- Email: [email protected]
Reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration
Accepted Manuscript Demonstrating success in reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration Lilian Chiwera, Neil Wigglesworth, Carol McCoskery, Gianluca Lucchese, William Newsholme PII:
S0195-6701(18)30179-8
DOI:
10.1016/j.jhin.2018.03.028
Reference:
YJHIN 5388
To appear in:
Journal of Hospital Infection
Received Date: 7 March 2018 Accepted Date: 22 March 2018
Please cite this article as: Chiwera L, Wigglesworth N, McCoskery C, Lucchese G, Newsholme W, Demonstrating success in reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration, Journal of Hospital Infection (2018), doi: 10.1016/j.jhin.2018.03.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Demonstrating success in reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration Lilian Chiwera1, Neil Wigglesworth1, Carol McCoskery2, Gianluca Lucchese2, William Newsholme1 Directorate of Infection, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
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Cardiovascular Department, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
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Corresponding author: Lilian Chiwera
Floor 4, Block B, South Wing Lambeth Palace Road SE1 7EH
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Directorate of Infection, Guy’s & St Thomas’ NHS Foundation Trust
Running title
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Email: [email protected]
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Demonstrating success in reducing cardiac SSIs
Keyword
Surgical site infection, SSI, surveillance, cardiac, antimicrobial resistance, care bundles,
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ACCEPTED MANUSCRIPT Background Cardiac surgical site infections (SSIs) have devastating consequences and present several challenges for patients and healthcare providers. Adult cardiac SSI surveillance commenced in 2009 at our hospitals, Guy’s & St Thomas’ NHS Foundation Trust, London, as a patient safety initiative amid
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reported increased incidence of SSIs. Before this time, infection incidence was unclear because data collection was not standardised.
Aims
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Our aim was to standardise SSI data collection and establish baseline SSI
rates to facilitate deployment of evidence based targeted interventions within
with our organisational targets. Methods
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clinical governance structures to improve quality, safety and efficiency in line
We standardised local data collection protocols in line with Public Health England recommendations and identified local champions. We undertook
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prospective SSI surveillance collaboratively to enable us to identify potential practice concerns and address them more effectively through a series of initiatives. Clinical staff completed dedicated surveillance forms
Findings
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intraoperatively and post operatively.
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Overall adult cardiac SSI rates fell from 5.4% in 2009 to 1.2% in 2016 and Coronary Artery Bypass Graft (CABG) rates from 6.5% in 2009 to 1.7% in 2016, p<0.001. Gram negative bacteria were recognised as important SSI causative organisms and were better controlled after introducing stringent infection control measures.
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ACCEPTED MANUSCRIPT Conclusion We successfully implemented comprehensive, evidence-based infection control practices through a multidisciplinary collaborative approach; an approach we consider to have great potential to reduce Gram negative, Staphylococcus aureus, polymicrobial and overall SSI burden and/or
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associated costs. We now investigate all SSIs using an established SSI
detailed investigation protocol to promote continual quality improvement that
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aligns us perfectly with global efforts to fight antimicrobial resistance.
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ACCEPTED MANUSCRIPT Introduction Surgical Site Infections (SSIs) constitute about 16% of the overall burden of Healthcare Associated Infections (HCAI) in England [1] and can have negative consequences for patients and healthcare providers. In England, a cardiac SSI costs approximately £17 000 [2], whereas in the USA the additional cost
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of a mediastinitis was estimated to be $62,773 in 2009 [3]. A zero-tolerance approach to avoidable SSIs and getting it right the first time are some SSI reduction approaches which if correctly adopted can lead to significant reductions in SSI burden [4,5]. In his speech at the Infection control summit in
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2016, the Secretary of State for Health in England announced the appointment of the national infection control lead in light of increased focus
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and attention on infection prevention and control. He singled out an approach used for orthopaedics which was led by Briggs on the ‘Getting It Right First Time’ project as promising and with potential for significant cost savings and reduction in readmissions [5,6]. It can be argued that it’s becoming increasingly difficult to ignore the impact of SSIs in the current health climate [7] as National Health Service (NHS) organisations in England place
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increased focus on improved quality, safety and efficiency for healthcare in the 21st century [8,9].
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In recent years, infection control work in the UK has focused mainly on challenges posed by Meticilin-resistant Staphylococcus aureus (MRSA),
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Clostridium difficile, Carbapenem Resistant Organisms (CROs), Candida auris and most recently, bacteraemia caused by Gram-negative bacteria [10]. However, the aforementioned challenges, which may be attributed to inappropriate antibiotic usage and non-adherence to strict infection prevention and control principles, are not uncommon in surgical patients. Additionally, the emergency of multidrug-resistant organisms globally is very concerning. In Iran, at least 50% of identified nosocomial infections in open heart surgery patients were SSIs; with high resistance rates to common antibiotics being noted in Escherichia coli (23.3%), Klebsiella species (38.5%) and S. aureus
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ACCEPTED MANUSCRIPT (54.2%) [11]. Therefore, a more comprehensive infection control approach that incorporates SSI surveillance is desirable.
Despite SSI reduction success after mandating orthopaedic SSI surveillance in England in 2004 [12], it appears that the extent of morbidity associated with
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non-mandated procedures is not fully understood in most settings and yet this information is critical in directing quality improvement initiatives. Because of the potentially devastating consequences of an SSI, voluntary cardiac SSI surveillance is undertaken by some organisations in England but a lack of
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resources is attributed to poor uptake of robust SSI surveillance in most, which inevitably results in inconsistent data collection approaches and / application of SSI definitions and missed opportunities to improve patient
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outcomes [13]. Recently, researchers have shown an increased interest in SSIs, but reports suggest a lack of generalisability of SSI rates due to variable data collection approaches [14,15,16]. With the increased focus on more transparent healthcare services however, there is an urgent need to establish efficient SSI surveillance systems to reduce infection burden and promote
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quality improvement [17,18]. We therefore introduced PHE recommended prospective cardiac SSI surveillance in 2009 to enable us to accurately quantify the size and nature of our SSI problem to direct potential improvement initiatives. In this paper, we report the outcomes of our
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prospective SSI surveillance programme.
Methods
Our prospective adult cardiac SSI surveillance was coordinated by a surveillance team consisting of a team leader and two support workers; supported by an infection control consultant. Clinical staff completed paper surveillance forms (appendix 1) in line with local guidance (appendix 2); in 2014 we introduced electronic wound documentation (appendix 3). The SSI surveillance team leader reviewed and verified infections with attending physicians; additionally visits to clinical areas, review of available electronic
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ACCEPTED MANUSCRIPT and paper documentation to identify SSI evidence were undertaken. SSI data was fed back to clinical teams monthly and published on the Trust intranet.
Setting and sample We undertook SSI surveillance at Guy’s and St Thomas’ NHS Foundation
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Trust (GSTT), a large acute health care organisation in central London which has 2 acute hospital sites and over 1000 beds. We included over 8000 eligible patients who had cardiac surgery at one site from the 1st of January 2009 to
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the 31st of December 2016.
Ethics
This work was undertaken as part of the surgical site infection surveillance
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scheme in line with PHE recommendations as a service evaluation, hence no ethics approval was required. Patients’ privacy and dignity were maintained and all data was handled confidentially.
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Interventions
Using our surveillance data, we implemented a locally developed care bundle approach, (appendix 4) that was based on Department of Health High Impact Interventions (HII) [19] and the NICE clinical guideline [20]. A zero tolerance
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approach to all avoidable SSIs enabled us to review practice even when SSI incidence was comparable to that reported nationally. A summary of our
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interventions is presented in figure 1.
Data analysis
We used descriptive statistics to establish whether patient demographic data had changed for the duration of our evaluation by calculating the ratio of diabetic to non-diabetic patients; ratio of females to males; and ratio of smokers to ex-smokers. We subsequently undertook univariate analysis for these identified known SSI risk factors. We reported SSIs as superficial 6
ACCEPTED MANUSCRIPT incisional, deep incisional and organ space infections21 . We used the R-Gui statistical package to upload statistical graphs and to calculate p-values using Chi square with Yates correlation two tailed test; we considered a p value of < 0.05 to be statistically significant.
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Results There were no notable changes in patient demographics over the 8-year
period (Table 1). The ratio of female to males was 0.4; the ratio of diabetic to non-diabetic patients and smokers to ex-smokers was about 0.3; for the 3
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periods shown in Table I. Limited data were available for smoking status for the period 2009 – 2011. We excluded procedures with limited data in the
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demographic and risk factor data analysis.
Figure 1 highlights decreasing trends in SSI incidence together with intervention points; Table 2 presents SSI data by type of infection. Overall adult cardiac SSI rates decreased significantly from 5.4% (n=55) in 2009 to 1.2% (n=14) in 2016, p<0.001 and CABG rates from 6.5% (n=46) in 2009 to
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1.2% (n=8) in 2016, p<0.001. The number of deep / organ space infections also decreased significantly from 32 in 2009 to 7 in 2016, p<0.001. SSI causative microorganism data are presented in Table 3 and Figure 2.
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Estimating SSI costs
Table 4 presents estimated costs related to patients returning to operating rooms for further interventions, readmissions due to SSIs and negative
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pressure therapy dressing usage for infected patients. These are conservative costs which do not take into account extended length of stay due to SSI and other interventions including admission to critical care and related costs. Assuming that without SSI surveillance, SSI rates continued at the 2009 rates, estimated SSI costs would be approximately £2 320 000 with an estimated cost avoidance of £1 168 000 based on measuring the above conservative parameters only.
