ABSTRACT

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. SSIs remain an important cause of morbidity and mortality after surgery and have a significant impact on the health system. Preventive measures are essential to decrease the prevalence of SSIs, and significant data on literature in the nursing management of SSIs after pediatric surgeries are scarce and current guidelines for the prevention of SSIs are mainly focused on the adult population. The aim of this research was based on the Surgical Site Infections: Prevalence, Nurses Knowledge and Practice in Their Management After Pediatric Surgeries In The Buea And Limbe Regional Hospitals. This study was a three years’ hospital-based retrospective, prospective cross sectional study, on the prevalence of surgical site infections amongst the pediatric age group 0-16years by reviewing all pediatric records in both hospitals from 1^st of January 2020 to December 31^th 2022. And also this study involved assessing nurse’s knowledge and practices on their management of surgical site infections after pediatric surgeries in the Buea and Limbe Regional Hospitals. Authorization forms were gotten from the Faculty of Health Science Administrative Review Broad, from Delegation of Public Health, and from the Buea and Limbe Regional Hospitals. This study was also carried out involving 188 nurses who meet the inclusion criteria in both hospitals were the questionnaires were administered to them. Data was in entered in Microsoft Excel spreadsheets and analyzed using SPSS version 20 software. Results are demonstrated using charts, histograms, percentages. Eight hundred and fifty-eight surgeries were performed in the BRH and LRH from 2020 to 2022, from the results 208 developed surgical site infections. The overall prevalence of SSI in children was 24.2% (95% CI (20.6 – 28.4). The current study also revealed that out of the 188 nurses sampled, 85 (45.2%) had an overall bad knowledge (54.8%) on the management of surgical sites after pediatric operations. This indicated lower levels of knowledge in the perspective of pediatric surgeries and this could be attributed to the fact that more than 28.3% of the nurses had never worked in the surgical unit and not receive any in-service training in SSIs. And This study revealed that the average practicing scores of the nurses regarding the management of surgical sites infections after surgeries was 9.25 on a scale of 12 questions. Of the 188 nurses sampled, 118 (62.8%) had an overall good practice (had a score greater than the mean score) and was representing regarding the management of surgical sites after pediatric surgeries. Based on the study findings, the nurses in the present study had an overall poor level of knowledge as evidences by 59.0% and good level of practices regarding prevention of SSI as evidences of results of 62.8% of nurses who had good practices. Moreover, the results show that nurses’ practices is positively significant correlated with their knowledge (r = 0.218; p = 0.003).

Key Word: Prevalence, Pediatrics, Nurses, knowledge, Practice, Surgical site, and Infections, Surgeries.

CHAPTER ONE

INTRODUCTION

1.1  Background

Surgical site infections (SSI) are infections that occur postoperatively in the area of the body where the surgery took place that is within 30 days after an operation or a year after an implant [1]. SSI can be superficial and involve the skin, or more serious and involve other tissues, organs, or implanted materials. SSIs are among the most common hospital acquired infections causing complications, morbidity and mortality in all patients and this include the pediatric population [1, 2].

United States Center for Disease Control and Prevention (CDC) defined surgical site infection as an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infection can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can affect tissues under the skin, organs or implanted materials.

The prevalence and risk factors for SSIs in adult and more recently children have been defined and management guideline have been established [3,4]. Yet little is known about neonates. The prevalence of SSI is 2–5% in adult patients undergoing surgery [3]. Risk factors associated with SSI in adult includes co-morbidities, advanced age, risk indices, patient frailty, and surgery complexity [5]. In children the rate of SSI ranged from 2.5 to 5.4% and dirty wounds, inpatient status, increased duration of surgery, or certain surgical disciplines (cardiovascular, general surgery, neurosurgery, and orthopedics) were associated with increased risk of developing an SSI [4].

According to a research which was carried out in the develop countries of Iceland, Norway and Croatia in European, the research was published in 2014 which analyzed pediatric data collected from the European Centre for Disease Control (ECDC) gathered between 2011 and 2012 [24]. This research analyzed the prevalence of hospital-associated infections (HAIs) in the pediatric population, including neonates. The data was gathered from hospitals in the European Union and Iceland, Norway and Croatia. On the day of the survey, 17,273 of the patients surveyed were children. Among these, a total of 770 HAIs were reported in 726 children, corresponding to a prevalence of HAIs of 4.2%. Among those analyzed (bloodstream infections, lower respiratory tract infections, gastrointestinal infections, ear, nose and throat infections, urinary tract infections and SSIs), SSIs were the least frequent, with a prevalence of 4.4% among all HAIs [9,8].  

As mentioned before, the type of surgery a patient undergoes greatly influences the risk of SSIs, and many studies have investigated the incidence of SSIs in specific subcategories of surgery. Edward and colleagues identified risk factors for SSIs in neurosurgical pediatric patients who underwent craniotomy or spinal fusion [13]. With regard to craniotomy, a longer time in the operating room, a longer procedure and previous craniotomy were significant risk factors for SSIs. In the cohort of patients who were treated with spinal fusion, longer time at the lowest body temperature and use of anticoagulants post-operatively were significantly associated with SSIs [13].

