure:
NICE (2008) guidelines recommend that the usage of the antiseptic preparation along with povidone-iodine and chlorhexidine before the incision of the skin is highly effective in terms of preventing the risk of SSI. Unlike the NICE guidelines, the guidelines from the CDC and WHO do not make any recommendation regarding the use of antiseptics in the preoperative condition.
Methods of the wound Closure:
NICE guidelines also identify the closure material as well as techniques that are associated with reducing the risk of the SSI. Before updating and reforming the NICE guidelines there was lack of proper guidelines regarding the techniques and the closure methods that are needed to reduce the risk of the SSI in the patients who undergo the surgery. After updating the changes in the NICE guidelines in 2019, the sets of effective infection control and prevention standard are made based on which the ODP and the care professionals need to work in relation to reduce the overall risk associated with the SSI.
The NICE guidelines to the SSI prevention and control also provide clear information to the cares and the patients regarding how to maintain and safe and high-quality care of the surgical wound of the patients after discharge of patients. In this context, NICE guidelines improve the health literacy of the patients that enhances patients’ self-management skill in terms of taking proper care of the wound at home thereby reducing the chances of any infection.
Under NICE (2019) guidelines the care professionals and operation department practitioners [ODP] must inform the patient about all the information regarding the usage of the antiseptic such as the name, type, associated health benefits and precautions of the antiseptic while using before incision of the skin.
The NICE guidelines are highly effective ad relevant to the current context of health care context, in which there are still increasing cases of SSI. In this context, the NICE guidelines will help the ODP to prevent the infection by using effective measures thereby promoting the health and wellbeing of patients.
Critical analysis of the NICE guidelines to the SSI: treatment and prevention:
The NICE guidelines (2019) for the treatment and prevention of SSI have achieved their objectives in terms of assisting the local trust and other NHS healthcare providers to use the guidelines as the benchmark for providing safe and high-quality care throughout the pre, intra and post-surgical journey of a patent.
NICE guidelines provide clear information regarding what pre, intra and post-operative surgical care mean. Based on the NICE guidelines, preoperative care is associated with nasal decolonisation, preoperative showering, assisting patients to wear the theatre wear, staff leaving the operating areas, use of antiseptic agent before the incision of the skin, staff theatre wear, antibiotic prophylaxis and mechanical bowel preparation. The NICE (2019) guidelines are associated with developing a safeguarding environment for both the patients the care providers to ensure that there is no risk of SSI to patients and also there is lack of risk of the spreading of the infection from the patients who undergoes the surgery to the healthcare staffs and the patients in the surrounding environment.
The intraoperative phase is associated with the incise drape, hand decontamination, sterile gown, diathermy, antiseptic skin preparation, intracavity lavage, maintaining patient homeostasis and wound irritation
The post-operative phase is associated with post operating cleansing, changing dressings, wound healing by the secondary intention, using topical antimicrobial agents for healing the wound by primary intention, the antibiotic treatment for the SSI, specialist wound care.
Although the NICE (2019) guidelines are proved to be highly effective and relevant to the operation department practitioners to reduce the risk of SSI, there are many advantages ad disadvantages that are associated with the implementation of these guidelines into practices the ODP and care professionals need to consider the advantages and disadvantages while implementing these NICE guidelines to deal with SSI.
The NICE guidelines are legally bunded through the case law
The guidelines are involved in providing a certain basis for preventing the risk of SSI and treating patients with safe and high-quality care throughout the pre, intra ad post-operative journey of the patient.
The guidelines provide the proper information to the healthcare professional and ODP to follow the evidence-based approach to entre the protection of the patient from the risk of SSI.
The guidelines provide proper safeguarding to the care providers the patients in terms of protecting them from developing and spreading SSI.
Involve in meeting the high standard f car by the regulatory bodies.
For understanding the significance of the SSI proper surveillance is required by using the closure methods and the proper standardisation which are currently lacking in the NICE guidelines.
For reduction of the ever-increasing cases of SSI, it is important to follow a strict discipline and the evidence-based approach which is not covered under the NICE guidelines. In this context, it is important to carry out different research projects on SSI prevention and treatment to develop innovative and high-quality safety measure that enable the care providers to better implement the NICE policies into practices thereby eliminate the risk of SSI.
Effective standardisation of NHS practices is required to improve the infection control and prevention techniques that are followed in the pre, intra and post-operative condition to improves the surgical journey of patients.
There is a lack of balance regarding the recruitment strategies and the sample size in the research projects regarding SSI prevention and control.
One of the major limitations of the NICE guidelines is that they are influenced and affected by some evidence that is inconclusive [NICE, 2019].
Other limitations of NICE guidelines to SSI prevention and treatment are language bias and publication bias. NICE guidelines are published in the English language that may not be understood by many people who face difficulties in reading the language.
NICE guidelines exclude the patient who undergoes the surgical process that does not involve a visible incision, which can restrict the boundary of the implementation of these guidelines to a certain type of patients but not for all types of the patient undergoing any surgery.
The NICE guidelines are highly important and necessary aspects in the modern health care which enables the healthcare professionals an ODP to use systematic measure in terms of preventing the risk of SSI in patients who undergoes a surgery that involves a cut through the skin. NICE guidelines provide safeguarding to both the patients and carers by improving their knowledge regarding take safe care of a surgical wound to reduce the risk of any infection. There is reformation made in the NICE guidelines in 2019, which assist the health care professionals to use the appropriate techniques and closure methods to use the safe and high-quality care of the surgical wound.
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Guys & St Thomas NHS Foundation Trust (2017) Successful implication of NICE guideline and quality standard for prevention and treatment of surgical site infection Available at: https://www.guyandstthomas.nhs.uk/patients-and visitors/infection /infection - home. aspx: [Accessed 3 January 2020].
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Royal College of Surgeon (2019) Risk factors surgical site infection in neurosergy. Available at:https://publishing.rcseng.ac.uk/doi/abs/10.1308/rcssan.2019.0001?mobileUi=0& [Accessed 4 January 2020]
Surveillance of surgical site infections in NHS Hospitals in England (2015) Available at:https://www.gov.uk/publications /surgical - site - infections - ssi - surveillance - NHS-hospital-in-England [Accessed 20 December 2019].
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World Health Organization (2016) Available at: Global guidelines on the prevention of surgical site infection. Available at: https://www.who.int/gpsc/ssi-guidelines/en/ [Accessed 15 December 2019].
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