Successful implementation of NICE guidance and quality standard for prevention and treatment of surgical site infection

The aims were:

1. Establish baseline SSI rates
2. Employ targeted interventions in line with NICE guidelines for SSI reduction.
3. Standardize practice along patient’s journeys
4. Promote multidisciplinary working through a strong SSIS leadership to ease the burden of data collection e) Embed the SSI detailed investigation protocol which mirrors the NICE SSI quality standard within existing clinical governance structures.

The incidence of surgical site infection was unknown initially hence the need to establish robust SSIS structures to enable a baseline to be established. Clinical teams reported worrying trends of patients developing serious infections that required complex interventions and led to extended length of stay and bed blockages.

Clearly there were significant cost implications associated with surgical site infections over and above patient experience implications where a price could not be attached. Some felt a high rate of infections reflected the nature of a tertiary referral centre that deals with complex patients. It was important to ensure that patients were involved as much along the patient's surgical journeys to minimize their risk of developing SSIs.

Initial work focussed on cardiac surgery. Following an initial audit of practice from wards, theatres, recovery rooms and intensive care units, it was identified that the NICE SSI guidance was not being fully adhered to.

Headline findings from the cardiac audit:

1. SSI incidence for CABG was 7%
2. Causative organisms, Coagulase Negative Staphylococcus, Gram Negative organisms suggested patient origin and highlighted potential concerns with preoperative skin decolonisation or vein harvesting procedures
3. Vein harvesting procedure – same trolley used for donor site and sternal site therefore high risk of cross contamination with gram negative organisms if preoperative skin decolonisation poor
4. Theatre environment - Reports of overheating / poor air conditioning and temperature control leading to use of fans in theatres during summer periods – involved estates department
5. Theatre cleanliness - reports of dust in operating theatres and redundant equipment
6. Theatre attire – Poor compliance to wearing of masks for staff in close proximity to operating field
7. Preoperative washes were done inconsistently – poor evidence
8. Asepsis principles during wound care - poor adherence
9. Dressings often changed in recovery rooms unnecessarily despite the existence of a protocol to leave dressings intact for a minimum of 4 days unless otherwise indicated
10. Patient information for monitoring wounds for infection embedded in generic cardiac surgery information and patient feedback suggested information not clear enough

The following generic and specific steps were taken to improve practice:

• Standardization of Surgical Site Infection Surveillance (SSIS) processes and paperwork.
• Active campaigns to promote SSIS through 1:1 meetings with key stakeholders and frontline staff and presentations at various fora
• Addressing basic practice concerns on hand hygiene.
• Adherence to asepsis principles during wound dressing changes couple with active competencies for all clinical staff.
• Use of antimicrobial dressings and standardisation of wound care practices in paediatric cardiac surgery. This directorate has a strong SSIS leadership comprising of a consultant SSIS lead, 2 audit and surveillance practitioners, matron and operating surgeons. An email group was created to ensure that all suspected and confirmed SSIs are reported to the group by any member of staff.
• Introduction of Chlorhexidine Gluconate (CHG) antimicrobial wipes for adults and Octenisan wash mitts for paediatrics and neonates to optimise preoperative skin decolonisation. This was done after establishing causative organisms suggested patients' own flora infected wounds therefore we were not confident that patients were washing effectively with soap at home as directed.
• Introduction of “Chloraprep” skin disinfectant, to standardise preoperative skin preparation in the operating rooms.
• Introduction of antimicrobial sutures for adult cardiac surgery patients in light of emerging evidence.
• Close monitoring of theatre discipline including development of a cleanliness checklist to be signed by surgeons before procedures commenced; rearranging equipment in theatres.
• Guidelines development aimed at standardising preoperative, intra-operative and post operative practices in line with NICE evidence-based recommended practices.
• Development of a generic patient wound monitoring leaflet; gynaecology and obstetrics further developed specific patient information stickers for identified high risk procedures.
• Development of leaflets for preoperative skin decolonisation.
• Active feedback of SSI data to all consultants / SSIS leads via monthly and quarterly SSI reports as well as further feedback and discussions at clinical governance and other relevant fora via identified SSIS leads / local champions.
• Standardising SSI detailed investigations in line with NICE SSI quality standard. This was coupled with an educational campaign for all staff on NICE SSI quality standard expectations via SSIS monthly newsletters Effective C-section SSIS including post discharge surveillance.

