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Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices.
This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses.
Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.
Over 300 million surgical procedures are performed annually worldwide (
In recent years, guidance on the prevention of SSI has been published by key organizations; National Institute for Health Care and Excellence (NICE), Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) (
Primary objective:
To identify the barriers to establishing standardized SSI prevention practice. To identify intra- and inter-specialty variations in surgical site infection prevention practice. To identify variations in practice amongst financial systems such as state and privately funded healthcare systems and economical classifications.
Secondary objectives:
This is an international, pan-specialty, collaborative cross-sectional survey. A global panel of experts will form the study steering committee (SSC), providing a consensus-based approach to survey development, validation, and distribution. This study will be reported in line with the checklist for reporting of survey studies (CROSS) and the checklist for reporting results of internet E-surveys (CHERRIES) (
To collect data, the survey will be delivered electronically online using the QualtricsXM Platform™, Utah, USA. The format will be designed to include a combination of binary, Likert or multi-select. Free text comments will be used to collect further detail but will be kept to a minimum to help ensure good completion rates.
A pilot questionnaire will be developed based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. Additionally, feedback from the survey of surgical site infection prevention practice in UK vascular surgery will be used to inform survey questions/design (
The questionnaire will be structured into five sections; demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention domains. Data will be collected on participant surgical specialty, operative grade, country of practice and financial healthcare system of practice. SSI data will include criteria used for diagnosis. There were 15 perioperative domains formulated the UK questionnaire, which will be scrutinized against the CDC, WHO, NICE and ISWCAP guidelines outlined above by the SSC, to form a pilot questionnaire. The process of questionnaire development will be carried out through discussion by members of the SSC and a record of any question refinement will be documented. The number of questions will not be rigidly defined but the SSC will consider the impact on survey duration which can influence completion rates.
The pilot questionnaire will be distributed to at least two consultants of each surgical specialty; vascular, general, orthopedic and trauma, urology, plastic and reconstructive, cardiothoracic, neurosurgery and otolaryngology for multiple rounds of validation. After each round feedback will be analyzed by the SSC and consensus-based changes will be adopted. Any alterations will be done so on unanimous decision and documented as major (questions removed or added), and minor (wording alterations). The survey will be validated further in subsequent rounds until the SSC agrees no further alterations are required.
The survey will be sent out electronically to surgeons of any specialty and at all levels of training worldwide. This includes consultants, and surgical trainees (specialties registrars/residents). To be included in the study, surgeons must be currently practicing and be registered with the national surgical body/college/society. The validated online survey will be distributed through QualtricsXM for single-stage cluster sampling in addition to dissemination through social media, where snowballing may occur. Each network of distribution will provide a cluster, i.e., VERN for the vascular surgeons and PIACO group for general surgery. The study population will provide a representation of existing SSI preventative measures used worldwide.
Given the global nature of the survey, no sample size will be calculated. Raking will be used to assign weight values to each survey respondent in such a manner, that the weighted distribution of the sample is in very close agreement with two or more marginal control variables. Socio-economic (developing vs. developed countries) variables and surgical specialties will be used to weigh the sample of responses. As such, results will be able to be extrapolated into wider populations, irrespective of the distribution of responses received.
The survey will be advertised in weekly rounds, 1 month prior to dissemination using affiliated society social media accounts and the Surgical Infection Research Network Twitter account (@SIRNglobal).
The survey will be disseminated worldwide, with an international SSC to establish a network of distribution. The committee has been involved in previous successful surveys and collaborative projects through the PIACO group, the Vascular Endovascular Research Network (VERN), James Lind Alliance (JLA) and ISWCAP surveys (
Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures (
The incidence of SSI varies across surgical procedures, specialties, and conditions. Diagnostic and reporting challenges make true SSI rates difficult to capture. SSI rates are reported to vary from 0.1% to 40%. There are several patient- and procedure-related factors that influence the incidence of SSI. Patient comorbidities, advanced age, frailty and surgical complexity can increase the risk of developing an SSI. Additionally, prolonged duration and classification of the surgery are important procedure-related factors (
Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries. It will ascertain whether surgeons could feasibly participate in recruiting to platform randomized controlled trials assessing multiple interventions, including antibiotic prophylaxis.
Reminders will be sent on a 2-weekly basis to increase the response rate and to prevent sampling bias. Additionally, the study will be advertised on its own Twitter account to gain attention. Response fatigue is a common issue, leaving some questions unanswered. To keep this to a minimum, the survey has been designed to only ask relevant questions and to be succinct, clear, and unambiguous.
Due to the nature of the study, there is room for responder and recall bias. To minimize this, questions wording and survey length have been considered carefully during all steps of the development of the survey. Questions will be categorized into SSI-related preoperative, perioperative, and postoperative themes to preserve the structure and enable ease of organization for respondents to follow.
Additionally, there may be discrepancies in the response rates between different countries, not providing an accurate representation of certain regions. There may also be different local/national guidelines and unequal access to certain resources depending on the geographical regions. As this survey will be delivered worldwide, questions are based on guidelines from the National Institute for Health and Care Excellence (NICE), Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). These guidelines are internationally recognized and available, therefore discrepancies between geographical regions and differences in local guidelines should be kept to a minimum.
There is no standardized consensus recommendation on SSI prevention regarding perioperative practice. Unsurprisingly this can lead to a discrepancy in clinical practice, as shown by a questionnaire study within the UK (
Authors contributed to the following roles as per CRediT taxonomy; Conceptualisation: RL, JL, IC, MY. Methodology: JH, JW, JK, JL, DC, JT (6th author), KK, PL, LH, GS, BH, DG-O, DS, CB, JT (16th author), ML, RG, RL, IC, MY. Writing—original draft: JH, RL. Writing—review and editing: JH, JW, JK, JL, DC, JT (6th author), KK, PL, LH, GS, BH, DG-O, DS, CB, JT (16th author), ML, RG, RL, IC, MY. Visualisation: JH, RL, MY. Supervision: RL, IC, MY. Project administration: RL, MY. Funding acquisition: RL. All authors contributed to the article and approved the submitted version.
The sponsor of the study is Hull University Teaching Hospitals NHS Trust, R&D Department, Office 13, 2nd Floor Daisy Building, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU15 JQ. The study is funded by the Vascular and Endovascular Research Network.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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