On Patient Safety: Infection Prevention in Orthopaedics: Pearls and Pitfalls of a Global Perspective

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From the Column Editor,
The World Health Organization (WHO) recently published recommendations on pre, intra, and postoperative measures for surgical site infection (SSI) prevention [3, 4]. These recommendations represent a renewed effort to improve care in low- and middle-income countries, specifically with respect to healthcare-associated infections (of which SSIs are the most common) [2, 5]. The WHO guidelines are truly global, in that they also can (and should) apply to high-income countries where SSIs are proportionally less frequent, yet still represent one of the largest burdens in terms of cost to patients, hospitals, payers, and society in general. The WHO documents take into account the balance between harm and benefit, the level of evidence, costs, and resource implications.
While those of us practicing in resource-rich environments can easily implement the WHO recommendations, in many places where failing to do so is literally a life-or-death proposition, it is not so easy. Today, more than 50% of people on the planet still do not have access to the Internet (this includes physicians, policymakers, and hospitals). And for those who do, the fee required to access key scientific publications might render it out of reach—particularly those in resource-poor environments. Finally, even with accessible scientific information and knowledge, the implementation of guidelines and protocols remains a challenge in an environment where the culture of quality and safety is not the priority.
Implementing the WHO guidelines requires the awareness that such guidelines exist. Limited access to knowledge is sadly common in many low- and middle-income countries. I have lived and practiced medicine on three different continents and have witnessed busy rural hospitals in South East Asia and India with no easy access to the Internet. How can local healthcare providers keep current with the latest WHO infection prevention recommendations if providers in those countries that need it the most cannot access the guidelines? One hope is that the universal Internet access (by 2020) pledge made by Mark Zuckerberg and Bill Gates is successful [1]. In the meantime, it is in the hands of the WHO to promote and properly distribute their documents to those who truly need it. Local physicians should consider traveling to the nearest town with Internet access. Universal Internet access will enable global organizations like WHO to share important documents and recommendations where they are most needed strategically, at no cost.
But even this is not sufficient since financial restrictions also will impede universal access to scientific information. The goal of open access publication of biomedical research is to create free access to scientific information on the receiving end. Open access allows the dissemination of research; guidelines and recommendations free of charge for the users wherever they are and whatever their financial means [7]. I coauthored a recent editorial on open-access publications [8] highlighting how critical this modern publication option is for low- and middle-income countries. The transfer of fees from users to authors is a key ethical consideration for clinician-scientists in high-income countries who want to improve access to critical information in areas where clinical application of that information will have the greatest impact. This is easier said than done. And, importantly, the biggest challenge lies not in access, but in implementation.
Applying guidelines and protocols, particularly infection prevention measures, requires providers to embrace a culture of patient safety and quality. Successful patient-centered culture is achieved when providers buy in and the leadership establishes a no-blame culture, which facilitates accountability of each provider for every patient. In addition, key infrastructure—including education about how to implement checklists, guidelines, and protocols, as well as resources for continuous data monitoring—are essential.

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