CHAPTER ONE

INTRODUCTION

1.1 Background of  the study

Surgical Site Infection (SSI) refers to an infection that occurs after surgery in the part of the body where the surgery took place (Silver, & Jarvis, 2019). SSI is one type of nosocomial infection in which a surgical infection occurs after invasive procedures (Parikumsil, 2020). According to the National Nosocomial Infection Surveillance (NNIS) system and the Centers for Disease Control and Prevention (CDC), SSI         accounted for 14% to 16% of all nosocomial infections and was the most common health care associated infections among surgical patients in the United States (USA) (Mangram et al. 2020). Incidence of SSIs may vary from hospital to hospital in different countries. Developed countries, such as the USA, the United Kingdom (UK), and Sweden have the lowest incidence of SSIs ranging from 2% to 6.4% ( Swenne, 2019;). In developing countries, such as India, Pakistan, Nepal, Turkey, and Iran, the incidence of SSIs is higher ranging from 5.5% to 25% (Kashani, & Jafarian, 2021).

  In Africa, little is known about its determinants because of the paucity of studies and diversity of methods used considering the results of the study carried out , the prevalence rate of SSI seems high in the central African republic ,18% was reported (Bercion et al,2017) ,12% in the south Ethiopia (Amenuet et al 2018).

 In Cameroon, a study principally conducted with surgical patients showed that the prevalence of postoperative wound infection in hospitals in Cameroon ranged from 6% to 18% (Hadi, 2019).

SSI also causes unnecessary increased health care cost resulting in financial constraints to both patients and health care system as a whole. SSI caused prolonged hospitalization 14 extra days and it was estimated that direct cost of hospitalizations per infected patient was US$ 24,344, compared to US$ 6,636 per uninfected patient (Whitehouse et al., 2018). Yet another study conducted in a European university hospital found that patient with SSI spent additional postoperative length of hospital stay of 16.8 days and additional hospital cost was US$ 11,586 (Weber et al., 2008). SSI has a significant impact on quality of life and economic status. SSI patients spent significantly more time in out-patient department visits, emergency room visits, investigation services, readmission in hospital, and other health care services than patients without SSI. It was found that average estimated total cost of caring patient with SSI was US$ 5,155 compared to US$ 1,773 in patient without SSI (Barnard, 2017).

Intrinsic and extrinsic risk factors were related to the development of SSIs. Intrinsic factors include advanced age, malnutrition, metabolic diseases, smoking, obesity, hypoxia, immunosuppression, and length of pre-operative stay. Extrinsic factors include duration and application of skin antiseptics, preoperative shaving, antibiotic prophylaxis, pre-operative skin preparation, inadequate sterilization of instruments, surgical drains, surgical technique, surgical hand scrub, and dressing technique ( Seltzer et al., 2018).

Among several contributing factors to SSI, nurse’s responsibility seems to be a significant importance, particularly nurses’ knowledge and skills in prevention of SSI.

The malnutrition rate is high in patients before undergoing gastrointestinal surgery due to nurses’ lack of knowledge and inability to evaluate nutritional status of the patients (Aydin & Karaoz, 2017). Nurses applied unsterile and                     inappropriate technique of using glove in surgical wound care and surgical procedures (Hampton, 2019) and 85% of nurses used inappropriate dressing technique in caring for surgical patients (McFadden & Miller, 2017). According to (Small 2018), it was found that nurses violated hospital’s protocol for pre-operative hair removal due to their negligence.

1.2 Statement of Problem

SSI is a significant clinical problem leading to morbidity and mortality. SSI caused pain, misery, and possible deformity (Fry & Fry, 2018). SSI also added to functional disability and emotional stress to the patients and in some cases disabling condition led to reduce quality of life (Ponce-de-Leon, 2018). Furthermore. Patients with SSI had 2 to11 times higher risk of death compared to patients without SSI (Sexton, 2017).

Based on a literature review, approximately 25% of the infections could be prevented by nursing personnel by following proper precautions during nursing care           of surgical patients (Sharma, 2018). Successful nursing care of surgical wounds depended on nurses’ evidence-based knowledge and practice in terms of understanding normal wound healing process, type of surgery, methods of wound closure, preventive techniques, risk factors for surgical wound, and management of the surgical wound care. Using these knowledge and practices, nurses can provide a systemic and holistic patient assessment and management to prevent SSI (Vuolo, 2020).

For the prevention of SSI, nurses should have proper knowledge and they should have skills on this matter during pre-operative, intra-operative, and post- operative period. For this study, the intra-operative prevention of SSI by nurses working at operation theatre will not be assessed because in Cameroon operating theater mostly is controlled by surgeons. Preoperatively, nurses need to have

Knowledge and they should provide care in the following scopes: hygiene and skin preparation, controlling underlying medical conditions, maintaining nutritional status, and antibiotic prophylaxis. Postoperatively, nurses also need to have knowledge and maintain good practice in the following scopes: surgical wound care with aseptic precaution, wound assessment and monitoring of SSI, and nutritional support (Mangram et al., 2020).

Application of current knowledge and practices by nurses can help prevent SSIs, reduce patients’ and hospitals’ expenditure and improve patients’ quality of life. The incidence of SSI is very high in Cameroon. Information about standard nursing practice guidelines in prevention of SSI are lacking in Cameroon. Currently, infection control training program for nurses is existed, but no special training program on prevention of SSI has yet been conducted in Cameroon.  Nurses have a lot of roles to play in prevention of SSI, thus, there is a need to examine their state of knowledge and practice. The examination of nurses’ knowledge and practices regarding the prevention of SSI has not been conducted in Cameroon. Therefore, this study was proposed with the following objectives.