The results obtained in this study were divided into two time periods: years 2009–2013 (first period – before accreditation) and years 2014–2018 (second period – after accreditation). Unfortunately, the actions implemented – multimodal strategy – turned out not to be fully effective since a significant reduction regarding incidence was obtained in only one category of treatments, i.e. both open and closed reductions of fractures, where the incidence was significantly decreased by 3 and 2.5 times. It is a very significant accomplishment for the investigated department, as these were the surgeries that were most often performed. In the previous analyses by Wałaszek et al. , in 2008–2012, in the same department, FX incidence was 2.6–4.1%. In the literature, there are no other reports on the scale of this phenomenon in Polish trauma and orthopaedics wards. Furthermore, there are no reports from Europe on the incidence rate concerning infections associated with FX. In American NHSN research of 2006–2008 , the average SSI incidence associated with FX ranged from 1.1–3.4% depending on the presence of SSI risk factors, such as: duration of operation, ASA score, the degree of cleanliness of the operative field. A similar observation concerns CR procedures, for which in the studied department in 2008–2012, SSI incidence was 1.2–4.8% . The nature of the procedure – no exposure of open tissues to external factors – and the fact that these procedures involved closed fractures, in which stabilization was introduced percutaneously, may indicate a close relationship between the occurrence of these infections and the moment of their implementation. It seems that the very labelling of these infections as a separate population in targeted surveillance directed the attention of the investigated department to the problem of SSI and resulted in reducing the number of SSIs. In the literature, data concerning the problem of SSI in such surgeries has not been touched upon.
On the other hand, the observed total incidence of 1% is a significantly good result considering previous Polish reports concerning SSI in orthopaedic surgery, e.g. in Sosnowiec, the SSI incidence was 6.6% , and, in Kraków, 2.6% . However, multicentre data are needed to give a more complete picture of the situation and allow to draw comparisons, because, in view of the fact that data on SSI epidemiology in Polish trauma and orthopaedics wards are absent and that there are such considerable discrepancies regarding the epidemiological results, rational inference is limited. Therefore, it is recommended to implement a broad and unified programme of surveillance of HAIs, including SSIs, which would involve a large number of entities, also in Poland.
A research on European Union countries conducted by the ECDC in 2008–2009 confirms the differences in incidence rate after HPRO and KPRO procedures between various countries; e.g. for HPRO, the lowest was recorded for Great Britain and Lithuania 0.3–0.4%, while the highest for Norway and Malta, from 2.8–3.8% . The discrepancies are probably associated with the sensitivity of the method, as the presumed high SSI detection in Norway, but also with the organization of work and the whole system of health care organization as well as the flow of information between different participants of the surveillance systems, which is connected with infection detection in post-discharge care. At the same time, the risk of exposure to SSI following HPRO and KPRO observed in the examined ward for several years reflects the expected level of risk, i.e. it is comparable to the average obtained in the European HAI-Net programme. Also, the microbial aetiology does not differ from the reports of other authors .
Unfortunately, the data presented are not so optimistic. Our attention is drawn to the dominance of one of the forms of SSI, that is, the lack of superficial infections, despite the fact that they should make up – in the case of HPRO and KPRO – around 50–60% of cases . At this point, two hypotheses can be made, one suggesting SSI-D overdetection, that is, the tendency to incorrectly classify cases, the other indicating too low detection of superficial SSIs. Therefore, it is very likely that the real SSI incidence is even 2 times higher. The investigated hospital does not conduct any procedures with respect to process validation regularly, either in terms of the correctness of procedure performance or as regards the correctness of infection classification. In the authors’ opinion, it is the most important element concerning infection control that currently requires implementation in the study hospital.
An interesting observation, made possible by this analysis, can be done as regards patient demographics. A review of European data indicates that Polish patients are significantly younger (67 years and older) than the average patient population operated for HPRO and KPRO in Europe: median of 72 years. Also other Polish reports confirm this observation. In studies conducted in two Polish orthopaedic centres in 2005, the median ages were 68 and 67 years . These results may suggest that inhabitants of other European countries enjoy better health than people in Poland, who require surgical intervention 5 years earlier, on average. This fact is even more disturbing when data from OECD from 2017 is taken into consideration, since the average waiting time for HPRO in Poland was 405 days, while, for example in the Netherlands, it is 42 days .
This retrospective study had some limitations. Firstly, the research involves only one centre. Secondly, in the period studied, despite participation in the multicenter programme, the surveillance of infection method was not validated, hence, its sensitivity is not known in this particular case.