The Impact of Patients’ Engagement in the Prevention of Surgical Site Infections: A Systematic Review

Introduction and Literature Review

Surgical site infection (SSI) occurs within 30 days of surgery or one year after a transplant when a foreign body is implanted at the surgical site.¹ Subcutaneous tissue involvement and sternal osteomyelitis with or without mediastinitis determine whether an infection is superficial or deep.² Patients undergoing all types of surgery are at risk of surgical site infections (SSIs), which result in increased hospitalization and health care costs, morbidity, and mortality.³ The most troubling burdens associated with hospital-acquired infections (HAI), including wound infections, are the longer lengths of stay (LOS) and the increased costs of care that result in poorer outcomes for patients mainly because nearly 20% of infections acquired in hospitals are caused by surgical site infections.¹

A study conducted on 1,770 wounds over 12 months in Saudi Arabia revealed a postoperative infection rate of 9.4%. The ratio of postoperative infection of females to males was 4:1. The patients’ age was between four days and ninety years old. All patients who had an appendectomy were prevented from receiving antibiotics.⁴ A retrospective analysis of 2716 wound infection cases were conducted in a tertiary hospital in Saudi Arabian. The study found that 289 patients had SSI, and a decrease in SSIs from 20 per 1000 operations in 2009 to 3.5 per 1000 operations in 2018 has been observed. This reduction in the SSI rate was achieved through the implementation of comprehensive self-assessment strategies in preparation for hospital accreditation.¹

In a study conducted by the National Healthcare Safety Network (NHSN) that included data from 850,000 general surgeries performed in the United States, the overall incidence of surgical site infections (SSIs) was found to be 1.9%.⁵ In comparison, the cumulative incidence of SSIs in hospitals in Africa is significantly higher, at 5.6 per 100 surgical procedures.⁶ This shows the huge rate of disparity in surgical site infections between developed and developing countries. Microorganisms may cause surgical site infections either endogenously or exogenously. A Gram-positive bacterium, such as Staphylococcus aureus, causes most SSIs when an incision is made on the skin. Infections at surgical sites occur when organisms throughout the body of a patient are exposed to pathogens while undergoing surgery. For example, surgical procedures on the stomach increase the risk of developing an enteric gram-negative infection.⁷

Research studies conducted in the United States and England, have concluded that the occurrence of SSIs increases hospital stays, which results in more costs for hospital.⁸ Centers for Disease Control and Prevention (CDC) reports that SSIs account for 20% of all health-associated infections (HAIs) and are linked with an increase in mortality risk of two- to elevenfold; at least 75% of all SSI-related deaths are directly related to SSIs. Moreover, the annual cost of SSIs is estimated to be $3.3 billion; the cost of treatment of SSIs is estimated to be more expensive than the cost of treatment of HAI. In addition, hospitalization costs increase by more than $20,000 per admission due to the 9.7 days longer hospital stay.^9–11 The extent to which the LOS is increased depends on both the severity of the SSI, whether superficial or deep. Depending on the type of procedure performed, SSI results in an additional 4–13 days of hospitalization, a 3-fold increase in rehospitalization rates, and an increase in length of hospital stay.¹

Unfortunately, there is a dearth of published literature about SSI rate in Saudi Arabia in any of the following forums 1) World Health Organization (WHO) website, 2) the Saudi General Directorate of Infection Prevention and Control in Healthcare Facilities website, and 3) the Saudi Ministry of Health website. Studies that have been published have revealed that SSI rates vary, with some showing high rates of SSI (30%) and others showing 0%.^12,13

A Multi regional cross-section study was done in Saudi Arabia to assess awareness and knowledge of SSI among surgical patients and there were 375 patients equally distributed among the five regions of Saudi Arabia. Males accounted for 55.7% of patients, while patients aged 18–34 accounted for 44%. There was a significant correlation between illiteracy and location (P = 0.001) among respondents with poor awareness (49.1%). A poor awareness level was also observed in patients who had never had surgery (P = 0.001) or injuries to the spinal cord (P = 0.003). Knowledge levels were significantly associated with region (P = 0.001), with 45.8% having fair and 35.2% having poor knowledge. The conclusion was that there was a lack of awareness and knowledge of SSIs among the participants. This confirms the significance of preoperative education as a critical component of minimizing surgical site infections.¹⁴

