Wound management: Why good healing is good business

Most surgeons are vigilant about not leaving anything behind after they have finished operating. Not so in orthopaedics. The vast majority of procedures involve inserting some kind of artificial structure, whether an entirely new joint or simply screw, pin and plate to fix a fracture.

It’s a reality that means few specialties offer a better illustration of the potential financial and patient cost of wound infection.

“Ninety per cent of what we do involves leaving something behind,” explains Simon Pickering, consultant orthopaedic surgeon and clinical director of orthopaedics at Derby Teaching Hospitals Foundation Trust. “And the trouble when you have foreign objects in the body is that they’re very easy to colonise [meaning bacteria grow on them]. Once they become colonised, they can become infected and that infection can be very difficult to treat.

“So if you have a wound that’s allowed to become infected because it’s not been looked after properly, that can put in chain events that result in a disastrous outcome for the patient – it can mean ultimately their new knee joint, for instance, gets infected and that may mean having to have it taken out.”

If you avoid one deep infection, the benefits – economically and for patients as well – are huge

Pragash Wesley David, an advanced nurse practitioner in elective orthopaedic surgery at Gloucestershire Hospitals Foundation Trust, knows just how unpleasant that outcome can be.

“At our trust, we do a two stage revision if the implant is infected: first stage, remove the implant, and second put an implant back in after a couple of months,” he says. “In that time, the majority of patients can’t walk so they stay in bed and are at risk of more medical problems.”

The impact of seeing patients have that experience is such that Mr David has a target of zero infection in elective orthopaedics at his trust. “My goal is to not have anybody go through that situation. It may not be possible, but it’s what I’m trying to see.”

Reaching such a goal wouldn’t only mean better patient outcomes, it would also lead to significant financial savings for the healthcare system. “There’s no accurate figure for the cost of a revision procedure, but it’s likely several times the cost of a first procedure,” reports Mr Pickering.

“If you have to have multiple operations to take out someone’s artificial joint, and then put something back in, the cost runs to thousands and thousands of pounds. So if you avoid one deep infection, the benefits – economically and for patients as well – are huge.”

Securing those savings – which may be particularly obvious in orthopaedics, but which apply across all surgical specialties – often involves exploring new protocols. Using a new type of wound dressing, for example, might lead to faster healing or reduced risk of infection. The challenge? Such innovations might be more expensive than the products currently being used.

Difficult tightrope

In his role as clinical director of orthopaedics, Mr Pickering is well aware that “spend to save” can be a challenging proposition for budget holders.

“Of course part of the clinical director role is looking at the cost of things. But the other part is ensuring quality and safe practice and best practice is carried out. And that’s a very difficult tightrope sometimes, because innovation costs money. But if the innovation is going to generally have a good impact, it’s [about] trying to make that argument as to why you should spend a bit more on something.”

A key obstacle is giving budget holders evidence that they will see the “save” part after they’ve spent

For Mr David, it’s all about ensuring a full understanding of costs. He cites the example of negative pressure dressings, which he uses for patients at high risk of wound infection.

“I used the dressing for a patient last week, and she’s going home today. The dressing costs £150. If I hadn’t put that dressing on, she would have stayed [in hospital] for at least two or three more days. Even if she stayed for one more day, that would cost the trust around £400 [for] a bed. And it’s not just the £400 – for me, it’s all about getting the next patient into that bed [so ensuring good patient flow through the system].

“A lot of people just think about the dressing costing £150. But if a patient [on whom we use the dressing] even goes home one day early, that gives back the money.”

According to Mr Pickering, a key obstacle is giving budget holders evidence that they will see the “save” part after they’ve spent. “If I wanted to try to prove a new drug prevents a stroke, or helps with angina, then there are tens of thousands of people in the region who I can recruit into the study, and very quickly you’ll have an outcome,” he says.

“Nobody’s ever going to have tens and thousands of people with an infected joint replacement to do a study. So the challenge is trying to make a case as to why you should try something different that might cost a little bit more money, and justify it. Because it’s a very easy retort for anybody who is holding a budget to say: ‘Show me the evidence’.”

He suggests the way to overcome this is, essentially, to build a business case. “The way that you have that conversation is very much framing it as: ‘We’ve identified we have a problem, the size of the problem is this, if we were to reduce that by this percentage, this is how much money it would save.’ The business case must include close evaluation of the change in practice, so very good audit is essential.”

A powerful reason

Mr Pickering feels arguing for the use of new products in wound care may actually be easier than in some other spheres.

“Wound care is very much multidisciplinary, so nursing staff are aware of oozy, difficult wounds when they’re changing dressings several times a week, and the outreach teams are having to see people repeatedly. So I think everybody feels it’s a better situation if you have a dressing that you leave undisturbed for five days, for instance.

“When it’s just one [professional] group saying we need to do this, it’s difficult; when other groups are all saying the same thing, then it makes it a very powerful reason to change, which influences opinion.”

He adds: “And of course if negative pressure dressings were widely accepted in orthopaedics as a good thing to do with difficult wounds, there would be an argument to use it elsewhere.”