The Trust implemented a quality improvement programme across the two Trust hospitals, one elective and one acute hospital. The programme was informed by recommendations from the NICE guidance for prevention and treatment of surgical site infection (SSI) (NG125) and aimed to reduce infection rates in order toi improve patient outcomes. Additionally the team sought to reduce readmission rates attributable to SSI.
This example describes the process and results of our improvement programme for surgical site infection in trauma and orthopaedic surgery.
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 The guideline has now been updated and replaced by NG125.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.
Aims and objectives
The first aim was to establish a true reflection of the surgical site infection rates in our orthopaedic service across two separate hospital sites (one acute hospital - Royal Liverpool University Hospital, and one elective - Broadgreen Hospital). This would provide a baseline value upon which the planned changes could be accurately compared against. In addition, using Public Health England data we could compare our progress against the infection rates in other hospital trusts.
Improvement to the service would be alongside the NICE guidelines, published in 2008 and a wealth of developing literature on the subject of Surgical Site Infection (SSI) in orthopaedic surgery. These guidelines structure recommended practice at each step of the patient journey.
We aimed to provide information to patients and empower them to reduce their own risk of SSI. This would also facilitate our enhanced recovery programme in joint replacement surgery. Additionally, we sought to raise awareness within the entire musculoskeletal service about the factors influencing SSI and structure a team approach to dealing with them.
One aim in particular was to reduce the readmission rates secondary to SSI. By patients self-presenting early, they could be effectively managed in the community, with lower financial costs. Our trust has a developing enhanced recovery programme for joint replacement and the management gap between primary and secondary care requires attention. We aimed to provide rapid access for primary care staff to obtain expert opinions from the index surgeon on problematic post-operative wounds.
The overall aim of the project was reduce infection rates in order to improve patient outcomes. Infection in trauma and orthopaedic surgery can be devastating. Although SSI is a recognised risk in any surgery, the largely clean environment in orthopaedic surgery makes SSI largely preventable.
Reasons for implementing your project
The implementation of mandatory data sharing for Surgical Site Infections (SSI) with Public Health England (PHE) stimulated a review of the orthopaedic service across both hospital sites. The combined output of surgery encompasses roughly 400 knee replacements, 500 hip replacements and 300 hip fracture surgeries per year. There are more than 30 consultant orthopaedic surgeons working within the trust.
The original SSI orthopaedic service was coordinated by a specialist nurse who worked part-time across the two hospital sites. The SSI management lacked funding and support at the large acute hospital, which reflected in the care provided to patients. Management became aware of the growing need for improvement in the SSI service from the department. Patients, district nurses and local GP's also commented on the difficulty in obtaining opinions of problem wounds from the index surgeon after the operation. In 2010 we had an unacceptably high SSI rate (4.2% verses the national average of 1.7% for hip replacements) and readmission rate (4.2% verses the national average of 0.7%). There were poor patient outcomes, unnecessary inpatient bed occupancy and an additional financial penalty for < 30-day readmissions. Delayed discharge and high readmission rates reduced the productivity of the elective wards due to bed unavailability.
The first set of SSI data collected for PHE in 2010 provided a baseline assessment to improve upon. In one area of our practice there was an infection rate of 5% within a 4-month stretch, which was in stark contrast to the national average of 1%. The high SSI rate was not clearly accountable to a single factor, but rather a collection of variables. It was felt that the ungoverned collection of wound swabs from post-operative patients was creating a high false-positive rate of infections. In addition, there was a need for a liaison between microbiology services, orthopaedic surgeons, infection control nurses and ward staff to create a unified effort against SSI in orthopaedic surgery. The published NICE guidance identified areas where our practice could be developed. One specific recommendation (1.2.11) was for a locally agreed antibiotic prophylaxis guideline to be administered prior to surgery. This was not established in either hospital. The theatres in the acute hospital lacked filtered laminar airflow and the operating staff wore standard gowns, which goes against current evidence for infective prevention.
How did you implement the project
There was an organisational approach to change. Our strategy was to review the process of the patient journey to identify specific areas for improvement. The broad extent of the NICE guidelines and the growing complexity of the changes required in the service highlighted the need for a collaborative leadership. Senior consultant leads for SSI were appointed for orthopaedic surgery and microbiology.
Additionally, two full time specialist nurses were appointed to monitor and liaise with the growing multi-disciplinary team for SSI prevention. Changes in the operating theatre began with the installation of two new airflow systems which keep the operating table clean with filtered air (cost: approximately £28000). All joint replacement surgery was to be performed using hooded sterile gowns that provide a more robust sterile barrier. Mandatory skin preparation protocols and intraoperative body warming were implemented for all patients, based on peer-reviewed evidence. A formal teaching program run by the orthopaedic lead established the principles of the new kit and re-educated theatre staff on hand washing and theatre etiquette, recommended by NICE guidance. The guidance also called for a local antibiotic prophylaxis strategy for all surgery.
