The cardiac surgery department at University Hospital Bristol identified, through benchmarking with Public Health England, a higher than expected surgical site infection (SSI) rate following cardiac surgery. As part of an improvement initiative, the cardiac surgery team adopted the use of PICO dressing for closed surgical wounds for the prevention of SSI in high risk patients. This is in line with the NICE medical technologies guidance MTG43: PICO negative pressure wound dressings for closed surgical incisions. Prior to using PICO they used a standard post-operative film dressing.
Aims and objectives
Aim: to reduce the incidence of surgical site infection following cardiac surgery
- Adopt the use of PICO for closed surgical wounds in selected high-risk patients as part of an overall infection prevention strategy
- Develop a pathway and risk identification system to identify appropriate patients
- Undertake training and thorough communications to ensure all the relevant staff in relevant departments were aware of the change in practice and rationale
- Monitor the impact of the adoption project to ensure the benefits were realised
Reasons for implementing your project
The trust carry out approximately 1300 adult cardiac surgeries per year.
In October 2016, the cardiac team started collecting and submitting data about their surgical site infection rates on all adult cardiac surgeries to Public Health England. This was done by a Surgical Site Infection (SSI) nurse specialist. This process allowed their rates to be benchmarked and identified they had higher rates than expected.
They created a SSI reduction steering group with the aim of reducing the incidences of surgical site infection following cardiac surgery. The group was chaired by the clinical director for the directorate and attended by a consultant anaesthetist, cardiac consultant, microbiology consultant, cardiac wound care nurse specialist and SSI nurse specialist. Support from senior staff from these specialities which span the care pathway for patients who received PICO, helped support adoption.
They implemented a staged change to practice, firstly implementing a risk scoring system using the Brompton and Harefield risk scoring tool, and also undertaking a project to ensure good pre operative skin preparation. The final stage to the project was adoption of PICO for use on closed surgical wounds in high risk patients. This was implemented in January 2018.
How did you implement the project
Prior to adopting the use of PICO at wound closure, a system for risk scoring all patients planned for cardiac surgery had been fully implemented. During the pre-operative checks a patient was risk scored using the Brompton and Harefield risk score. Patients identified as high risk received a red sticker on their notes to ensure all the staff in the care pathway were aware.
Having this system in place facilitated the adoption of PICO because the next step was for the ward nurses to identify patients at high risk of SSI by the red sticker, and when transferring the patient to theatre, a PICO dressing was also taken with the patient. Patients were informed about the risk scoring process and PICO was explained if they were high risk.
The PICO dressing is put on by the surgeon closing the chest. This is often the registrar. The patient then goes to CICU for 24-48 hours and then to the ward.
The dressing is removed before discharge.
Training was focused on the healthcare professionals who would be responsible for using the PICO dressing. This included registrars who commonly close the chest, theatre staff, CICU and ward nurses and healthcare assistants. Training focused on:
- The importance of not removing the dressing unless it was full.
- How to use the second dressing.
- That removal should happen at day 5-7 (before discharge)
- Trouble- shooting the pump and making sure there is a good seal.
Initially, training was provided by the manufacturer clinical advisers on a rolling programme but as adoption has been achieved this is no longer required. Training for new starters and staff updates are provided as required by the manufacturer’s clinical adviser and tissue viability team.
They started adoption in January 2018 and it took a good few months to embed it in to every day practice. The lead team then did checks to see if it was being adopted
Procurement and storage
One of the challenges was in securing funding for the dressings. The theatre budget could not pay for them therefore a business case was developed which was underpinned by the evidence from the SSI benchmarking work. As a result there was an agreement to provide funding to the ward to procure the dressings. As a result, the cardiac ward is now responsible for buying the PICO dressings and storing them.
A small amount of stock is held on intensive care and in theatre for emergency cases.
PICO was already on the trust ordering system for ad hoc use so there were no issues with adoption from this perspective
The baseline SSI audit was conducted from January to March 2017, where data on Non-CABG (n=161) and Coronary artery Bypass graft (CABG) (n=148) were collected. The baseline SSI rate was 17.6% (n=26) and 3.1% (n=5) for CABG and Non-CABG respectively.
The Brompton and Harefield Infection Score (BHIS) risk stratification system and the PICO pathway was implemented and audited from January to March 2018, where data on Non-CABG (n=153) and CABG (n=148) procedures were collected. During this quality improvement period, the overall SSI rate was 8.8% (n=13) and 5.2% (n=8) for CABG and Non-CABG respectively. There was a 50% reduction in the CABG procedure SSI rate after the implementation of the pathway. Twenty-five PICO 10cm x 30cm devices were used during the quality improvement period. Patients, who did not receive a PICO device, received a standard dressing. The cost impact calculation indicates that with the implementation of the BHIS risk scoring and PICO, not only was there a 50% reduction in CABG procedure SSI, but the resultant saving was £83,271.
The implementation of the pathway resulted in a 50% decrease in CABG SSI, however there was an increase in the non-CABG related SSI. A deeper analysis of the audit data showed that not all patients were being risk scored and therefore compliance with the pathway could have affected the overall SSI rates. The approximate cost of utilising the PICO device for the audit period was £3,213; when compared to the standard post op dressing is more expensive. However, the 50% reduction in cardiac SSI incidence resulted in an overall saving of approximately £83,271, when compared to the costs of SSI recorded during the baseline audit. This represents a 31% reduction in costs. The higher cost of PICO is therefore not increasing trust spend but in fact one of the contributing factors to reducing costs associated with cardiac SSI
Key learning points
- Establish a steering group, comprising of senior healthcare professions who represent the departments and specialities relevant to the patients care pathway.
- Clinical director or senior representative who will champion the project and who is engaged in the want to reduce SSI rates
- Development of real-world data to support the need for change
- Collect baseline data showing current practice and then collect data and audit following implementation to show the impact of adoption. Collect information about SSI rates, costs of managing SSI’s or wound complications such as return-to-theatre cases due to SSI or poor healing, bed days, antibiotic use and cost of Vacuum Assisted Closure therapy.
- Provide training of all healthcare professional directly involved in implementation and patient care.