According to global statistical report, it was reported that Worldwide an estimated 1.7 billion children predominantly from low-income and middle-income countries (LMICs), lack access to safe, affordable and timely surgical and anesthesia care causing surgical site infection amongst the pediatric age group. [14] Although surgery has gained increased awareness in the global health agenda in recent years, [15, 16] surgery for children has received less attention. The burden of surgical disease among children in LMICs is high, with 15%–20% of children in LMICs having surgically amenable conditions [17, 18]. In addition, the consequences of untreated surgical conditions for children include life-long disabilities and social stigmatization. [19] National investments in surgical care for children are needed to improve children’s health across all regions and income levels. [20].

Furthermore, statistical information from a research carried out on the topic Pediatric surgical outcomes in sub-Saharan Africa: a multicenter, international, prospective cohort study, amulticenter, international, prospective cohort study was undertaken in hospitals providing pediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for pediatric surgery [21]. The primary outcome was all-cause in-hospital mortality. Mortality in sub-Saharan Africa was compared with published benchmark mortality in HICs using χ² analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant. Which results indicated 1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformations, 225 intussusceptions, 250 appendicitis and 633 inguinal hernias. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis [22]. Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres [23].

Following a research carried in Africa in Gambia a total of 1726 children were admitted with surgical problems. Surgical patients accounted for 11.3% of pediatric admissions and 34 625 total inpatient days. The most common admission diagnoses were injuries (46.9%), congenital anomalies (24.3%), and infections requiring surgery (14.5%). The diagnoses that accounted for the greatest number of inpatient days were burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). Gambian children were rarely admitted for appendicitis and never admitted for hypertrophic pyloric stenosis. The leading causes of surgical deaths were burns, congenital anomalies, and injuries other than burns [24].

In addition, reports for a research carried in the developing country of Kenyan on Pediatric surgical site infection in the developing world. Which main purpose of the current study was to determine the incidence of pediatric surgical site infections (SSIs) at an academic children’s hospital in rural sub-Saharan Africa and to identify potentially modifiable risk factors [25]. Data collection was prospectively done from 1,008 surgical admissions to Bethany Kids Kijabe Hospital (Kijabe, Kenya) were analyzed retrospectively. Follow-up data were available in 940 subjects. Results from the research indicated that SSIs occurred in 6.8% of included subjects (N = 64). Superficial (69%) and deep (29%) infections of the back (38%) and head (25%) were most common [26]. When comparing children who developed SSI to those who did not, we found that wound contamination classification and duration of operation were the only variables with significant differences between groups. And the rate of SSI among pediatric patients insub-Saharan Africa is the lowest reported in the literature to date. More work is needed to identify modifiable risk factors for pediatric SSI in low- and middle-income countries [26].

Following epidemiology and microbiology data information on SSI in Cameroon, which was carried out as a prospective cohort study at the Mbouo Protestant Hospital in the West Region of Cameroon. The incidence, microbial spectrum and respective antimicrobial resistance of SSI and the risk factors of SSI was systematically investigated. The study included 300 patients at the Hôpital Protestant de Mbouo (HPM) who underwent surgery and gave their informed consent for inclusion, the timeframe is 04/2021 – 11/2021. And it was concluded an active SSI surveillance system will be put in place for 30 postoperative days to diagnose SSI [27].

Looking at statistical information from the Buea regional hospital it was reported according to a research carried out on the topic prevention and management of surgical wound infection and the challenges faced by nurses at the regional hospital Buea that, Surgical wound infections threaten the lives of millions of patients each year and contribute to the spread antibiotic resistance. In low income countries like Cameroon, the patient has 2-5% chances of developing an infection at the site of incision and those that get infected are two to three times likely to die as a result of the infection. Which the study aim was to assess the role of the nurses in the prevention and management of surgical site infection and also the study was a hospital-based study carried out at the Buea Regional Hospital for a period of 5weeks. A descriptive cross-sectional study design was used and a random sampling technique was used to collect data from nurses working in the theatre, casualty and the surgical units [28]. Results obtained revealed most nurses practiced strict aseptic techniques in the prevention and management of SSIs but there was negligence in the area of speaking over sterile field, closure of doors and windows before setting, use of sterile drapes to cover equipment after setting and use of sterile gloves. [29].