A robust guideline was established by the SSI team and was implemented with great success. The successful audit of the guideline implementation was presented at the Clinical Audit Awards in 2011 and won the 2nd prize. Ward, clinic and tissue viability nurses created a protocol for dressings, depending on the wound condition. This gave strategic action for problem wounds and prevented unnecessary costs on expensive dressings. Senior nurses and consultants were the only staff allowed to swab wounds due to inappropriate practices in the trust. The weekly joint orthopaedic and microbiology ward round gave expert advice on wound problems and insured appropriate antibiotic use.
Confirmed cases of SSI underwent a root cause analysis. Outpatients set up a wound clinic, available at short notice. Patients were educated prior to discharge and empowered to self-present if they had any concerns. The clinic gave access to primary care via a wound bleep accessed through switchboard. The clinic provided us with a surveillance strategy and reinforced feedback on our developing service. All cases were prospectively recorded in a locally developed database. The PHE national data allowed us to monitor progress against other hospitals.
Data was collected, analysed and submitted for both hospitals as separate entities. Outcome measures were rates of superficial/deep infection and < 30 day readmission. Surgical procedures were separated to 'hip fracture surgery', 'long bone surgery', 'total knee replacement' and 'total hip replacement'. Our patient comorbidities, age and anaesthetic risk demonstrated that the local population is disadvantaged compared to the national average. For example 62% of our patients have significant life threatening comorbidities verses 40% of the national average. Liverpool is the most socioeconomically deprived local authority in England and Wales, which may impact wound infection and outcomes.
Our annual infection rates for total hip replacement went from 1.9% in 2010 to 0.2% in 2013 (compared to the national average of 1.1%). Our infection rates in 2013 for total knee replacement also improved against that national average (1.3% vs. 1.7% nationally). The same is true for hip fracture surgery (1.6% vs. 1.8% nationally) and long bone fracture surgery (0.8% vs. 1.7% nationally). Hip fracture surgery dramatically improved from 5% infection in 2010 to 1.6% in 2013. Annual readmission rates also dropped from 1.2% in 2010 to 0.2% in 2013 (national average of 0.7%). The wound clinic established in 2013 has seen over 100 patients and may have contributed significantly to the drop in readmission. The route of access to the wound clinic came from eight sources: patients self-presenting, district nurses, GP's, the 'arthroplasty class' and others using the 'wound bleep' via switchboard.
An audit mapping prophylactic antibiotic regime uptake demonstrated a baseline compliance of 60% in the first cycle, followed by 100% and 98% in the 2nd and 3rd cycles respectively. The audit won a prize at the 2011 Junior Doctor Clinical Audit Awards.
A cost analysis has not been undertaken due to the complexity of factors. However, reduction in < 30 day readmission rate will impact financial penalties. Productivity has also improved, particularly at Broadgreen Hospital: in 2010 there were 316 total hip replacements verses 420 done in 2013. Productivity however is influenced by confounding factors other than our SSI program. The recent improvements surpassed expectations.
The service evolved in all aspects of care and is now well established. Our local database will allow us to maintain our high standards and also contribute to the literature with our own future research.
Key learning points
The single most important step was to take ownership of the data collection. By having a dedicated team to monitor trends in SSI reporting and management meant that false positives were excluded. Prospectively monitoring patient outcomes also facilitated rapid treatment plans and stopped infection early. The mechanism of reporting infection to the department had previously come from our Chief Executive via Public Health England (PHE) reports. By rigorously collecting the data ourselves, we were able to provide timely information directly to our management team and improved working relations.
Delegating defined leadership roles for both orthopaedics and microbiology created a dialogue and catalyzed action. The monthly MDT meeting allowed a group with different agendas to discuss cases and trends in detail. The MDT is a highly recommended pointer for likeminded trusts.
A review of the process of patient care highlighted areas for change. This analysis is best performed by a multidisciplinary group who can shed light on a variety of shortcomings in the patient journey. This group also has a better insight into providing focused solutions.
One aspect that did not work well was using paper records to collect data. We converted to a spreadsheet database, which was time consuming, but ultimately allowed us to review data more efficiently.
Funding was not provided for our quality improvement programme. We recommend performing local audit to provide evidence for the need of change, prior to funding applications. If funding is not readily available then the role of local education to promote SSI awareness is the single most cost effective intervention. Posters with clearly defined protocols for SSI prevention/management were displayed on the ward, in clinic and in theatre. These posters are cheap but accessible and effective at getting simple messages across to the team.