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ACCEPTED MANUSCRIPT Discussion We demonstrated significant reductions in SSI incidence between 2009 and 2016, delivering a rate that is significantly lower than PHE rates for CABG surgery of about 4%, p<0.001 [12]. We attribute this success to the correct implementation of an evidence based bundled care pathway which was
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supported by our strong SSIS leadership and the wider multidisciplinary teams [19,20]. We used evidence based comprehensive infection control practices (figure 1) which were similar to those adopted by Frenette [22] in Canada. These evidence based SSI prevention interventions as well as locally agreed
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approaches included the use of chlorhexidine (CHG) for preoperative skin decolonisation; use of 2% chlorhexidine in 70% alcohol (ChloraPrep™) prior to skin incisions and comprehensive patient information leaflets for
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preoperative skin preparation and post-operative wound care.
To date, benefits of using CHG for preoperative skin decolonisation over soap are not clearly defined [23,18]. This is therefore a subject of ongoing debate however we introduced 4% CHG washes as part of our care bundle approach
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with demonstrated SSI reductions. This decision was inspired by the success demonstrated in our local ICU setting where MRSA bacteraemia cases were significantly reduced following introduction of a care bundle that incorporated CHG wash cloths [24]. We noticed a significant difference in the overall SSI
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incidence between the second financial quarter in 2010, i.e. July – September, (5.6%) before CHG wipes were introduced together with CHG skin
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preparation intra-operatively for 1 surgeon and the fourth financial quarter in 2011 (1.2%), p=0.01. CABG rates decreased from 8.2% to 1% during the same period and for this reason we decided to continue with this practice rather than using octenisan which is now anecdotally reported to be used in various organisations. Interestingly, a study conducted in Germany reported no benefits to the overall SSI incidence when using octenidine for preoperative skin decolonisation, albeit harvest site and organ space infections decreased significantly [25]. Octenidine is nevertheless used in our organisation for MRSA decolonisation regimes.
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ACCEPTED MANUSCRIPT It is not clear if improvements after introducing CHG for preoperative skin decolonisation were a direct result of this intervention only, as several potential confounders may exist. Additionally SSI rates are reported to vary seasonally [26], which may explain increased SSI incidence from the first quarter of the next financial year, April – June 2011. However, we found the
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data intriguing since 2 surgeons had 2/3 of the SSIs for the next 3 quarters, suggesting a link between surgical technique and patients’ SSI outcomes. In fact Graf et al [27] highlight surgical technique as an important contributing factor to deep sternal SSIs. Birkmeyer et al [28] also argued that surgical
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technique can vary considerably between different surgeons and recommends peer reviews to improve surgical outcomes. Furthermore, Ashish et al [29] reported on potential large variations in surgeon outcomes from similar
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institutions and stresses on surgeons being ‘team leaders with a unique and outsized critical role’. Nevertheless, Aggarwal et al [30] recommended caution and suggested that appropriate tools should be utilised to measure surgical performance as this also depends on other intraoperative factors, complexity of surgery and volume of procedures undertaken. In view of this, we looked at
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surgical technique together with other potential contributory factors. However, surgeon role and engagement in SSI prevention work remained central and critical to ensure that evidence-based SSI prevention care bundles were embedded within patients’ surgical pathways. We found that having separate
discuss
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meetings with individual surgeons in a supportive non-punitive environment to surgical
technique
including
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harvesting,
causative
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microorganisms data and patient pathways during periods of increased Gramnegative deep SSIs actually improved engagement with them and the wider surgical teams. Furthermore, to support surgeons and reduce variation, in 2011 we also introduced ChloraPrep™ to standardise preoperative skin decolonisation [31,19]. This intervention is supported by current WHO SSI guidelines [18], although Raja et al [32] suggested that aqueous and alcoholbased skin preparations are equally as effective. Madej et al [33] in Germany produced results that favoured the use of chlorhexidine-isopropyl alcohol for skin disinfection to reduce mediastinitis after cardiac surgery. Our deep and organ space sternal SSIs decreased significantly from 32 in 2009 to 7 2016,
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ACCEPTED MANUSCRIPT an incredible outcome for us since these deep sternal SSIs significantly increase mortality by an estimated 15% -40% [27]. It is important to acknowledge that some surgical patients carry a higher SSI risk than others. For example diabetes and poor intra-operative blood glucose control are reported to increase SSI risk and should be monitored closely. Our
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results demonstrated that diabetic patients were at least twice as likely to
develop SSIs when compared with patients who were not diabetic, p<0.01, for the period 2009 – 2011, which was similar to that reported previously [34]. Smoking is also a known risk factor for SSIs [35]. Although smoking was
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found to increase SSI risk, [RR 1.7, 95% CI 1.03-2.90] for the 2012-2014
period, this was not found to be statistically significant (p>0.05) suggesting
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that correct adherence to evidence-based interventions does reduce SSI incidence for patients who present with underlying comorbidities. Interestingly, risk of SSI did not appear to change much once people had stopped smokingsmokers. Our data, however lacked detail on how long patients had been exsmokers for and could possibly have led to different conclusions if full information was available. Contrary to our findings, where female gender did
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not stand out as a significant risk for SSI, Raja et al [34] reported that females were at a significantly higher risk of developing SSI when compared to male counterparts and subsequently introduced specific interventions to address this. In fact, our results for the 2012 – 2014 period suggested that males were
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at a higher risk of getting SSIs compared to female patients but we acknowledge that potential confounders may exist. It may also be possible
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that interventions that were already in place ensured risks related to the female gender were already being addressed sufficiently. It is unclear however whether different patient demographics may have influenced our results or not but clearly identifying well documented risk factors and putting measures to control them may reduce SSI incidence. In addition to addressing patient risk factors, establishing local practices is an important component of any measures that seek to reduce SSI burden. Our initial infection control audits highlighted potential practice concerns at ward level, in operating rooms and recovery rooms as well as high incidence of 10
ACCEPTED MANUSCRIPT Gram -egative SSIs. We therefore immediately introduced separate donor and sternal scrub trolleys intraoperatively to reduce possible risk of cross contamination; prior to that, only one trolley was used. We felt this to be a timely intervention considering Gram-negative organisms caused at least 55% of the SSIs; followed by Staphylococcus spp. (22%) which suggested potential
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practice concerns with vein harvesting procedures or inadequate preoperative skin decolonisation. When Gram-negative isolates were combined with
polymicrobial isolates that included coliforms, this constituted about 75% of
the overall isolates. This trend continued throughout the surveillance period
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despite a decrease in the overall Gram-negative SSI burden, suggesting that measures that seek to reduce cardiac SSIs should also seek to target practices that are potentially linked with increased risk of infection of surgical
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sites with gram negative organisms. Schweizer et al [36] recommend mupirocin decolonisation of patients who are S. aureus carriers as well as adding a glycopeptide to the usual antibiotic prophylaxis regime to reduce incidence of S. aureus SSIs. Our standard antibiotic prophylaxis were gentamicin and teicoplanin, thus cover for sensitive and resistant S. aureus
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species was provided. Additionally, patients had blanket standardised preoperative skin decolonisation regimes with chlorhexidine. We perceived that the complexity linked with screening all patients and then decolonisation
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of positive patients could potentially be more costly and difficult to manage.
The level of MRSA isolates was very low at only 2%, which probably reflects stringent measures to drive down MRSA bacteraemia rates which were already in place in line with mandatory requirements in England. In comparison, in an Australian study [37] almost 15% of isolates were MRSA. Interestingly, after their review of 10 years CABG SSI data, they also identified Gram-negative bacteria as important causative organisms and advocated for cardiac surgeons to maintain constant dialogue with microbiologists to ensure adherence to the right antibiotic prophylaxis regimes. Polymicrobial SSIs constituted about 15% of the overall isolates. In the USA, Nguyen et al [38] 11
ACCEPTED MANUSCRIPT reported a polymicrobial outbreak of cardiac SSIs which they attributed to potential environmental concerns and possibly suboptimal infection control practices. In our experience, at the very onset of the patient safety initiative in 2009, an exercise of decluttering operating room environments and design of a cleanliness checklist to be signed off by surgeons before procedures was
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undertaken following reports of dust on equipment in operating rooms and presence of redundant equipment; the direct impact of these actions on SSI outcomes is debatable.
Patients are increasingly being discharged from hospitals early which implies
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that most wound care now occurs in the community. Patient empowerment is therefore a critical component of any efforts to reduce cardiac SSI incidence
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[35,27]. We produced leaflets and laminates for bathrooms with detailed instructions on how to prepare the skin prior to surgery to ensure patients were fully informed of preoperative SSI risk and how they could help to reduce it. Patients received verbal advice; additionally, we gave leaflets for monitoring surgical wounds for infection from PHE initially until we developed our own inhouse leaflets. This was an important intervention [39] as reports suggest a
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lack of knowledge among SSI patients [7].
Multidisciplinary collaboration Managing change can be a huge undertaking for large organisations and yet it is a critical component of any SSI surveillance programmes as resistance to change has been reported in various institutions. Effective change management models are therefore required for complex health care systems to support continual quality improvement [40]. Levin Kurt proposed a 3 step model; unfreezing, change and then refreezing stages that enable change leaders to plan, risk assess, execute and sustain required changes that are needed to mobilise the workforce with a clear rationale for proposed changes. 12
ACCEPTED MANUSCRIPT Traditional change models often highlight denial and resistance as initial starting points therefore a good exploration of reasons for displayed behaviours is critical to achieving full engagement. Our approach aimed to understand the pressures and challenges on staff working under often stressful busy conditions. Coincidentally, the Clinical Lead and the Head of
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Nursing welcomed our patient safety initiative which subsequently reduced the level of resistance. Involving our Chief Nursing Officer to disseminate SSIS newsletters in a focussed campaign on the SSI quality standard to provide
clarification on individual responsibilities to ensure the 7 quality statements
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were embedded within the organisation’s clinical governance structures [39] and the nurse led introduction of electronic documentation in 2014 led to a
marked decrease in superficial SSIs from 19 in 2014 to only 3 in 2015. We felt
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that involving senior management from conception of a project as key opinion leaders promoted greater engagement. Cove et al [41] highlight risk modification through multidisciplinary collaboration as a key component in the identification of numerous quality improvement opportunities for surgical patients. Frenette et al [22] also used a multidisciplinary approach that led to a
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66% reduction in infection rates in CABG procedures from 11.9% to 4%. Furthermore, Graf et al [27] suggested that surgeons participate fully in comprehensive infection prevention initiatives when they are aware of local baseline deep incisional SSI rates and associated risk factors. Our results and
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use of MDT corroborate with those from Spain, albeit in a paediatric cardiac surgery population where a significant reduction in SSI from 10.9% to 1.9%
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was reported [42]. The use of shoulder to shoulder working rather than top down management is also advocated as it has potential to increase staff morale and consequently improve patient outcomes [5].