In the preoperative phase, noncompliance can result from a lack of patient engagement, placing the patient at greater risk of SSIs.¹⁵ As part of SSI prevention bundles, skin antisepsis, antibiotic prophylaxis, glycemic control, maintaining normothermia, and preoperative skin antisepsis with 2% Chlorhexidine Gluconate (CHG) were applied to reduce bacteria on the skin, leading to fewer SSIs and a reduction of 27.5% to 16.9% in the SSI rate when colorectal surgery was performed.¹⁶

With Enhanced Recovery After Surgery (ERAS) programs in surgical specialties, patients take part either passively or actively in various aspects of preoperative and postoperative care as a way of improving their care and recovery.¹⁷ The ERAS is an evidence-based program to perioperative care (before, during, and after surgery) designed to improve patient outcomes, reduce complications, and speed up recovery after surgery. The WHO has developed a Surgical Safety Checklist that is widely advocated and used by surgeons, physicians, and other stakeholders to reduce errors during surgery and improve surgical safety.¹⁸ For positive surgical outcomes, patients must cooperate and participate in preoperative and postoperative care, including surgical wound care.¹⁹ The purpose of these initiatives is to foster patient engagement and participation. However, it is vital that granular data be collected on how patients are involved explicitly in infection care.¹⁸ Patient engagement is used synonymously with terms like participation and involvement. Patient engagement encompasses situations where patient centered approach is enacted and this means involving patients in all aspects of their care.^20,21 Several studies have investigated the relationship between patient engagement and surgical site infection.^22–24 However, there has not been a recent review summarizing such evidence. Summarizing the events is important to plan for interventions. Through a systematic review, the existing evidence was analysed and reviewed on the impact of patient engagement and participation on surgical site infection rates.

Aim of the Study

This systematic review intends to determine the outcomes of patient engagement in improving health outcomes with SSI. To achieve this, a structured and transparent search approach was employed, including electronic database searches (eg Pub Med, Science Direct, Scopus, web of sciences and Google Scholar).

Specific Objectives

A systematic review was conducted to find out the impact of patient engagement in surgical site infection prevention and determine what the outcomes are of patient engagement in improving health outcomes.

Materials and Methods

This systematic review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency, consistency and completeness.

Strategy for Literature Search

Literature research was conducted across four distinct databases which were Science Direct, Scopus, Web of Science and PubMed. There were no restrictions on the countries, however the time of publication was restricted to between 2010–2024.

The databases were searched using broad keywords (“Patient involvement”, “Surgical site infection”, “Prevention”, AND “patient engagement”) and articles that met these criteria were retrieved. This approach ensures that the database search is conducted efficiently and that all the relevant articles are retrieved. Additionally, the broad keywords helped to avoid missing any articles that might contain relevant information. Moreover, the use a broad search strategy key terms helps in uncovering article that might be missed if narrow search terms are used.²⁵

Study Selection

Following deduplication, titles were screened, and potentially relevant articles analyzed based on their abstracts. All relevant studies, including abstracts and full-text papers, were reviewed independently.

This process helped to ensure that the articles were of the highest quality and most relevant, as deduplication helped to weed out duplicate studies and the screening process assisted to identify any articles that may have been missed. Additionally, the full-text review helped to ensure that the articles were relevant in relation to the objective of the review and that they met all the criteria for inclusion.

Inclusion and Exclusion Criteria for Selecting Studies

Different studies such as cross-sectional studies, cohort studies, qualitative studies, mixed methods, and observational studies were included in this study. For inclusion criteria articles addressing patient understanding and participation in surgical site infection prevention, published in English since 2010, involving family members or parents, and affecting patient engagement in their health and hospital experience were considered. Exclusion criteria included articles with no full-text access, duplicates, not published in English, retracted, and not involving patients and their families. This process ensured that only studies with a direct and measurable focus on patient engagement in SSI prevention were included for synthesis.

Data Extraction and Synthesis

Based on articles selected by four independent reviewers, the information was compiled. Clarification of any discrepancies was achieved through a discussion. The data were extracted from each study that was included.

