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Checklist aims to help prevent surgical infections in Africa

For the last year, Stanford surgery resident Jared Forrester, MD, has been living in Ethiopia, tackling one of surgery’s most troubling issues – how to prevent infections after an operation. Infection is always a risk with surgery, but those risks can be as much as five times higher among patients in low- and middle-income countries, Forrester said.

Inadequate hand-washing, the lack of sterile equipment and improper use of antibiotics are among the issues that can contribute to higher infection rates in countries where resources are limited, he says.

A year ago, Forrester signed up for a fellowship with Lifebox, a global nonprofit that aims to make surgery and anesthesia safer in low-resource communities. Through the program, he worked with colleagues in Jimma, a town of about 100,000 people in southwest Ethiopia, developing a system to change surgical practices with the aim of improving compliance with proven infection prevention standards.

The tertiary hospital there serves a regional population of 15 million people, with just six operating rooms and surgeons performing at least five cesarean sections a day, he said. C-sections can be a frequent cause of complications or even death among women in the East African country.

“In sub-Saharan Africa, it’s more of a death sentence to be pregnant than to have a heart attack,” Forrester said.

He said there are some simple techniques that can be used to address the problem. For instance, the microbiologists at Jimma studied the bacteria of infected surgical wounds, which were as high as 90 percent resistant to the antibiotic ampicillin, which is commonly used during C-sections. Through improving communication among hospital departments, the team was able to switch antibiotics to better protect patients, Forrester said. Surgical teams there also rely on soap and water for hand-washing, but this isn’t the most effective for killing microbes; instead, a switch to alcohol-based solutions can more effectively decontaminate the skin.

Forrester and his Ethiopian colleagues incorporated these kinds of innovations in a program called Clean Cut, a program to help improve compliance with infection prevention areas in the World Health Organization's surgical safety checklist. The program led to an 180 percent improvement in use of proper hand hygiene, a 92 percent improvement in use of antibiotics and an 87 percent improvement in inclusion of indicators to insure instruments are sterile, Forrester reported at a meeting this week of the American College of Surgeons in San Diego, Calif.

“At Lifebox, we are focused on the use of the checklist. We wanted the program to measure adherence to these infection prevention standards and couple it with patient outcomes to develop local solutions and create meaningful change,” he said.

He and his colleagues believe the system could be a model that could be adapted in other countries where resources are limited. They already are beginning to implement the system in two hospitals in Addis Ababa, the Ethiopian capital, with a plan to extend it a hospital in each region of the country within a year.

“Hopefully when it goes to the next phase, it will be driven by the local champions in Ethiopia so they can take it forward and continue on,” he said. “Having local people who are engaged and influential will go a long way in developing some sustainability.”

Forrester said he and his colleagues now are trying to document whether these improved procedures lead to better patient outcomes.

“By improving use of the checklist, it should go hand in hand that patient outcomes should improve,” he said.

Among his colleagues in the work is Thomas Weiser, MD, an associate professor of surgery at Stanford who is also on the board of Lifebox.

Previously: Women less likely than men to receive surgery in conflict areas, study shows, Surgery in the time of Ebola: A conversation and Automated safety checklists prevent hospital-acquired infections, Stanford team finds
Photo of surgery in Ethiopia courtesy of Jared Forrester

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