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Economic impact of this evaluation Paediatric cardiac SSIs cost at least twice the amount of hospital costs when compared to non-infected patients due to increased length of stay in critical
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care units [43]. For our adult cases, we estimated an NHS cost avoidance of approximately a million pounds using conservative parameters only. Using
estimates of £17000 for a cardiac SSI [2], continuing at 2009 rates would have costed the NHS over £7 million but with reported reductions, SSI costs were
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estimated to be just over £4 million demonstrating a cost avoidance in excess
Significance of the findings
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of £3 million.
We demonstrated decreasing incidence of SSIs and associated costs, contrary to propositions that SSI rates are not declining [44]. The use of multidisciplinary collaboration, not only reduces the burden of data collection critical in financially constrained healthcare organisations but has clear
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benefits for surgical patients. Initial infection control audits and surveillance highlighted several potential practice concerns which were positively addressed; highlighting the part surveillance plays in quality improvement. Feeding back results in a timely and supportive manner facilitated open
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discussions on possible improvement initiatives [45]. The need for increased
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transparency in NHS organisations supports our patient safety initiative [17].
It is very clear from our experience that various factors and practices affect SSI related patient outcomes. To that end, Schweizer et al [46] used bundled interventions that included mupirocin nasal ointment and chlorhexidine for MRSA- and MSSA-positive patients, and chlorhexidine for skin decolonisation in negative patients and those of unknown status in a multicentre study done in the USA between 2013 and 2014; this intervention led to marginal reductions in S. aureus deep and organ space SSIs. Similarly, Frenette et al [22] highlighted that bundling infection control interventions can potentially half 14
ACCEPTED MANUSCRIPT SSI incidence. Current debates however question impact of interventions without an accurate measure of compliance to evidence-based care bundles. Future SSI prevention interventions should therefore ideally aim to address this in order to strengthen or dispute evidence that is already available. We demonstrated clear benefits for patients and would recommend other
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organisations to adopt our approach to achieve similar success.
Limitations
Our surveillance focused on collection of inpatient and readmission data.
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Oliveira and Carvalho [45] estimate rates could be under-reported by up to a factor of 5 if surveillance is limited to inpatient and readmission stages.
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Following multidisciplinary discussions, we decided not to pursue postdischarge surveillance; however a wound clinic is available where changes in SSI trends can be picked up to inform our future SSI surveillance direction.
Conclusion
We demonstrated sustained improvements in SSI incidence through
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prospective continuous SSI surveillance. Our findings strongly suggest that use of evidence based care bundled interventions, effective feedback of SSI data to clinical teams, identification of local champions and adoption of a multidisciplinary collaborative approach can effectively reduce cardiac surgery
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SSI burden. We not only managed to successfully implement and sustain an important, cost effective patient safety initiative through multidisciplinary
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collaboration, but also reduced Gram negative, S. aureus and polymicrobial SSI challenges thereby improving the quality of cardiac surgical care provision.
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ACCEPTED MANUSCRIPT Acknowledgments: We would like to thank the following for their support and participation in this important patient safety initiative. Dr Rachel Boocock, former clinical governance manager; Mr Christopher Blauth, consultant cardiac surgeon and Clinical Lead for Adult cardiac surgery (Lead at onset of patient safety
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initiative); Mr James Roxburgh consultant cardiac surgeon and Clinical Lead for adult cardiac surgery; Mr Christopher Young, consultant cardiac surgeon and clinical governance lead for the cardiovascular services directorate;
Bronagh James & Helen Chan – Matrons for cardiovascular services; Lauren
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Gable, Head of Finance for Cardiovascular services; all staff within
cardiovascular services and perioperative medicine and last but not least all
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patients who had cardiac surgery during the reported period.
Conflict of interest statement WN is on the editorial board for the Journal of Hospital Infection. LC, NW, CM and GL have nothing to declare.
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Funding statement No funding was received. Author contribution
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LC, NW, WN conceived of the idea. LC coordinated data collection and analysis. CM and GL promoted multidisciplinary collaboration within cardiovascular services. All authors LC, NW, CM, GL and WN contributed to writing, reviewing and approving the final version of the paper.
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[17] Department of Health (DH) (2013) The NHS Outcomes Framework 2013/14. [Online] Available at: https://www.gov.uk [18] World Health Organisation (2016) Global guidelines for the prevention of surgical site infections. Available at: http://www.who.int/gpsc/global-guidelinesweb.pdf?ua=1. [19] Department of Health (2011) High Impact Intervention: Care bundle to prevent surgical site infection. [Online] Available at: http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Prevent-Surgical-Site-infectionFINAL.pdf [20] National Institute for Health and Clinical Excellence (2008). Surgical site infection: prevention and treatment of surgical site infection. Clinical Guideline 74. London [21] Public Health England (2013) Protocol for the Surveillance of Surgical Site Infection. Version 6. [Online] Available at: http://www.hpa.org.uk [22] Frenette, C. Sperlea, D. Tesolin, J. Patterson, C. Thirion, DJG. Influence of a 5-year serial infection control and antibiotic stewardship intervention on cardiac surgical site infections. Am J Infect Control 2016; 44 (9): 977-982 [23] Webster, J and Osbourne, S (2015) Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. The Cochrane database of systematic reviews 20(2): CD004985 [24] Wyncoll, D. Shankar-Hari M, Beale R (2011) Daily Bathing with 2% CHG Washcloths Leads to Almost Total Elimination of MRSA Bacteremia. Kings Health Partners conference Poster [25] Reiser, M. Scherag, A. Forstner, C. Brunkhorst, FM. Harbarth, S. Doens, T. et al. Effect of preoperative octenidine nasal ointment and showering on surgical site infections in patients undergoing cardiac surgery. J Hosp Infect 2017; 95(2): 137-143 [26] Durkin, MJ. Dicks, KV. Baker, AW. Seasonal Variation of Common Surgical Site infections: Does Season Matter? Infect Control Hosp Epidemiol 2015; 36 (9), 1011-6 [27] Graf, K. Sohr, D. Haverich, A. Kühn, C. Gastmeier, P. Chaberny IF. Decrease of deep sternal surgical site infection rates after cardiac surgery by a comprehensive infection control program. Interact Cardiovasc Thorac Surg 2009; 9: 282–286 [28] Birkmeyer, JD. Finks, JF. O’Reilly, A. Oerline M. Carlin, AM. Nunn, AR. et al. Surgical Skill and Complication Rates after Bariatric Surgery. N Engl J Med 2013; 369: 14341442 [29] Ashish, K. (2017) Public Reporting of Surgical Outcomes: Surgeons, Hospitals or Both. The JAMA Forum. Available at: https://newsatjama.jama.com/2017/08/24/jama-forum-public-reporting-of-surgicaloutcomes-surgeons-hospitals-or-both/ [30] Aggarwal, R. Intraoperative Surgical Performance Measurement and Outcomes. JAMA Surg. 2017; 152(11): 995-996 [31] Darouiche, RO. Wall, MJ. Itani, KMF. Otterson MF. Webb, AL. Carrick MM. et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362: 18-26 [32] Raja, S.G. Rochon, M. Mullins C, Morais C. Kourliouros, A. Wishart, E. et al. Impact of choice of skin preparation solution in cardiac surgery on rate of surgical site infection: a propensity score matched analysis. Journal of Infection Prevention 2017: 1-6
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[33] Madej, T. Plotze, K. Birkner, C. Jatzwauk, L. Kiaus, M. Waldow, T. Reducing mediastinitis after sternotomy with Combined Chlorhexidine-Isopropyl Alcohol Skin Disinfection: Analysis of 3,000 Patients. Surg Infect (Larchmt) 2016; 17(5): 552-6 [34] Raja, SG. Rochon M. Jarman, JWE. (2015) Brompton Harefield Infection Score (BHIS): Development and validation of a stratification tool for predicting risk of surgical site infection after coronary artery bypass grafting. Int J Surg. 2015; 16: 69-73 [35] Haas, JP. Evans, AM. Preston, KE. Larson, EL. Risk factors for surgical site infection after cardiac surgery: the role of endogenous flora. Heart Lung 2005; 34 (2): 108-14 [36] Schweizer, M. Perencevich, E. McDanel, J. Carson, J. Formanek, M. Hafner, J. et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. BMJ 2013; 346: f2743 [37] Si, D. Rajmokan, M. Lakhan, P. Marquess, J. Coulter, C. Paterson, D. (2014) Surgical site infections following coronary artery bypass graft procedures: 10 years of surveillance data. BMC Infect Dis 2014; 14: 318 [38] Nguyen, DB. Gupta, N. Abou-Daoud, A. KleKamp, BG. Rhone, C. Winston, T. et al. A polymicrobial outbreak of surgical site infections following cardiac surgery at a community hospital in Florida, 2011-2012. Am J Infect Control 2014; 42(4): 432-435 [39] National Institute for Health and Care Excellence (NICE) (2013) Surgical Site Infection: quality standard. [Online] Available at: http://www.nice.org.uk [40] Wojciechowski E, Pearsall T, Murphy P and French E. A case review; Integrating Lewin’s Theory with lean’s System Approach for change. Online J Issues Nurs 2016; 21(2):4 [41] Cove, ME. Spelman, DW. MacLaren, G. Infectious Complications of Cardiac Surgery: A Clinical Review. J of Cardiothoracic Vas Anaest 2012; 26(6): 1094 – 1100 [42] Izquierdo-Biasco, J. Campins-Marti, M. Soler-Palacin, P. Balcells, J. Abella, R. Gran, F. et al. Impact of implementation of an interdisciplinary infection control programme to prevent surgical wound infection in paediatric heart surgery. Eur J Paediatr 2015; 174(7): 957-63 [43] Sochet, AA. Cartron, AM. Nyhan A. Spaeder, MC. Song, X. Brown, AT. et al. Surgical Site Infection After Paediatric Cardiothoracic Surgery. World J Pediatr Congenital Heart Surg 2017; 8(1): 7-12 [44] Leaper DJ and Ousey K Evidence update on prevention of surgical site infection. Curr Opin Infect Dis. 2015; 28(2): 158-63 [45] Humphreys, H. Preventing surgical site infection. Where now? J Hosp Infect 2009; 73(4): 316–322 [46] Oliveira, A.C. Carvalho, D.V. Post discharge surveillance: the impact on surgical site infection incidence in a Brazilian university hospital. Am J Infect Control 2004; 32: 358-361 [47] Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 2015; 313(21): 2162-71
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Appendices
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Appendix 1: Cardiac SSI surveillance form
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ACCEPTED MANUSCRIPT This first page of the surveillance form is completed by operating room staff with
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compliance levels above 99%.