Obstacles / challenges

Initially some staff felt that there were no concerns with their practice since patients involved were already high risk. Some highlighted that there was too much paperwork already in circulation and so refused to do the required SSIS documentation. Management also felt that there was too much paperwork for staff to complete and did not feel that SSIS was a priority.

Some surgeons felt surveillance was a direct challenge of their performance and were not willing to participate. The SSIS team leader invested time in providing support through one to one meetings with individual consultants who became local champions and frontline staff; presentations on SSIS and the rationale for the patient safety initiative at various audit meetings / departmental team meetings to ensure that staff understood the rationale of SSIS, NICE guidance and what we were trying to achieve. Various groups of staff were offered the opportunity to attend SSIS study days at Public Health England and became local champions for their areas upon completion.

Monthly SSIS newsletters aimed at raising awareness were sent to the Chief Nurse for circulation to the whole organisation with other key patient safety messages. SSIS pages were created on the trust intranet with all relevant support information as well as monthly and quarterly SSI reports over and above the monthly reports / support information and posters that were circulated to clinical directorates.

SSIS consultants leads were identified for the different directorates who formed the SSIS committee which meets quarterly to discuss SSI rates for the organisation.

In cardiac surgery which is a key highlight for this submission, the strong SSI leadership which included the Head of Cardiac surgery and the Head of Nursing enabled improvement work to be carried out without much resistance. There were no additional upfront costs since most of the interventions were around improving pathways and ensuring compliance with NICE guidance. There was a small cost implication when antimicrobial wipes were introduced into the pathway, however at the time this cost was considered insignificant compared to the cost due to SSIs.

Progress was monitored through prospective surgical site infection surveillance and active data feedback to directorates. Patient outcomes improved through reduction of avoidable infections and work is continuing to maintain or improve current standards further. The reductions are highlighted below:

* Gynaecology rates initially decreased to only 0.8% in 2014 however commencement of more complex procedures in 2015 / 2016 has seen an increase.

Antibiotics protocols have been reviewed and more work is in progress to identify other options available to manage the new challenge. This is a reminder for us not to become complacent despite all the success demonstrated.

We achieved success through working together collaboratively as professionals and also through implementing NICE guidance, listening to our patients’ feedback and making changes to practice as needed. We made significant cost savings in excess of £1 million since the program commenced.

A paper by Jenks et al (2014) was used to provide estimated costs of SSIs for adult cardiac surgery. In their paper, the total cost attributable to 43 SSIs was £722537 i.e. an average of £16803 per SSIs which we used for our estimate. We acknowledge that we did not perform detailed patient level costing which may result in a different estimate depending on the method of re-imbursement for the organisation. Crude savings are clear from our data considering patients who developed deep and organ space SSIs returned to theatres several times for washout and debridement of wounds, had increased length of hospital stay, admissions to critical care, required specialised dressings and other specialists to manage infected wounds.

We also feel that no amount of money can buy patient experience and good quality of life through SSI prevention and is a priceless outcome for the organisation and its reputation.

• Adopt a multidisciplinary collaborative approach
• Involve the chief nurse and the director of infection prevention & control
• Identify local champions
• Share results widely / feedback data effectively to all clinical staff and publish locally
• Use existing platforms / key messages media via the Chief Executive or as newsletters circulated from the chief nurse or equivalent individual who commands authority in an organisation
• Use patient feedback to drive improvement
• Adopt a resilient, patient focused approach to convince colleagues

Reference:

Jenks PI, Laurent M, McQuarry S, Watkins R (2014) Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. The Journal of Hospital Infection, 86(1):22-33