Surgical Site Infections – The history of prevention
Every medical procedure is accompanied by a risk of infection. Preventive measures in particular are key to avoiding... read more
Choosing the optimal surgical gown for each type of surgical procedure is complex. Many aspects including hygienic requirements, wearing comfort, and cost-effectiveness have to be considered, so as to optimise infection control. Recent studies show that disposable surgical gowns could offer better protection during high-risk surgeries.
Every day 80,000 patients – or one in 18 patients – in European hospitals suffer from at least one healthcare associated infection (HAI)1 . Approximately 20 per cent of these infections are surgical site infections (SSI). This is because, during surgical procedures in particular, tissue is exposed that is otherwise protected by the skin. Open wounds serve as entry points for pathogenic germs. Targeted hygiene and control measures are intended to prevent infections before, during or after the operation. Hospital staff are trained to observe strict hygiene procedures. But further possibilities for protecting patients and staff exist in the facility’s organisational processes, as well as in the use of special products. Surgical gowns, for example, form an effective barrier to pathogens. They protect not only the patients, but also the medical staff.
National recommendations and guidelines consider disposable and reusable materials to be equivalent in terms of infection prevention2. The European standard for surgical gowns and drapes (EN 13795) is the same for disposable and reusable fabrics. In other words, according to the standard, disposable and reusable materials are equivalent in preventing infections.
This wasn’t always the case. In the mid 20th-century, gowns were made of a relatively loosely woven cotton. To reduce bacterial strike-through and thus infection, the requirements on gown materials have increased. Modern gowns are made from liquid-repellent and breathable materials with a significant barrier function. These provide a high level of protection – and comfort – during surgery.
Fabrics used for both disposable and reusable surgical gowns must fulfil stringent performance criteria, and must be free of defects which could impair the materials’ barrier function and facilitate infections. As disposable surgical gowns are always new, they minimise the transfer of infectious material during direct contact between the surgical team and surgical wound, whereas reusable gowns must undergo regular checks to exclude the possibility that repeated use reduces their quality3. Although the EN 13795 (part 1 and part 2) regards disposable and reusable gowns the same in terms of preventing SSI, research on this matter has been ongoing.
For example, Mislav Nedi? and his team at the University of Zagreb took a closer look4: In this prospective randomised study, the researchers evaluated the ability of disposable and reusable surgical gowns to prevent infections during cardiac surgeries. Patients were randomly divided into two groups and protected with disposable or reusable gowns, respectively. The incidence of infections such as urinary tract infections, central vein catheter and wound infections, pneumonia, sepsis, and other non-specific infections was determined during a six-week postoperative period. More than half of the patients who acquired an infection had undergone coronary bypass graft surgery and one third had undergone valve-related procedures. Results of this study showed that almost 68 per cent fewer infections occurred in the group where surgeons had worn single-use surgical gowns. This prompted the authors to recommend a more liberal use of disposable gowns in surgical procedures.
A number of recent studies support these findings. They show that using disposable gowns and disposable surgical drapes is associated with a lower rate of infection than using reusable products. This was investigated in surgeries with a high risk of infection, particularly in cardiac surgery, implant-based breast reconstruction5 and surgical procedures with implants such as total joint arthroplasty. 6 7
However, surgeons and medical staff who spend several hours in the operating theatre every day have greater demands on the gown material. In addition to infection prevention, surgical personnel highly value criteria such as wearing comfort and a skin-friendly surface. In fact, concentration during surgery could be hampered by surgical clothing that is distracting, unpleasant to wear or restricts the wearers’ movements.
To investigate these aspects, Melanie Prenner, a healthcare worker at the Danube University Krems, Austria, evaluated 42 questionnaires sent to surgical nurses, surgical assistants and anaesthesia nurses of a hospital in Vienna. The results were clear. A full 95 per cent of participants stated that “comfortable surgical clothing influences the quality of their work”. Prenner then analysed how satisfied participants were with disposable and reusable surgical gowns and drapes. Here, more than 70 per cent of the participants preferred disposable gowns. In addition, reusable gowns were blamed much more frequently for allergic reactions of the skin than disposable ones (31 per cent vs. 2 per cent)8.
A survey of the TU Dresden in 865 clinics delivered similar results9. The main reasons for using disposable surgical gowns were safety (66 per cent) and easy handling (48 per cent), whereas reusable gowns were preferred for comfort (68 per cent) and ecological aspects (53 per cent). Another survey conducted in Austria in 2011 among clinical and administrative personnel showed that 60 per cent of the doctors and nurses favoured disposable surgical materials for surgeries with an increased risk of infection. According to the respondents, disposable gowns were preferred for orthopaedic procedures (32 per cent), general, abdominal and endoscopic procedures (21 per cent), and for gynaecological operations (16 per cent), and C-section (15 per cent)10 .
These insights might be useful for administrators responsible for selecting surgical gowns in hospitals, as they are free to choose between disposable or reusable materials. Decision-makers should routinely evaluate the performance of surgical products worn in their medical facilities and make sure that surgical clothing still meets the requirements of resistance to liquid strike-through and low particulate release. In addition making sure that gowns fulfil their key function of infection prevention and hygiene, administrators should evaluate the role of the gown during each type of operation, and select disposable or reusable gowns accordingly. Wearing comfort, cost efficiency and ecological life cycle are also important factors in the decision11.
In summary, definitive evidence on which type of gown to use is still needed. Even if different analyses might favour the one or the other type of gown, the focus should always remain on their main purpose, namely, to reduce SSI.