Note: Wound observations were completed by all staff responsible for wound care during inpatient episodes of care.
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Appendix 2: Surgical Site infection surveillance guidance for clinical staff
Note: This guidance was developed at the onset of the patient safety initiative to ensure SSI definitions were clear and to provide clarity on SSI surveillance expectations.
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Appendix 3: SSIS electronic wound observation data capture form
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Appendix 4: Locally developed care bundle
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Preoperative patient preparation 1. Preoperative skin decolonisation with 4% chlorhexidine washes on the night before surgery and 2% chlorhexidine gluconate (CHG) cloths on the day of surgery 2. Patient information leaflets on how to prepare the skin before surgery
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together with laminated instructions in patient bathrooms / showers 3. Use of electric clippers only where hair removal was indicated
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Intra-operative practices
1. Use of 2% Chlorhexidine gluconate in 70% Isopropyl Alcohol (ChloraPrep™) skin preparation prior to skin incisions
2. Adherence to administration of antibiotic prophylaxis within 1 hour prior to skin incision
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3. Use of masks by all staff in the operating room 4. De-cluttering of theatres and design of cleanliness checklists to be signed off by surgeons before procedures commenced 5. Segregation of scrub nurse trolleys for donor sites and sternal sites (only
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one used prior)
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6. Enhanced monitoring of theatre discipline Post-operative wound care and patient support 1. Adherence to asepsis principles for all wound care. All staff assessed for competency to asepsis principles 2. ‘No peek’ policy for all surgical wounds 3. Patient information leaflets for monitoring surgical wounds for infection 4. Standardisation of wound care protocols (dressings left in situ for 4 days unless there was a clinical indication to change sooner)
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Tables Table I: Univariate analysis of’ selected surgical site infection (SSI) risk factors for the surveillance period. 2009 – 2011 RR 95% CI
Significance (p-value)
Total number of procedures (% SSI, total number of SSIs)
RR
723 (4.6%, n=33) 2.5
1.7 -3.6
P<0.01
3128 (2.3%, n=73)
2012 – 2014 95% CI Significance (p-value)
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Diabetic (Oral, insulin, diet) Non – diabetic
Total number of procedures (% SSI, total number of SSIs) 780 (5.8%, n=45)
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Risk Factor
1.9
1.3-3.0
Total number of procedures (% SSI, total number of SSIs)
1566 (1%, n=15)
418 (3.1%, n=13)
291 (2.1%, n=6)
1.7
0.9-3.3
0.17
1264 (1.8%, n=23)
809 (0.7%, n=6)
Ex – smokers
1555 (3.6%, n=56)
947 (1.7%, n=16)
2282 (3.2%, n=74)
1467 (1.4%, n=20)
2787 (3.3%, n= 91)
*Mean age *Mean BMI
1134 (2.4%, n= 27)
66.8 (69) 28.7 (30.3)
1.4
0.9-2.1
0.17
1.7
1.03-2.9
952 (1.9%, n=18)
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Female
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Non – smokers
Male
65.3 (68.3) 28.6 (33.5)
2015 – 2016 95% CI Significance (p-value)
2.8
1.4-5.9
0.008
2.8
0.9-8.6
0.13
1
0.4-2.2
1
481 ( 2.7%, n=13)
0.002
2514 (2.3%, n=59)
Smokers
RR
0.05 578 (1.4%, n= 8)
64.7 (66.2) 28.8 (31.3)
*Data for age and BMI are presented as: mean for all patients (mean for infected patients)
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Table II: Surgical site infection (SSI) data by type of infection Superficial incisional infections
Deep / organ space infections
Annual Total SSIs / Total number of procedures
P-value (current period vs. previous period)
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Year
10
17
27/2368
0.001
2012 – 2014
46
34
80/3345
0.002
2009 – 2011
64
58
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2015 - 2016
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122/3239
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Table III: Surgical site infection causative microorganisms Causative microorganism grouping
Number of isolates (% of all isolates)
Gram-negative bacteria isolated individually, excluding Pseudomonas species Pseudomonas species
78 (39.2%)
Mixed growth including coliforms
29 (14.6%)
Staphylococcus species MRSA Fungi Other microorganisms
44 (22.1%) 4 (2%) 5 (2.5%) 8 (4%)
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31 (15.6%)
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Table IV: Conservative costs of surgical site infections (SSI) Patients readmitted to hospital due to SSI
Negative
theatre for
pressure
intervention
wound
Estimated
Superficial
Deep SSIs
costs
incisional SSIs
Number
Total
Number
Total
Number
Total
Episodes
Episodes
of SSIs
Length of
of SSIs
LOS
of SSIs
LOS
(£1008 per
(£335 per
episode)
episode)
therapy dressings
stay (LOS) (assuming
14
495 (198
4 out of
000)
24
134
4 out of
(£53600)
8
28
14 out of
467
31
51 + 1* deep
16 deep +
+2
3
superficial
superficial
(£53424)
(£6365)
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2017
55
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£400/day) 2009
59**
Total
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Year
Return to
3 out of 6
75
3 Deep + 1
3 deep + 1
superficial
superficial
(£4032)
(£1340)
£257789
£58976
*CT drainage of infected sternal collection
** One patient with superficial SSI stayed for 38 days (not a straightforward
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case, underlying comorbidities)
These data are based on information that was available at the time of follow up. It is acknowledged that data on superficial infections which possibly
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surveillance.
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deteriorated into deep infections may not have been captured during routine
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ACCEPTED MANUSCRIPT Figures Figure 1: Decreasing trends in surgical site infection incidence together with intervention points, January 2009 – December 2016
3. 4.
1. 2.
3.
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2.
Theatre/Ward/Recovery audit followed by decluttering, segregation of donor & sternal scrub trolleys & other generic changes to improve theatre discipline Standardisation of data collection & reporting + SSIS leadership (Consultant surgeon, Senior nursing leadership, clinical governance facilitator) Active campaigns to promote SSIS / rationale of patient safety initiative Asepsis competencies for clinical staff Monitoring surgical wounds for infection leaflets Standardisation of preoperative skin decolonisation 2% Chlorhexidine gluconate (Sage CHG) cloths & Chloraprep™ for 1 surgeon then all from 2012 Patient information leaflets for preoperative skin decolonisation
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1.
NICE SSI quality standard implementation & SSI detailed investigation protocol
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Active monthly/quarterly SSI data feedback at various clinical governance fora
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Figure 2: Distribution of surgical site infection (SSI) causative microorganisms by surveillance period
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Note: Microorganisms causing SSI that presented only after the active surveillance period may not have been included in these data.
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S0195-6701(18)30179-8
DOI:
10.1016/j.jhin.2018.03.028
Reference:
YJHIN 5388
To appear in:
Journal of Hospital Infection
Received Date: 7 March 2018 Accepted Date: 22 March 2018
Please cite this article as: Chiwera L, Wigglesworth N, McCoskery C, Lucchese G, Newsholme W, Demonstrating success in reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration, Journal of Hospital Infection (2018), doi: 10.1016/j.jhin.2018.03.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Demonstrating success in reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration Lilian Chiwera1, Neil Wigglesworth1, Carol McCoskery2, Gianluca Lucchese2, William Newsholme1 Directorate of Infection, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
2.
Cardiovascular Department, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
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1.
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Corresponding author: Lilian Chiwera
Floor 4, Block B, South Wing Lambeth Palace Road SE1 7EH
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Directorate of Infection, Guy’s & St Thomas’ NHS Foundation Trust
Running title
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Email: [email protected]
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Demonstrating success in reducing cardiac SSIs
Keyword
Surgical site infection, SSI, surveillance, cardiac, antimicrobial resistance, care bundles,
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ACCEPTED MANUSCRIPT Background Cardiac surgical site infections (SSIs) have devastating consequences and present several challenges for patients and healthcare providers. Adult cardiac SSI surveillance commenced in 2009 at our hospitals, Guy’s & St Thomas’ NHS Foundation Trust, London, as a patient safety initiative amid
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reported increased incidence of SSIs. Before this time, infection incidence was unclear because data collection was not standardised.