In 2014 a research was carried on the prevalence and risk factors associated with post-operative infections in the Limbe regional hospital of Cameroon statistical information reported that Postoperative infections (POIs) contribute to morbidity and mortality of surgical patients. There was no data on the prevalence and associated risk factors of POIs in the Limbe Regional Hospital (RLH). Postoperative infections (POIs) contribute to morbidity and mortality of surgical patients. There was no data on the prevalence and associated risk factors of SSI in the Limbe Regional Hospital (RLH) [30]. On the Results 848 patients were selected among whom 78.8% were females. 62.1% of the patients were selected from the Obstetrics and Gynecology ward, while 37.9%were from the surgical ward. The mean age of the study subjects was 32.3±12.4 years. 175 patients met the criteria for SSI giving a prevalence of 20.6%. The Obstetrics and Gynecology ward had the highest prevalence of SSI (61.7%). Prevalence of SSIs was highest (64.3%) among patients in the 0 – 10 years’ age group. Males (26.7%) were at a higher risk of developing SSIs. There was a statistically significant difference between SSIs and participants’ age group (p`0.05). Peritonitis displayed the highest rate of SSI (36.6%) while tubal ligation had the lowest (0%). Purulent wound discharge was the most frequent diagnostic criteria for postoperative infection [31]. 

This research was aimed to establish the prevalence SSIs after pediatric surgeries, to also assess nurse’s knowledge and practice on their management of surgical site infection after pediatric surgeries in the Buea and Limbe Regional Hospitals. And in addition intended to provide more baseline data on the prevalence of SSIs infections, encouraging more research in the file of surgery and in relation to pediatrics in the nursing domain. This can go long way to prolong life though proper prevention and management strategies by the nurses, thereby reducing complications, disabilities and death as a results of surgical site infection amongst the pediatric age group.

1.2 Statement of the Problem

Surgical site infections are the most common hospital acquired infection which don’t only affect the health of adult patients but also causes an increase in the mortality and mobility rate which goes a long in affecting on the pediatric age group and it was reported that Worldwide an estimated 1.7 billion children predominantly from low-income and middle-income countries (LMICs), lack access to safe, affordable and timely surgical care causing surgical site infections especially amongst the pediatric age group[14].The nurses and other health care team are at the four forth of providing the health care package in the fight against surgical site infections so as to reduces the occurrence of the infection by use evidence base knowledge and practices in the prevention and management of surgical site infections amongst the pediatric age group. But in the past years looking at the considerable efforts put forward by the Cameroon’s Government through the establishment of the Cameroon’s Ministry of Public Health which was aimed at providing and ensuring a quality health package for all age groups in Cameroon, however they still remain a great call for concern in the domain of health of the pediatric age group Although surgery has gained increased awareness in the global health agenda in recent years [15,16]. Surgery for children has received less attention. The burden of surgical site infection among children in LMICs is high, with a percentage of 15%–20% of children in LMICs having surgically amenable conditions [17,18]. Does making a great need to assess nurse’s knowledge and practice in their management of surgical site infections after pediatric surgeries.

1.3 Justification of Study

The research is intended to provide more base line data on nurse’s knowledge in the management of surgical site infections, which will provide more data on the prevalence in both hospitals there by aiding the hospital policy makers in addressing area of lope holes regarding nurse’s knowledge in the management of SSIs.

This research was also intended to identify areas of weakness in nurse’s management of surgical site infections after pediatric surgeries in the Buea and Limbe Regional Hospitals.

This research could also help serve as a guide on the on go management practices by the nurses on surgical site infections after pediatric surgeries, which will help in providing and strengthen the labor force of the health department of nurses on enforcing good practices in the management of SSIs.

In a larger scale, this research could help national and international health organizations in making policy regarding the management of SSIs in the perspective of the pediatric age group

1.4 Research Goal

The goal of this research was to educated and create more information about the prevalence of surgical site infection in pediatric surgeries, and how it can better managed and improve by the nurses through their knowledge and practice which will go long way to improve patients safety and hospital standard care toward pediatric care.

1.5 Research Questions

• What is the prevalence of surgical site infections in the Buea and Limbe Regional Hospitals?
• What is nurse’s knowledge in the management of surgical site infections after pediatric surgeries in the Buea and Limbe Regional Hospitals?
• What are nurse’s practice in their management of surgical site infections after pediatric surgeries in the Buea and Limbe Regional Hospitals?

1.6 Research Hypotheses

1) The prevalence of surgical site infections after pediatric surgeries are high in both hospitals

2) The knowledge of nurses on surgical site infections after pediatric surgeries is good in the Buea and Limbe Regional Hospital

3) The practice of nurses in their management of surgical site infections is good in the Buea and Limbe Regional Hospitals?

1.7 Research Objectives

17.1 General Objective

Prevalence of surgical site infections nurse’s knowledge and practice in their management after pediatric surgeries in the Buea and Limbe regional hospitals.

1.7.2 Specific Objectives

1) To determine the prevalence of surgical site infections after pediatric surgeries in the Buea and Limbe Regional Hospitals.

2) To assess the knowledge of nurses in their management of surgical site infections after pediatric surgeries in the Buea and Limbe Regional Hospitals.

3) To evaluate the practice of nurses on the management of surgical site infection after pediatric surgeries in the Buea and Limbe Regional Hospitals.