Recent improvements in infection control of prominent hospital-acquired diseases can be supported with a zero tolerance battle against surgical site infections, say Paul Trueman and Phil Adams-Howell.

The NHS has made great improvements in infection control in recent years, largely as a result of initiatives to address common hospital-acquired infections such as C difficile and MRSA. While improved infection control is to be welcomed, the focus on C difficile and MRSA has resulted in other common causes of hospital-acquired infections receiving less attention.

Surgical site infections are estimated to account for 15 per cent of all hospital-acquired infections and are believed to affect around 5 per cent of all patients undergoing a surgical procedure. The rates differ according to the nature of the surgery, with vascular surgery, gastric surgery and amputation being associated with above average rates of infection.

Monitoring of surgical site infections is complicated; while many occur during hospitalisation, the majority manifest only after discharge, a phenomenon that has increased as hospitals have sought to reduce the length of inpatient stays. In these instances, the infection is often managed in primary care and is only recognised by the host institution if the patient is readmitted and these cases are typically not captured in monitoring/surveillance studies.

Surgical site infections represent a sizeable financial burden to the NHS. Recent estimates suggest that patients who experience a surgical site infection have an extended length of stay of between seven and 10 days.

A recent study suggested the cost to the NHS surgical site infections is around £700m a year based on an estimated cost per infection of £3,500. Such sums of money need to be taken seriously, particularly when many surgical site infections are avoidable through modest changes to practice.

However, recent announcements from the Department of Health have brought surgical site infections to the fore. In 2010 the health secretary announced that the costs of readmissions to hospital within 30 days of discharge would be the responsibility of the hospital rather than primary care payers.

The intention is that hospitals will be incentivised to improve the discharge status of patients, particularly those having undergone surgery, and ensure that unnecessary readmissions are avoided. 

While this introduces a financial mechanism for improving the performance of infection control, the devil is, of course, in the detail. Providing definitive proof that a post-surgical infection was acquired during the initial hospital stay, rather than after discharge, is near impossible and it is likely attempts to withhold payment for readmissions in such instances will be challenged.

However, a number of trusts have shown that it is possible to achieve significant improvements in infection rates by adopting a zero-tolerance approach to infections.

Case Study: University College London Hospitals

Since 2000 University College London Hospitals Foundation Trust has initiated projects with the aim of reducing surgical site infections across the trust. Driven by the director of infection control and prevention, the trust began by attempting to change attitudes in the organisation. It did this initially by ensuring that senior management, including the chief executive and chief nurse, were seen to endorse initiatives to reduce infection rates and promulgate a culture where infection control remained high on the trust agenda.

Furthermore, the holding to account of divisional/general managers, medical directors and departmental sisters/charge nurses was integral to the adoption of best practice and a culture where infection avoidance was of paramount importance.

On a practical level, an SSI prevention bundle was implemented, procedure packs were developed, and new products including catheter securing devices, pre-operative skin antiseptics, advanced dressings and needle-free access devices were introduced.

The SSI prevention bundle includes information for patients on recognising infection and wound care and screening for MRSA. Shaving before surgery has stopped, antibiotic prophylaxis is administered and a 2 per cent chlorhexidine skin prep used. Warming blankets are used to maintain patient temperatures and closure methods chosen that optimise healing and minimise further tissue damage. Blood glucose levels are closely controlled. A rigorous process of observation and documentation of wounds takes place post-operatively.

The results show a dramatic, 10-fold reduction in all bacteraemias since 2000 (see graph, top).

While such initiatives involve a significant time investment from staff, the levels of financial expenditure on infection control products are relatively modest. Indeed, in many cases the levels of expenditure compare favourably with other routine infection control measures.

For example, while so-called “deep-cleans” have caught the attention of the media and politicians, evidence of their clinical and cost effectiveness remains highly equivocal, and arguably, the resources put into these initiatives might have been better used to address other sources of hospital acquired infection. While the media has focused attention on C difficile and MRSA, the evidence suggests that infection control resources might have been put to more efficient use in other ways.  

Balancing the pressures of financial constraints with the need to promote patient safety demands better evidence on the relative cost effectiveness of infection control measures to ensure that scarce resources are allocated appropriately.

As financial pressures bite, identifying preventable expenditure is a priority for managers. The example of UCLH shows that cultural change coupled with a modest investment has the potential to significantly reduce infections and the associated costs. Unlike many “spend to save” investments, where immediate capital outlays are often justified on the basis of returns that may occur in a generation, investment in better infection control has the potential to lead to significant savings in the short term while also improving the patient experience.

As the quality, innovation, productivity and prevention programme promotes “doing more for less” and finance managers are looking for disinvestment opportunities, a zero-tolerance approach to surgical site infections can contribute to a variety of targets.

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