Aims
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Our aim was to standardise SSI data collection and establish baseline SSI
rates to facilitate deployment of evidence based targeted interventions within
with our organisational targets. Methods
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clinical governance structures to improve quality, safety and efficiency in line
We standardised local data collection protocols in line with Public Health England recommendations and identified local champions. We undertook
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prospective SSI surveillance collaboratively to enable us to identify potential practice concerns and address them more effectively through a series of initiatives. Clinical staff completed dedicated surveillance forms
Findings
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intraoperatively and post operatively.
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Overall adult cardiac SSI rates fell from 5.4% in 2009 to 1.2% in 2016 and Coronary Artery Bypass Graft (CABG) rates from 6.5% in 2009 to 1.7% in 2016, p<0.001. Gram negative bacteria were recognised as important SSI causative organisms and were better controlled after introducing stringent infection control measures.
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ACCEPTED MANUSCRIPT Conclusion We successfully implemented comprehensive, evidence-based infection control practices through a multidisciplinary collaborative approach; an approach we consider to have great potential to reduce Gram negative, Staphylococcus aureus, polymicrobial and overall SSI burden and/or
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associated costs. We now investigate all SSIs using an established SSI
detailed investigation protocol to promote continual quality improvement that
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aligns us perfectly with global efforts to fight antimicrobial resistance.
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ACCEPTED MANUSCRIPT Introduction Surgical Site Infections (SSIs) constitute about 16% of the overall burden of Healthcare Associated Infections (HCAI) in England [1] and can have negative consequences for patients and healthcare providers. In England, a cardiac SSI costs approximately £17 000 [2], whereas in the USA the additional cost
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of a mediastinitis was estimated to be $62,773 in 2009 [3]. A zero-tolerance approach to avoidable SSIs and getting it right the first time are some SSI reduction approaches which if correctly adopted can lead to significant reductions in SSI burden [4,5]. In his speech at the Infection control summit in
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2016, the Secretary of State for Health in England announced the appointment of the national infection control lead in light of increased focus
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and attention on infection prevention and control. He singled out an approach used for orthopaedics which was led by Briggs on the ‘Getting It Right First Time’ project as promising and with potential for significant cost savings and reduction in readmissions [5,6]. It can be argued that it’s becoming increasingly difficult to ignore the impact of SSIs in the current health climate [7] as National Health Service (NHS) organisations in England place
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increased focus on improved quality, safety and efficiency for healthcare in the 21st century [8,9].
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In recent years, infection control work in the UK has focused mainly on challenges posed by Meticilin-resistant Staphylococcus aureus (MRSA),
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Clostridium difficile, Carbapenem Resistant Organisms (CROs), Candida auris and most recently, bacteraemia caused by Gram-negative bacteria [10]. However, the aforementioned challenges, which may be attributed to inappropriate antibiotic usage and non-adherence to strict infection prevention and control principles, are not uncommon in surgical patients. Additionally, the emergency of multidrug-resistant organisms globally is very concerning. In Iran, at least 50% of identified nosocomial infections in open heart surgery patients were SSIs; with high resistance rates to common antibiotics being noted in Escherichia coli (23.3%), Klebsiella species (38.5%) and S. aureus
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ACCEPTED MANUSCRIPT (54.2%) [11]. Therefore, a more comprehensive infection control approach that incorporates SSI surveillance is desirable.
Despite SSI reduction success after mandating orthopaedic SSI surveillance in England in 2004 [12], it appears that the extent of morbidity associated with
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non-mandated procedures is not fully understood in most settings and yet this information is critical in directing quality improvement initiatives. Because of the potentially devastating consequences of an SSI, voluntary cardiac SSI surveillance is undertaken by some organisations in England but a lack of
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resources is attributed to poor uptake of robust SSI surveillance in most, which inevitably results in inconsistent data collection approaches and / application of SSI definitions and missed opportunities to improve patient
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outcomes [13]. Recently, researchers have shown an increased interest in SSIs, but reports suggest a lack of generalisability of SSI rates due to variable data collection approaches [14,15,16]. With the increased focus on more transparent healthcare services however, there is an urgent need to establish efficient SSI surveillance systems to reduce infection burden and promote
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quality improvement [17,18]. We therefore introduced PHE recommended prospective cardiac SSI surveillance in 2009 to enable us to accurately quantify the size and nature of our SSI problem to direct potential improvement initiatives. In this paper, we report the outcomes of our
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prospective SSI surveillance programme.
Methods
Our prospective adult cardiac SSI surveillance was coordinated by a surveillance team consisting of a team leader and two support workers; supported by an infection control consultant. Clinical staff completed paper surveillance forms (appendix 1) in line with local guidance (appendix 2); in 2014 we introduced electronic wound documentation (appendix 3). The SSI surveillance team leader reviewed and verified infections with attending physicians; additionally visits to clinical areas, review of available electronic
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ACCEPTED MANUSCRIPT and paper documentation to identify SSI evidence were undertaken. SSI data was fed back to clinical teams monthly and published on the Trust intranet.
Setting and sample We undertook SSI surveillance at Guy’s and St Thomas’ NHS Foundation
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Trust (GSTT), a large acute health care organisation in central London which has 2 acute hospital sites and over 1000 beds. We included over 8000 eligible patients who had cardiac surgery at one site from the 1st of January 2009 to
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the 31st of December 2016.
Ethics
This work was undertaken as part of the surgical site infection surveillance
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scheme in line with PHE recommendations as a service evaluation, hence no ethics approval was required. Patients’ privacy and dignity were maintained and all data was handled confidentially.
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Interventions
Using our surveillance data, we implemented a locally developed care bundle approach, (appendix 4) that was based on Department of Health High Impact Interventions (HII) [19] and the NICE clinical guideline [20]. A zero tolerance
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approach to all avoidable SSIs enabled us to review practice even when SSI incidence was comparable to that reported nationally. A summary of our
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interventions is presented in figure 1.
Data analysis
We used descriptive statistics to establish whether patient demographic data had changed for the duration of our evaluation by calculating the ratio of diabetic to non-diabetic patients; ratio of females to males; and ratio of smokers to ex-smokers. We subsequently undertook univariate analysis for these identified known SSI risk factors. We reported SSIs as superficial 6
ACCEPTED MANUSCRIPT incisional, deep incisional and organ space infections21 . We used the R-Gui statistical package to upload statistical graphs and to calculate p-values using Chi square with Yates correlation two tailed test; we considered a p value of < 0.05 to be statistically significant.
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Results There were no notable changes in patient demographics over the 8-year
period (Table 1). The ratio of female to males was 0.4; the ratio of diabetic to non-diabetic patients and smokers to ex-smokers was about 0.3; for the 3
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periods shown in Table I. Limited data were available for smoking status for the period 2009 – 2011. We excluded procedures with limited data in the
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demographic and risk factor data analysis.
Figure 1 highlights decreasing trends in SSI incidence together with intervention points; Table 2 presents SSI data by type of infection. Overall adult cardiac SSI rates decreased significantly from 5.4% (n=55) in 2009 to 1.2% (n=14) in 2016, p<0.001 and CABG rates from 6.5% (n=46) in 2009 to
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1.2% (n=8) in 2016, p<0.001. The number of deep / organ space infections also decreased significantly from 32 in 2009 to 7 in 2016, p<0.001. SSI causative microorganism data are presented in Table 3 and Figure 2.
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Estimating SSI costs
Table 4 presents estimated costs related to patients returning to operating rooms for further interventions, readmissions due to SSIs and negative
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pressure therapy dressing usage for infected patients. These are conservative costs which do not take into account extended length of stay due to SSI and other interventions including admission to critical care and related costs. Assuming that without SSI surveillance, SSI rates continued at the 2009 rates, estimated SSI costs would be approximately £2 320 000 with an estimated cost avoidance of £1 168 000 based on measuring the above conservative parameters only.
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ACCEPTED MANUSCRIPT Discussion We demonstrated significant reductions in SSI incidence between 2009 and 2016, delivering a rate that is significantly lower than PHE rates for CABG surgery of about 4%, p<0.001 [12]. We attribute this success to the correct implementation of an evidence based bundled care pathway which was
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supported by our strong SSIS leadership and the wider multidisciplinary teams [19,20]. We used evidence based comprehensive infection control practices (figure 1) which were similar to those adopted by Frenette [22] in Canada. These evidence based SSI prevention interventions as well as locally agreed
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approaches included the use of chlorhexidine (CHG) for preoperative skin decolonisation; use of 2% chlorhexidine in 70% alcohol (ChloraPrep™) prior to skin incisions and comprehensive patient information leaflets for
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preoperative skin preparation and post-operative wound care.
To date, benefits of using CHG for preoperative skin decolonisation over soap are not clearly defined [23,18]. This is therefore a subject of ongoing debate however we introduced 4% CHG washes as part of our care bundle approach
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with demonstrated SSI reductions. This decision was inspired by the success demonstrated in our local ICU setting where MRSA bacteraemia cases were significantly reduced following introduction of a care bundle that incorporated CHG wash cloths [24]. We noticed a significant difference in the overall SSI
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incidence between the second financial quarter in 2010, i.e. July – September, (5.6%) before CHG wipes were introduced together with CHG skin
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preparation intra-operatively for 1 surgeon and the fourth financial quarter in 2011 (1.2%), p=0.01. CABG rates decreased from 8.2% to 1% during the same period and for this reason we decided to continue with this practice rather than using octenisan which is now anecdotally reported to be used in various organisations. Interestingly, a study conducted in Germany reported no benefits to the overall SSI incidence when using octenidine for preoperative skin decolonisation, albeit harvest site and organ space infections decreased significantly [25]. Octenidine is nevertheless used in our organisation for MRSA decolonisation regimes.
