The Photo at Discharge (PaD) for our cardiac surgery patients improves information and advice on wound care (NICE Quality Standard 49 and NICE clinical guideline 74).
At discharge, a colour picture of the patient's wound, accompanying assessment and care advice are given to the patient and carers.
This improves the link between acute and community care, and may also contribute to antibiotic stewardship (i.e. a baseline is available to determine if wound is improving or deteriorating).
Aims & Objectives
- To improve documentation/information and photo assessment of surgical wound at the time of discharge, for the patient, carer(s) and healthcare providers
- To improve patient experience of discharge and infection prevention advice
- To provide a tool or prompt to seek medical attention at the earliest opportunity if the wound shows signs of surgical site infection (SSI) or deterioration
- To reduce the incidence of readmission for incisional SSI
- To implement solutions to findings from root cause analysis of SSI
Root cause analysis of incisional SSI highlighted the lack of documentation on the appearance of the wound at the time of discharge (both in medical notes and in information provided to the patient/carer) and secondly, a delay in seeking treatment and/or community management of a deteriorating wound.
Our Trust spent over £1.6 million over a three year period managing readmissions for surgical site infection. We used indirect patient involvement (i.e. postal questionnaire) to determine if our patients found the PaD initiative useful.
Feedback indicates the majority of patients find the scheme 'very useful', finding the photo 'reassuring and comforting' during the recovery period as well as providing them with a follow-up mechanism to report concerns (Rochon et al, 2016).
The PaD scheme is in line with NICE guidance on providing information to patients and carers to reduce SSI. Over a two year period, we are able to demonstrate a significant reduction in readmissions for SSI and associated 'costs avoided'. We believe PaD is readily transferable to other surgery types and is a novel strategy to address the 'substantial disease burden' of post-discharge SSI (Wolberg et al, 2016).
We used the Institute for Health Improvement (IHI) Model for Improvement and small iterative tests of change using Plan-Do-Study-Act cycles.
At the end of 2014, the surveillance nurses undertook the PaD scheme, in order to scale up and sustain improvement, all staff nurses required PaD training.
Costs were avoided by modifying in-house resources: PaD uses an existing database with site wide licences. The colour print out costs 7p. Staff time did not meet criteria for 'additionality' (McMahon and Sin, 2015), as the time to assess and document the wound is part of standard discharge practice.
Results and evaluation
At our hospital, improving the wound care information and advice to patients and carers is associated with a 90% reduction in readmission for SSI (proportion of total readmission for incisional SSI no-PaD 95% [n=37] total minus proportion total readmission for incisional SSI PaD). Total 39 incisional SSI May 2014- February 2016 period.
We calculate the cost avoided by the reduction is £196,202 per annum (average cardiac SSI readmission cost is £25,164). To monitor this, we maintained prospective, continuous SSI surveillance by trained personnel using the Public Health England 2013 protocol. In addition, we monitored monthly compliance with PaD scheme (maintaining >90% compliance since January 2016).
These results exceed expectations and have the multiple unexpected benefits: staff receiving PaD training (includes use of photography for wound assessment & documentation, clinical governance issues, consent and privacy and dignity) have skills readily transferable for other uses, including photo documentation for pressure ulcers, other wound types etc.
The photo upload on to the electronic patient record (EPR) helps with remote multidisciplinary review of wounds, improves continuity for care and may contribute to antibiotic stewardship as photos improve the sensitivity of SSI detection (Sanger et al. 2016).
Key learning points
- Use quality improvement approach including key stakeholders, iterative changes and feedback regularly
- In line with the Quality Improvement approach, start small
- Feedback from patients/carers and staff using electronic patient record (EPR) will help drive spread
- Use existing in-house technology where possible, for instance most electronic forms (i.e. for discharge summary) have media upload feature for photos