Published: 30 June 2023
Improving surgical outcomes as a global health priority
Surgical site infections (SSIs), caused by bacteria entering wounds, are the commonest surgical complication and remain a major health challenge across the world. They are particularly common in low resource settings, where patients are 2–3 times more likely to experience or die from them. Those who survive suffer pain and poor wound healing, often resulting in longer hospital stays and financial difficulties for patients and their families through loss of work and medication costs.
The World Health Organization’s 2016 guidelines to improve surgical care made numerous recommendations designed to prevent SSIs but its evidence mainly related to high resource settings. As patients and resources differ widely between settings, few surgeons in resource-limited settings could put them into practice.
To redress this, a global network of surgeons supported by the NIHR Global Health Research Unit on Global Surgery (GSU) are working together on research projects to improve access to safe, affordable care for surgical patients in these settings. Based at the University of Birmingham and jointly run with the University of Edinburgh, the NIHR’s £7 million award for the GSU funded the organisation of international research centres across Africa, central America and south Asia.
As part of the GSU’s wide-reaching programme, the ChEETAh trial investigated whether the use of clean gloves and instruments to close wounds after abdominal surgery could reduce the number of SSIs occurring within 30 days of surgery.
Reducing life-threatening wound infections
Led by Associate Professor Anneel Bhangu, Consultant Surgeon at the University of Birmingham, the ChEETAh trial was run by clinical leaders across the global surgery network in Benin, Ghana, India Mexico, Nigeria, Rwanda, and South Africa. Between them they recruited 12,200 adults and children from 81 hospitals who needed abdominal surgery ( not including caesarean sections) as SSIs are common after such operations.
In half of the hospitals, the whole surgical theatre team changed gloves and used sterile instruments to close patients’ wounds. The remaining hospitals performed surgery using their current practices, without routine glove changing. The researchers then compared how many patients developed wound infections within 30 days of surgery using each approach.
Their results, published in The Lancet, showed that routine glove and instrument changing was not only implementable around the world, but also reduced infections in a range of surgical settings by 13 per cent.
The trial’s surgeons and their teams engaged well with the intervention and widely accepted the new practice into routine surgery. Reduced infection rates were recorded across the network, from large hospitals with advanced surgical services through to small, rural hospitals, improving care for patients in different resource settings around the world.
Changing surgical practice globally
Cost-effectiveness of healthcare practices is a key consideration in low resource settings. Evidence from ChEETAh showed that even when the cost of routinely changing gloves and instruments was taken into account, the prevention of SSIs actually reduced hospital costs. The intervention was therefore considered a cost-effective approach both for hospitals and for self-funding patients.
“Cheetah is the largest trial of abdominal wound infection prevention ever carried out and showed that this simple, cost-effective measure could prevent 1 in 6 wound infections. This can benefit several hundred thousand patients and their families every year and reduce the costs to the health service providers.”
Professor Dion Morton, Barling Chair of Surgery at the University of Birmingham and Co-Director of the GSU
However, the GSU recognised that cost isn’t always the main barrier to implementing change. Ensuring guidelines are updated and widely shared among surgeons is crucial too. The GSU is therefore working with international surgical societies, policy makers and governments to share ChEETAh’s findings and incorporate them into international clinical guidelines and surgical practice.
On a local level, many surgeons involved in the trial are keen to change their practice and ChEETAh’s results are already influencing day-to-day patient care. Programmes to evaluate and share the results are already underway in Benin and Ghana, and an international dissemination meeting is planned for Lagos in September 2023.
Achieving fewer wound infections leads to wider benefits too, including fewer and shorter courses of antibiotics. This in turn helps to reduce global antimicrobial resistance. Hospitals can also discharge patients earlier, reducing the financial consequences of injury for those patients.
As well as improving patient care, the GSU is committed to supporting countries’ researchers and surgeons to run their own research projects. The experience gained from participating in ChEETAh and the wider research programme may therefore have a broader, long-lasting impact for countries’ developing their own healthcare systems.
The study was funded by the NIHR Global Health Research Unit on Global Surgery.
More information about the study is available on the NIHR’s Funding & Awards website.