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ACCEPTED MANUSCRIPT It is not clear if improvements after introducing CHG for preoperative skin decolonisation were a direct result of this intervention only, as several potential confounders may exist. Additionally SSI rates are reported to vary seasonally [26], which may explain increased SSI incidence from the first quarter of the next financial year, April – June 2011. However, we found the
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data intriguing since 2 surgeons had 2/3 of the SSIs for the next 3 quarters, suggesting a link between surgical technique and patients’ SSI outcomes. In fact Graf et al [27] highlight surgical technique as an important contributing factor to deep sternal SSIs. Birkmeyer et al [28] also argued that surgical
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technique can vary considerably between different surgeons and recommends peer reviews to improve surgical outcomes. Furthermore, Ashish et al [29] reported on potential large variations in surgeon outcomes from similar
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institutions and stresses on surgeons being ‘team leaders with a unique and outsized critical role’. Nevertheless, Aggarwal et al [30] recommended caution and suggested that appropriate tools should be utilised to measure surgical performance as this also depends on other intraoperative factors, complexity of surgery and volume of procedures undertaken. In view of this, we looked at
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surgical technique together with other potential contributory factors. However, surgeon role and engagement in SSI prevention work remained central and critical to ensure that evidence-based SSI prevention care bundles were embedded within patients’ surgical pathways. We found that having separate
discuss
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meetings with individual surgeons in a supportive non-punitive environment to surgical
technique
including
vein
harvesting,
causative
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microorganisms data and patient pathways during periods of increased Gramnegative deep SSIs actually improved engagement with them and the wider surgical teams. Furthermore, to support surgeons and reduce variation, in 2011 we also introduced ChloraPrep™ to standardise preoperative skin decolonisation [31,19]. This intervention is supported by current WHO SSI guidelines [18], although Raja et al [32] suggested that aqueous and alcoholbased skin preparations are equally as effective. Madej et al [33] in Germany produced results that favoured the use of chlorhexidine-isopropyl alcohol for skin disinfection to reduce mediastinitis after cardiac surgery. Our deep and organ space sternal SSIs decreased significantly from 32 in 2009 to 7 2016,
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ACCEPTED MANUSCRIPT an incredible outcome for us since these deep sternal SSIs significantly increase mortality by an estimated 15% -40% [27]. It is important to acknowledge that some surgical patients carry a higher SSI risk than others. For example diabetes and poor intra-operative blood glucose control are reported to increase SSI risk and should be monitored closely. Our
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results demonstrated that diabetic patients were at least twice as likely to
develop SSIs when compared with patients who were not diabetic, p<0.01, for the period 2009 – 2011, which was similar to that reported previously [34]. Smoking is also a known risk factor for SSIs [35]. Although smoking was
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found to increase SSI risk, [RR 1.7, 95% CI 1.03-2.90] for the 2012-2014
period, this was not found to be statistically significant (p>0.05) suggesting
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that correct adherence to evidence-based interventions does reduce SSI incidence for patients who present with underlying comorbidities. Interestingly, risk of SSI did not appear to change much once people had stopped smokingsmokers. Our data, however lacked detail on how long patients had been exsmokers for and could possibly have led to different conclusions if full information was available. Contrary to our findings, where female gender did
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not stand out as a significant risk for SSI, Raja et al [34] reported that females were at a significantly higher risk of developing SSI when compared to male counterparts and subsequently introduced specific interventions to address this. In fact, our results for the 2012 – 2014 period suggested that males were
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at a higher risk of getting SSIs compared to female patients but we acknowledge that potential confounders may exist. It may also be possible
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that interventions that were already in place ensured risks related to the female gender were already being addressed sufficiently. It is unclear however whether different patient demographics may have influenced our results or not but clearly identifying well documented risk factors and putting measures to control them may reduce SSI incidence. In addition to addressing patient risk factors, establishing local practices is an important component of any measures that seek to reduce SSI burden. Our initial infection control audits highlighted potential practice concerns at ward level, in operating rooms and recovery rooms as well as high incidence of 10
ACCEPTED MANUSCRIPT Gram -egative SSIs. We therefore immediately introduced separate donor and sternal scrub trolleys intraoperatively to reduce possible risk of cross contamination; prior to that, only one trolley was used. We felt this to be a timely intervention considering Gram-negative organisms caused at least 55% of the SSIs; followed by Staphylococcus spp. (22%) which suggested potential
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practice concerns with vein harvesting procedures or inadequate preoperative skin decolonisation. When Gram-negative isolates were combined with
polymicrobial isolates that included coliforms, this constituted about 75% of
the overall isolates. This trend continued throughout the surveillance period
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despite a decrease in the overall Gram-negative SSI burden, suggesting that measures that seek to reduce cardiac SSIs should also seek to target practices that are potentially linked with increased risk of infection of surgical
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sites with gram negative organisms. Schweizer et al [36] recommend mupirocin decolonisation of patients who are S. aureus carriers as well as adding a glycopeptide to the usual antibiotic prophylaxis regime to reduce incidence of S. aureus SSIs. Our standard antibiotic prophylaxis were gentamicin and teicoplanin, thus cover for sensitive and resistant S. aureus
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species was provided. Additionally, patients had blanket standardised preoperative skin decolonisation regimes with chlorhexidine. We perceived that the complexity linked with screening all patients and then decolonisation
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of positive patients could potentially be more costly and difficult to manage.
The level of MRSA isolates was very low at only 2%, which probably reflects stringent measures to drive down MRSA bacteraemia rates which were already in place in line with mandatory requirements in England. In comparison, in an Australian study [37] almost 15% of isolates were MRSA. Interestingly, after their review of 10 years CABG SSI data, they also identified Gram-negative bacteria as important causative organisms and advocated for cardiac surgeons to maintain constant dialogue with microbiologists to ensure adherence to the right antibiotic prophylaxis regimes. Polymicrobial SSIs constituted about 15% of the overall isolates. In the USA, Nguyen et al [38] 11
ACCEPTED MANUSCRIPT reported a polymicrobial outbreak of cardiac SSIs which they attributed to potential environmental concerns and possibly suboptimal infection control practices. In our experience, at the very onset of the patient safety initiative in 2009, an exercise of decluttering operating room environments and design of a cleanliness checklist to be signed off by surgeons before procedures was
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undertaken following reports of dust on equipment in operating rooms and presence of redundant equipment; the direct impact of these actions on SSI outcomes is debatable.
Patients are increasingly being discharged from hospitals early which implies
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that most wound care now occurs in the community. Patient empowerment is therefore a critical component of any efforts to reduce cardiac SSI incidence
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[35,27]. We produced leaflets and laminates for bathrooms with detailed instructions on how to prepare the skin prior to surgery to ensure patients were fully informed of preoperative SSI risk and how they could help to reduce it. Patients received verbal advice; additionally, we gave leaflets for monitoring surgical wounds for infection from PHE initially until we developed our own inhouse leaflets. This was an important intervention [39] as reports suggest a
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lack of knowledge among SSI patients [7].
Multidisciplinary collaboration Managing change can be a huge undertaking for large organisations and yet it is a critical component of any SSI surveillance programmes as resistance to change has been reported in various institutions. Effective change management models are therefore required for complex health care systems to support continual quality improvement [40]. Levin Kurt proposed a 3 step model; unfreezing, change and then refreezing stages that enable change leaders to plan, risk assess, execute and sustain required changes that are needed to mobilise the workforce with a clear rationale for proposed changes. 12
ACCEPTED MANUSCRIPT Traditional change models often highlight denial and resistance as initial starting points therefore a good exploration of reasons for displayed behaviours is critical to achieving full engagement. Our approach aimed to understand the pressures and challenges on staff working under often stressful busy conditions. Coincidentally, the Clinical Lead and the Head of
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Nursing welcomed our patient safety initiative which subsequently reduced the level of resistance. Involving our Chief Nursing Officer to disseminate SSIS newsletters in a focussed campaign on the SSI quality standard to provide
clarification on individual responsibilities to ensure the 7 quality statements
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were embedded within the organisation’s clinical governance structures [39] and the nurse led introduction of electronic documentation in 2014 led to a
marked decrease in superficial SSIs from 19 in 2014 to only 3 in 2015. We felt
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that involving senior management from conception of a project as key opinion leaders promoted greater engagement. Cove et al [41] highlight risk modification through multidisciplinary collaboration as a key component in the identification of numerous quality improvement opportunities for surgical patients. Frenette et al [22] also used a multidisciplinary approach that led to a
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66% reduction in infection rates in CABG procedures from 11.9% to 4%. Furthermore, Graf et al [27] suggested that surgeons participate fully in comprehensive infection prevention initiatives when they are aware of local baseline deep incisional SSI rates and associated risk factors. Our results and
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use of MDT corroborate with those from Spain, albeit in a paediatric cardiac surgery population where a significant reduction in SSI from 10.9% to 1.9%
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was reported [42]. The use of shoulder to shoulder working rather than top down management is also advocated as it has potential to increase staff morale and consequently improve patient outcomes [5].
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Economic impact of this evaluation Paediatric cardiac SSIs cost at least twice the amount of hospital costs when compared to non-infected patients due to increased length of stay in critical
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care units [43]. For our adult cases, we estimated an NHS cost avoidance of approximately a million pounds using conservative parameters only. Using
estimates of £17000 for a cardiac SSI [2], continuing at 2009 rates would have costed the NHS over £7 million but with reported reductions, SSI costs were
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estimated to be just over £4 million demonstrating a cost avoidance in excess
Significance of the findings
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of £3 million.