Study Quality Assessment

To assess the quality of the selected studies, two quality assessment tools were used -Critical Appraisal Checklists for Studies developed by the Joanna Briggs Institute (JBI) and Newcastle-Ottawa Scale.^26,27 These two methods were used to assess the research quality and bias potential of the included studies. For qualitative studies, JBI scores of 49% or less indicated a high risk of bias, 50% to 69% indicated a moderate risk, and 70% or more indicated a low risk. For cross-sectional and cohort studies Newcastle–Ottawa Scale was used which evaluates studies across three domains ie comparability, selection and outcome/exposure. Each study was awarded up to 9 stars, where higher scores indicate better quality. Studies scoring 7–9 were considered high quality, 4–6 moderate quality, and ≤3 low quality. There were four independent reviewers who evaluated all studies included. The four independent reviewers were able to resolve their disagreements by discussing the content of the selected articles in relation to the objective of the review. Discussions and consensus were invoked to resolve the disagreements between the three independent reviewers.

Results

Identification and Description of Included Studies

A total of 574 citations were extracted from various databases. This included 284 duplicate studies. The citations were sourced from different databases as follows: 217 from PubMed, 110 from Science Direct, 150 from Web of Science, and 97 from Scopus. After an initial screening of the titles and a review of the abstracts of 290 papers, 210 studies were excluded. Out of the initial pool, 80 papers met the criteria for a full-text review. After applying the exclusion criteria, 72 complete texts were eliminated, yielding 6 articles for quantitative and 2 qualitative analyses. The flowchart illustrates the method used to select studies (see Figure 1). A summary of the characteristics of the included studies can be found in Table 1. In total, eight studies were reviewed. Most of the studies aim to enhance patient engagement in preventing surgical site infections. Generally, studies were of good quality, with rankings ranging from 6 to 9. Three studies were found to have a low risk of bias, as indicated in the table.

Table 1 Characteristic of Included Studies with Their Quality Assessment Using Newcastle Ottawa Scale (NOS) and Joanna Briggs Institute (JBI)

Figure 1 PRISMA flow chart.

Impact of Patient Engagement and Compliance with Post-Operative Surgical Site Infection Prevention Bundle

Patient engagement plays a pivotal role in the prevention of SSIs, which are among the most common healthcare-associated infections. When patients are actively involved in their care, such as following preoperative hygiene instructions, properly managing postoperative wounds, and promptly reporting signs of infection, the likelihood of SSIs significantly decreases. Empowering patients through education and shared decision-making fosters greater adherence to evidence-based practices and improves communication between patients and healthcare providers. Furthermore, patient engagement has been associated with better overall surgical outcomes and reduced healthcare costs. The ultimate outcome of engaging patients in treatment plans is to reduce infection, improve healthcare outcomes, and create a more patient-centred healthcare system.

Different studies emphasize that incorporating patients as active participants in infection prevention efforts can lead to improved compliance with infection control practices and enhances the overall safety culture within surgical care settings.^22,23,28,29

Participation in a patient-centred process is defined as a process in which the person is empowered to take more control over decisions and actions affecting their own health.²² Another intervention to prevent SSIs is patient involvement in surgical site care.²³ To improve SSI outcomes, a key strategy for an institution’s overall program is patient engagement, according to the Agency for Healthcare Quality and Research. To be able to collaborate effectively with the rest of the healthcare team, the individual must understand his/her role and acquire the necessary skills.²² Moreover, research has shown that improving outcomes while reducing patient anxiety can be achieved through informing patients about surgical site assessment and early detection of potential complications.²³ Active patient engagement has become increasingly popular as a way to improve patient safety on a global scale over the past few years, with more information, engagement and involvement in health-related decision-making processes being emphasized.²⁹

SSIs can prolong hospital stays, increase readmission rates, and increase intervention rates.²⁸ Due to the negative consequences of SSIs, patient outcomes are poor, mortality and morbidity are affected, and healthcare expenditures increase.²⁹ The majority of patients who develop post-discharge SSIs are readmitted to the hospital, making SSI the most costly and problematic healthcare-associated infection.³⁰ In addition to delaying rehabilitation and the return to normal activities, these conditions may have a serious psychological effect on the patient.²⁸ Non-financial costs associated with SSIs for patients are also high, as well as poorer quality of life.³⁰ Importantly, patients are recognized as key stakeholders in the evolving healthcare system, demanding more information that facilitates their participation.²⁹ A lack of discharge education may leave patients unaware of SSI and unable to recognize an infection as it develops.³⁰

Discussion

It has been shown in research that patient involvement benefits both the community and the health system. Patient involvement in healthcare decision-making and treatment planning improves community health outcomes. Whenever patients are actively engaged in their own care, they adhere to treatment plans. This leads to better overall health outcomes for the community. Additionally, involving patients in healthcare decision-making helps addresses their specific needs, leading to more patient-centred and effective healthcare interventions. In the eight studies that were selected for this review, there were various ways in which patients were involved in the planning, conducting, and disseminating of the research, but not consistently throughout.

