Shared learning database

Royal Brompton & Harefield NHS Foundation Trust
Published date:
June 2017

The Photo at Discharge (PaD) for our cardiac surgery patients improves information and advice on wound care in line with NICE Quality Standard 49 and NICE Guideline 125). At discharge, a colour picture of the patient's wound, accompanying assessment and care advice are given to the patient and carer(s).

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).

This example was originally submitted to demonstrate implementation of NICE guideline CG74. The guideline has now been updated and replaced by NG125. The example has been amended to reflect this and remains consistent with the updated guideline. NG125 should be referred to if seeking to replicate any aspects of this example.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and 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.

Reasons for implementing your project

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.

Despite low SSI rates overall, our Trust spent over £1.6 million over a three year period managing readmissions for surgical site infection. This in turn impacted on capacity.

To address this, we introduced the Photo at Discharge (PaD). Early detection of SSI is crucial to reduce the severity and duration of infection. PaD provides our patients and carers with a practical, simple tool for use between acute and community care and provides an unambiguous baseline as to whether the surgical wound is improving or deteriorating and a legible, documented full assessment of the surgical wound.

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).

How did you implement the project

We used the Institute for Healthcare 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 and 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.

Key findings

At our hospital, improving the wound care information and advice to patients and carers with PaD is associated.

with a reduction in avoidable non-elective readmissions to hospital for surgical site infection, releasing 285-336 bed days per annum, with ‘costs avoided’ between £122,132 and £216,569 (PaD is associated with an absolute risk reduction of readmission for SSI between 73-86%), This releases capacity for elective of admissions for cardiac surgery -at our hospital site this is an additional 41-48 patients per annum benefitting from surgery.

For every £1 spent, the PaD scheme generates between £1,586 and £2,813 of benefits.

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. (Rochon, Sanders and Gallagher, 2017)

SSI prevention strategies need to consider their role in reducing avoidable demand for emergency admissions, as well as demonstrate their impact on quality and productivity within the Five Year Forward View.

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 smallFeedback from patients/carers and staff (in hospital and community setting) 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.

  • The clear, well-lit photo should accompany documented assessment and wound care and protection advice

  • Ensure there is a process to monitor/quality control for PaD.

  • Long term success tools can help teams to identify areas which may need further attention (see Lennox et al. 2017).

  • Celebrate and share success across the organisation and externally*.

*Patient Safety Awards, Manchester 2017 Winner Infection Prevention, Photo at Discharge

*OneTogether Awards, Birmingham 2017 Gold Medal Winner, Photo at Discharge


Lennox L, Doyle C, Reed JE and Bell D. (2017) What makes a sustainability tool valuable, practical and useful in real-world healthcare practice? A mixed-methods study on the development of the Long Term Success Tool in Northwest London BMJ Open;7:e014417

McMahon A and Sin CH (2015) A guide to economic assessment in nursing. Nursing Management. January ISBN: 978-0-9571023-7-8.

Rochon M, Makecha S, Morais C. et al. (2016) Quality improvement approach to reducing readmission for surgical site infection. Wounds UK, 12 (2): 26-31

Rochon, M., Jenkinson, S., Ramroop, et al (2018). Retrospective analysis of the Photo at Discharge scheme and readmission for surgical site infection following coronary artery bypass graft surgery. Journal of Infection Prevention, 19(6), 270–276.

Rochon M, Sanders J and Gallagher R (2017) Service Design: A Database Approach for the Management of Digital Images of Surgical Wounds in The Hospital Setting. Wounds UK 13 (4): 41-48.

Sanger P, Simianu VV, Gaskill CE, Armstrong CAL, Hartzler AL, Lordon RJ, Lober WB and Evans HL. (2016) Diagnosing surgical site infection using wound photography: a scenario based study. Journal of the American College of Surgeons. 224:8-15

Sriram V, Cowell G, Roberts A, Trimlett R, Yadav R, Raja S and Desouza A. (2016) A quality improvement approach to reducing readmission for surgical site infections. Wounds UK 12 (2): 26-31.

Woelber E, Schrick EJ, Gessner BD and Evans HL. (2016) Proportion of surgical site infections occurring after hospital discharge: a systematic review. Surgical Infections. 17 (5): 510-519.

Contact details

Melissa Rochon
CNS in Surveillance
Royal Brompton & Harefield NHS Foundation Trust

Tertiary care
Is the example industry-sponsored in any way?