We demonstrated decreasing incidence of SSIs and associated costs, contrary to propositions that SSI rates are not declining [44]. The use of multidisciplinary collaboration, not only reduces the burden of data collection critical in financially constrained healthcare organisations but has clear
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benefits for surgical patients. Initial infection control audits and surveillance highlighted several potential practice concerns which were positively addressed; highlighting the part surveillance plays in quality improvement. Feeding back results in a timely and supportive manner facilitated open
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discussions on possible improvement initiatives [45]. The need for increased
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transparency in NHS organisations supports our patient safety initiative [17].
It is very clear from our experience that various factors and practices affect SSI related patient outcomes. To that end, Schweizer et al [46] used bundled interventions that included mupirocin nasal ointment and chlorhexidine for MRSA- and MSSA-positive patients, and chlorhexidine for skin decolonisation in negative patients and those of unknown status in a multicentre study done in the USA between 2013 and 2014; this intervention led to marginal reductions in S. aureus deep and organ space SSIs. Similarly, Frenette et al [22] highlighted that bundling infection control interventions can potentially half 14
ACCEPTED MANUSCRIPT SSI incidence. Current debates however question impact of interventions without an accurate measure of compliance to evidence-based care bundles. Future SSI prevention interventions should therefore ideally aim to address this in order to strengthen or dispute evidence that is already available. We demonstrated clear benefits for patients and would recommend other
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organisations to adopt our approach to achieve similar success.
Limitations
Our surveillance focused on collection of inpatient and readmission data.
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Oliveira and Carvalho [45] estimate rates could be under-reported by up to a factor of 5 if surveillance is limited to inpatient and readmission stages.
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Following multidisciplinary discussions, we decided not to pursue postdischarge surveillance; however a wound clinic is available where changes in SSI trends can be picked up to inform our future SSI surveillance direction.
Conclusion
We demonstrated sustained improvements in SSI incidence through
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prospective continuous SSI surveillance. Our findings strongly suggest that use of evidence based care bundled interventions, effective feedback of SSI data to clinical teams, identification of local champions and adoption of a multidisciplinary collaborative approach can effectively reduce cardiac surgery
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SSI burden. We not only managed to successfully implement and sustain an important, cost effective patient safety initiative through multidisciplinary
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collaboration, but also reduced Gram negative, S. aureus and polymicrobial SSI challenges thereby improving the quality of cardiac surgical care provision.
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ACCEPTED MANUSCRIPT Acknowledgments: We would like to thank the following for their support and participation in this important patient safety initiative. Dr Rachel Boocock, former clinical governance manager; Mr Christopher Blauth, consultant cardiac surgeon and Clinical Lead for Adult cardiac surgery (Lead at onset of patient safety
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initiative); Mr James Roxburgh consultant cardiac surgeon and Clinical Lead for adult cardiac surgery; Mr Christopher Young, consultant cardiac surgeon and clinical governance lead for the cardiovascular services directorate;
Bronagh James & Helen Chan – Matrons for cardiovascular services; Lauren
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Gable, Head of Finance for Cardiovascular services; all staff within
cardiovascular services and perioperative medicine and last but not least all
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patients who had cardiac surgery during the reported period.
Conflict of interest statement WN is on the editorial board for the Journal of Hospital Infection. LC, NW, CM and GL have nothing to declare.
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Funding statement No funding was received. Author contribution
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LC, NW, WN conceived of the idea. LC coordinated data collection and analysis. CM and GL promoted multidisciplinary collaboration within cardiovascular services. All authors LC, NW, CM, GL and WN contributed to writing, reviewing and approving the final version of the paper.
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References
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[1] Health Protection Agency (2012) English National Point Prevalence Survey on Healthcare Associated Infections and Antimicrobial Use, 2011: Preliminary data. Health Protection Agency: London [2] Jenks, PI. Laurent, M. McQuarry, S. Watkins, R. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect 2014; 86(1): 22-23 [3] Speir, AM Kasirajan, V. Barnett, SD. Fonner E. Additive costs of postoperative complications for isolated coronary artery bypass grafting patients in Virginia. Ann Thorac Surg 2009; 88: 40–45 [4] Adams-Howell, P. Moninder, B. Enright, M. Kiernan, M. Kolvekar S and Trueman P. Surgical site infection: the call for a zero tolerance approach in prevention. The Biomedical Scientist 2011; 639 [5] Briggs T (2012) Getting It Right First Time. British Orthopaedics Association. Available at http://www.boa.ac.uk/pro-practice/getting-it-right-first-time/. [6] Roberts, M. (2010) Hospitals to face financial penalties for readmissions. BBC News Health reporter. p. 8 [7] Tanner, J. Padley, W. Davey, S. Murphy, K. Brown, B. Patients’ experiences of surgical site infection. J Hosp Infect 2012; 13(5): 164-168 [8] National Health Service (NHS) England (2013). High quality care for all, now and for future generations. [Online] Available at: http://www.england.nhs.uk [9] NHS Commissioning Board (2013) Commissioning for quality and innovation (CQUIN): 2013/14 guidance. [Online] Available at: http://www.england.nhs.uk [10] NHS improvement (2017) Preventing healthcare associated Gram-negative bacterial bloodstream infections - an improvement resource Available at: https://improvement.nhs.uk/resources/preventing-gram-negative-bloodstreaminfections/ [11]Heydarpour, F. Rahmani, Y. Heydarpour, B. and Asadmobini A. Nosocomial infections and antibiotic resistance pattern in open heart surgery patients at Imam Ali Hospital in Kermanshah, Iran. GMS Hyg Infec Control 2017; 24:12 [12] Public Health England (2015) Surveillance of surgical site infections in NHS hospitals in England 2014/2015. [Online] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/5 77418/Surgical_site_infections_NHS_hospitals_2015_to_2016.pdf [13] Joan, N. and Hebden, RN. Rationale for accuracy and consistency in applying standardized definitions for surveillance of health care-associated infections. Am J Infect Control 2012; 40: S29-S31 [14] Leaper, D. Tanner, J. Kiernan, M. Surveillance of surgical site infection: more accurate definitions and intensive recording needed. J Hosp Infect 2013; 83(2): 83-6. [15] Tanner, J. Padley, W. Kiernan, MA. Leaper, DJ. Norrie, P. and Baggott, R. A benchmark too far: findings from a national survey of surgical site infection surveillance. J Hosp Infect 2013; 83: 87–91 [16] Wilson, J. Surgical Site Infection: the principles and practice of surveillance. Part 1: Key concepts in the methodology of SSI surveillance. J Hosp Infect 2013; 14: 6–12
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[17] Department of Health (DH) (2013) The NHS Outcomes Framework 2013/14. [Online] Available at: https://www.gov.uk [18] World Health Organisation (2016) Global guidelines for the prevention of surgical site infections. Available at: http://www.who.int/gpsc/global-guidelinesweb.pdf?ua=1. [19] Department of Health (2011) High Impact Intervention: Care bundle to prevent surgical site infection. [Online] Available at: http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Prevent-Surgical-Site-infectionFINAL.pdf [20] National Institute for Health and Clinical Excellence (2008). Surgical site infection: prevention and treatment of surgical site infection. Clinical Guideline 74. London [21] Public Health England (2013) Protocol for the Surveillance of Surgical Site Infection. Version 6. [Online] Available at: http://www.hpa.org.uk [22] Frenette, C. Sperlea, D. Tesolin, J. Patterson, C. Thirion, DJG. Influence of a 5-year serial infection control and antibiotic stewardship intervention on cardiac surgical site infections. Am J Infect Control 2016; 44 (9): 977-982 [23] Webster, J and Osbourne, S (2015) Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. The Cochrane database of systematic reviews 20(2): CD004985 [24] Wyncoll, D. Shankar-Hari M, Beale R (2011) Daily Bathing with 2% CHG Washcloths Leads to Almost Total Elimination of MRSA Bacteremia. Kings Health Partners conference Poster [25] Reiser, M. Scherag, A. Forstner, C. Brunkhorst, FM. Harbarth, S. Doens, T. et al. Effect of preoperative octenidine nasal ointment and showering on surgical site infections in patients undergoing cardiac surgery. J Hosp Infect 2017; 95(2): 137-143 [26] Durkin, MJ. Dicks, KV. Baker, AW. Seasonal Variation of Common Surgical Site infections: Does Season Matter? Infect Control Hosp Epidemiol 2015; 36 (9), 1011-6 [27] Graf, K. Sohr, D. Haverich, A. Kühn, C. Gastmeier, P. Chaberny IF. Decrease of deep sternal surgical site infection rates after cardiac surgery by a comprehensive infection control program. Interact Cardiovasc Thorac Surg 2009; 9: 282–286 [28] Birkmeyer, JD. Finks, JF. O’Reilly, A. Oerline M. Carlin, AM. Nunn, AR. et al. Surgical Skill and Complication Rates after Bariatric Surgery. N Engl J Med 2013; 369: 14341442 [29] Ashish, K. (2017) Public Reporting of Surgical Outcomes: Surgeons, Hospitals or Both. The JAMA Forum. Available at: https://newsatjama.jama.com/2017/08/24/jama-forum-public-reporting-of-surgicaloutcomes-surgeons-hospitals-or-both/ [30] Aggarwal, R. Intraoperative Surgical Performance Measurement and Outcomes. JAMA Surg. 2017; 152(11): 995-996 [31] Darouiche, RO. Wall, MJ. Itani, KMF. Otterson MF. Webb, AL. Carrick MM. et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362: 18-26 [32] Raja, S.G. Rochon, M. Mullins C, Morais C. Kourliouros, A. Wishart, E. et al. Impact of choice of skin preparation solution in cardiac surgery on rate of surgical site infection: a propensity score matched analysis. Journal of Infection Prevention 2017: 1-6