For example, in Italy, the bundle has already been implemented, but the level of compliance with best practices is still quite low (44.8%).³¹ In another study, three major challenges which were identified; the ability of patients to manage surgical wound complications after discharge has been influenced by their knowledge of wound monitoring at discharge, their self-efficacy to monitor wounds at home, as well as communication with the provider.³⁰ In UK, a patient reported feeling disempowered during a secondary care infection episode, leading to frustration, anxiety and ultimately distancing themselves from decision-making and this lack of communication may lead to individuals seeking information from alternative sources, including online, with concerns about reliability and individualisation.³² Implementation of SSI bundles could aid in empowering patients and reducing anxiety by providing patients with the information they need to participate in SSI prevention.²⁹

The professionals monitored in this study did not adhere to some of the preoperative measures for SSI prevention regarding hair removal based on international and national guidelines.³³ Following the implementation of a comprehensive SSI bundle, the overall SSI rate in Brazil decreased from 16.4% to 5.1%.²⁸ Prior to implementation in the UK, SSI rate was 16.4 and decreased significantly to 4.7%, specifically in all three surgical specialties, including colorectal surgery, which decreased from 3.2% to 2.7%, plastic surgery from 1.2% to 0.5%, and general surgery from 0.86% to 0.33%.²⁴ In a study conducted in Brazil in 2023, lower income and less education led to public institution patients being less likely to agree with the importance of participation and participate in the prevention of SSI.²³

In comparison to current practice, Health wound monitoring applications have proven to be highly acceptable to patients for the ability to provide more frequent, thorough, and convenient follow-ups, which could Improve patients’ outcomes by reducing post-discharge anxiety.³⁰ Evidence suggests that clinicians in secondary care fail to communicate effectively and provide accurate information to patients about infections.³² Patient involvement is becoming increasingly important as it is being promoted as a method of ensuring patient safety.²⁹ In clinical practice, combining evidence-based care bundles with strategies to enhance patient engagement can strengthen a patient engagement program for the prevention of SSIs and assist in improving outcomes for patients.²³ Involving the patient at every stage of the surgical process may Provide a better patient experience and ultimately lead to better healthcare outcomes.²²

There are also opportunities for patient engagement pathways along with bundles, such as lifestyle modification, infection prevention education, preoperative shower, preoperative hair removal, and preoperative temperature management. The journey from elective surgery to hospitalization is followed by wound care, early signs and symptoms of infection at the surgical site and postoperative wound care.²⁵ Patient engagement can only be effective if barriers to patient engagement are addressed.

Limitation

We found several limitations in this study. Because only a few studies were identified, our interpretations and thematic synthesis were limited. Although we used broad search terms, some articles may have been missed due to terminology variations. Finally, no articles have been published in Saudi Arabia or the Middle East that have not been taken into account. There was no detailed information on how patient involvement was incorporated into the paper. Our findings were drawn from a comprehensive literature review, but our findings were limited to what was reported in primary sources.

Conclusions

Including patients in healthcare decision-making and treatment planning has several benefits. Actively engaged patients adhere to treatment plans more often, leading to better overall health outcomes. Patient involvement in healthcare decision-making also helps address community preferences and needs, resulting in more patient-centered and effective healthcare interventions. Patients are recognized as important in research and healthcare, but patient engagement is not comprehensive during every stage. As a consequence, patients need to be better integrated into the planning, implementing, and disseminating of research. It has been identified in different studies that patients face number of challenges that hinder them from managing their healthcare in an efficient manner. A lack of knowledge and self-efficacy for self-care, communication issues with healthcare providers, and feelings of disempowerment and frustration are some of these challenges. Providing patients with the necessary information and support could facilitate addressing these challenges and implementing recommendations. Care bundles and patient engagement programs reduce surgical site infections (SSIs) and improve patient outcomes, according to several studies. There are variations in compliance with best practices among healthcare professionals, suggesting guidelines and protocols need to be improved.

Patients’ involvement in healthcare is essential for enhancing patient safety, improving healthcare outcomes, and creating a healthcare system that is more patient-centered across the board. To enhance their experience and achieve better outcomes, it is recommended to engage them at every stage of the healthcare process in order to make sure they have a positive experience.