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[33] Madej, T. Plotze, K. Birkner, C. Jatzwauk, L. Kiaus, M. Waldow, T. Reducing mediastinitis after sternotomy with Combined Chlorhexidine-Isopropyl Alcohol Skin Disinfection: Analysis of 3,000 Patients. Surg Infect (Larchmt) 2016; 17(5): 552-6 [34] Raja, SG. Rochon M. Jarman, JWE. (2015) Brompton Harefield Infection Score (BHIS): Development and validation of a stratification tool for predicting risk of surgical site infection after coronary artery bypass grafting. Int J Surg. 2015; 16: 69-73 [35] Haas, JP. Evans, AM. Preston, KE. Larson, EL. Risk factors for surgical site infection after cardiac surgery: the role of endogenous flora. Heart Lung 2005; 34 (2): 108-14 [36] Schweizer, M. Perencevich, E. McDanel, J. Carson, J. Formanek, M. Hafner, J. et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. BMJ 2013; 346: f2743 [37] Si, D. Rajmokan, M. Lakhan, P. Marquess, J. Coulter, C. Paterson, D. (2014) Surgical site infections following coronary artery bypass graft procedures: 10 years of surveillance data. BMC Infect Dis 2014; 14: 318 [38] Nguyen, DB. Gupta, N. Abou-Daoud, A. KleKamp, BG. Rhone, C. Winston, T. et al. A polymicrobial outbreak of surgical site infections following cardiac surgery at a community hospital in Florida, 2011-2012. Am J Infect Control 2014; 42(4): 432-435 [39] National Institute for Health and Care Excellence (NICE) (2013) Surgical Site Infection: quality standard. [Online] Available at: http://www.nice.org.uk [40] Wojciechowski E, Pearsall T, Murphy P and French E. A case review; Integrating Lewin’s Theory with lean’s System Approach for change. Online J Issues Nurs 2016; 21(2):4 [41] Cove, ME. Spelman, DW. MacLaren, G. Infectious Complications of Cardiac Surgery: A Clinical Review. J of Cardiothoracic Vas Anaest 2012; 26(6): 1094 – 1100 [42] Izquierdo-Biasco, J. Campins-Marti, M. Soler-Palacin, P. Balcells, J. Abella, R. Gran, F. et al. Impact of implementation of an interdisciplinary infection control programme to prevent surgical wound infection in paediatric heart surgery. Eur J Paediatr 2015; 174(7): 957-63 [43] Sochet, AA. Cartron, AM. Nyhan A. Spaeder, MC. Song, X. Brown, AT. et al. Surgical Site Infection After Paediatric Cardiothoracic Surgery. World J Pediatr Congenital Heart Surg 2017; 8(1): 7-12 [44] Leaper DJ and Ousey K Evidence update on prevention of surgical site infection. Curr Opin Infect Dis. 2015; 28(2): 158-63 [45] Humphreys, H. Preventing surgical site infection. Where now? J Hosp Infect 2009; 73(4): 316–322 [46] Oliveira, A.C. Carvalho, D.V. Post discharge surveillance: the impact on surgical site infection incidence in a Brazilian university hospital. Am J Infect Control 2004; 32: 358-361 [47] Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 2015; 313(21): 2162-71
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Appendices
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Appendix 1: Cardiac SSI surveillance form
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ACCEPTED MANUSCRIPT This first page of the surveillance form is completed by operating room staff with
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compliance levels above 99%.
Note: Wound observations were completed by all staff responsible for wound care during inpatient episodes of care.
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Appendix 2: Surgical Site infection surveillance guidance for clinical staff
Note: This guidance was developed at the onset of the patient safety initiative to ensure SSI definitions were clear and to provide clarity on SSI surveillance expectations.
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Appendix 3: SSIS electronic wound observation data capture form
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Appendix 4: Locally developed care bundle
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Preoperative patient preparation 1. Preoperative skin decolonisation with 4% chlorhexidine washes on the night before surgery and 2% chlorhexidine gluconate (CHG) cloths on the day of surgery 2. Patient information leaflets on how to prepare the skin before surgery
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together with laminated instructions in patient bathrooms / showers 3. Use of electric clippers only where hair removal was indicated
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Intra-operative practices
1. Use of 2% Chlorhexidine gluconate in 70% Isopropyl Alcohol (ChloraPrep™) skin preparation prior to skin incisions
2. Adherence to administration of antibiotic prophylaxis within 1 hour prior to skin incision
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3. Use of masks by all staff in the operating room 4. De-cluttering of theatres and design of cleanliness checklists to be signed off by surgeons before procedures commenced 5. Segregation of scrub nurse trolleys for donor sites and sternal sites (only
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one used prior)
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6. Enhanced monitoring of theatre discipline Post-operative wound care and patient support 1. Adherence to asepsis principles for all wound care. All staff assessed for competency to asepsis principles 2. ‘No peek’ policy for all surgical wounds 3. Patient information leaflets for monitoring surgical wounds for infection 4. Standardisation of wound care protocols (dressings left in situ for 4 days unless there was a clinical indication to change sooner)
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Tables Table I: Univariate analysis of’ selected surgical site infection (SSI) risk factors for the surveillance period. 2009 – 2011 RR 95% CI
Significance (p-value)
Total number of procedures (% SSI, total number of SSIs)
RR
723 (4.6%, n=33) 2.5
1.7 -3.6
P<0.01
3128 (2.3%, n=73)
2012 – 2014 95% CI Significance (p-value)
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Diabetic (Oral, insulin, diet) Non – diabetic
Total number of procedures (% SSI, total number of SSIs) 780 (5.8%, n=45)
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Risk Factor
1.9
1.3-3.0
Total number of procedures (% SSI, total number of SSIs)
1566 (1%, n=15)
418 (3.1%, n=13)
291 (2.1%, n=6)
1.7
0.9-3.3
0.17
1264 (1.8%, n=23)
809 (0.7%, n=6)
Ex – smokers
1555 (3.6%, n=56)
947 (1.7%, n=16)
2282 (3.2%, n=74)
1467 (1.4%, n=20)
2787 (3.3%, n= 91)
*Mean age *Mean BMI
1134 (2.4%, n= 27)
66.8 (69) 28.7 (30.3)
1.4
0.9-2.1
0.17
1.7
1.03-2.9
952 (1.9%, n=18)
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Female
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Non – smokers
Male
65.3 (68.3) 28.6 (33.5)
2015 – 2016 95% CI Significance (p-value)
2.8
1.4-5.9
0.008
2.8
0.9-8.6
0.13
1
0.4-2.2
1
481 ( 2.7%, n=13)
0.002
2514 (2.3%, n=59)
Smokers
RR
0.05 578 (1.4%, n= 8)
64.7 (66.2) 28.8 (31.3)
*Data for age and BMI are presented as: mean for all patients (mean for infected patients)
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Table II: Surgical site infection (SSI) data by type of infection Superficial incisional infections
Deep / organ space infections
Annual Total SSIs / Total number of procedures
P-value (current period vs. previous period)
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Year
10
17
27/2368
0.001
2012 – 2014
46
34
80/3345
0.002
2009 – 2011
64
58
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2015 - 2016
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122/3239
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Table III: Surgical site infection causative microorganisms Causative microorganism grouping
Number of isolates (% of all isolates)
Gram-negative bacteria isolated individually, excluding Pseudomonas species Pseudomonas species
78 (39.2%)
Mixed growth including coliforms
29 (14.6%)
Staphylococcus species MRSA Fungi Other microorganisms
44 (22.1%) 4 (2%) 5 (2.5%) 8 (4%)
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31 (15.6%)
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Table IV: Conservative costs of surgical site infections (SSI) Patients readmitted to hospital due to SSI
Negative
theatre for
pressure
intervention
wound
Estimated
Superficial
Deep SSIs
costs
incisional SSIs
Number
Total
Number
Total
Number
Total
Episodes
Episodes
of SSIs
Length of
of SSIs
LOS
of SSIs
LOS
(£1008 per
(£335 per
episode)
episode)
therapy dressings
stay (LOS) (assuming
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495 (198
4 out of
000)
24
134
4 out of
(£53600)
8
28
14 out of
467
31
51 + 1* deep
16 deep +
+2
3
superficial
superficial
(£53424)
(£6365)
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2017
55
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£400/day) 2009
59**
Total
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Year
Return to
3 out of 6
75
3 Deep + 1
3 deep + 1
superficial
superficial
(£4032)
(£1340)
£257789
£58976
*CT drainage of infected sternal collection
** One patient with superficial SSI stayed for 38 days (not a straightforward
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case, underlying comorbidities)
These data are based on information that was available at the time of follow up. It is acknowledged that data on superficial infections which possibly
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deteriorated into deep infections may not have been captured during routine
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3. 4.
1. 2.
3.
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2.
Theatre/Ward/Recovery audit followed by decluttering, segregation of donor & sternal scrub trolleys & other generic changes to improve theatre discipline Standardisation of data collection & reporting + SSIS leadership (Consultant surgeon, Senior nursing leadership, clinical governance facilitator) Active campaigns to promote SSIS / rationale of patient safety initiative Asepsis competencies for clinical staff Monitoring surgical wounds for infection leaflets Standardisation of preoperative skin decolonisation 2% Chlorhexidine gluconate (Sage CHG) cloths & Chloraprep™ for 1 surgeon then all from 2012 Patient information leaflets for preoperative skin decolonisation
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NICE SSI quality standard implementation & SSI detailed investigation protocol
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Active monthly/quarterly SSI data feedback at various clinical governance fora
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Figure 2: Distribution of surgical site infection (SSI) causative microorganisms by surveillance period
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Note: Microorganisms causing SSI that presented only after the active surveillance period may not have been included in these data.
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