Roundtable: Cutting the rate of surgical site wound infections

Thanks to medical advances, more patients with co-morbidities who are at greater risk of surgical site infections (SSIs) are now being considered for surgery.

The National Institute for Health and Care Excellence (NICE) has estimated that at least 5 per cent of patients develop a wound infection after surgery, which can have a huge impact on quality of life. SSIs can also double the length of post-operative hospital stay and cost between £2,100 and £10,500 per infection.

In early July, an HSJ and Nursing Times roundtable – held at the Patient Safety Congress, and run in association with Smith & Nephew – brought together a group of experts to explore how to improve patient safety post-operatively, and so reduce the human and financial costs of complications.

Financial costs

Chair Jenni Middleton, editor of Nursing Times, asked the group to reflect on a deputy chief nurse’s recent comment that finance was the one thing bound to switch staff off. Is focusing on the business case the wrong approach when it comes to improving post-operative care?

Frontline staff are, in fact, hugely motivated by the opportunity to save money at the same time as improving care, said Sue Smith, Morecambe Bay FT’s executive chief nurse.

“It really motivates the frontline staff to understand that not only are they making things better for patients, their job satisfaction is improving – and actually they’re saving the public purse as well,” she said. But she emphasised that the focus needed to be on the potential improvements to patient care, rather than the savings.

Rebecca Kenny, patient safety lead at University Hospitals of Leicester Trust, agreed that staff want to help the NHS to save money, adding that clinicians also require “a premise about quality first, because that’s what we all had at heart when we went into the jobs we’re doing”.

Several group members noted the need to appoint named individuals who could rally teams and ensure everyone remained fully engaged in patient safety programmes. Lilian Chiwera, infection control surveillance team leader at Guy’s & St Thomas’ FT, said a group of “local champions” played a central part in reducing adult cardiac SSIs at her trust.

The champions were responsible for putting forward ideas and driving changes in their own areas. She said: “We took our time and of course we needed to invest money for some of the initiatives we introduced, but last year we only had seven infections.” This is down from 55 in 2009, leading to estimated savings of over £700,000.

You need that focus to carry on. If you don’t, old habits come back

Nigel Richardson, clinical director of surgery at Mid Essex Hospitals Trust, credited a clinical nurse specialist with bringing the trust’s colorectal wound infections down to below the national average, and saving £330,000 as a result.

“She ensures the attention to detail,” he said, adding: “You need that focus to carry on. If you don’t, old habits come back. I’m sure SSI will prove to be exactly the same thing. It’s permanent education – encouraging, measuring, re-learning.”

Any member of staff – not necessarily a CNS – could take on the leadership role, “and they’re key to the success of any of this type of improvement programmes”, he argued.

It is vital for whole teams to get behind any patient safety programmes, Ms Kenny stressed. She recalled a recent incident at her own trust where a patient had developed a “horrific pressure ulcer”. Despite having regular medical reviews, “not one person apart from the nursing team at the time commented on [it]”, she said. The need for collective ownership of improvement programmes is just as important for SSIs, she said.

However, many in the group had come across senior team members who appeared highly resistant to change and behaved defensively when asked to adapt their practice. Mr Richardson recalled an “extraordinarily offensive email” from an anaesthetist in charge of a case involving a patient with a wound infection, after it was simply suggested that the patient’s temperature was a little low on entering theatre.

Policing poor behaviour

Tony Kelly – director of Kent Surrey Sussex (KSS) Patient Safety Collaborative and consultant obstetrician and gynaecologist at Brighton and Sussex University Hospitals Trust – spoke of a never event at his trust in which a consultant surgeon refused to participate in the pre-surgery safety check. The surgeon then carried out an operation on the wrong side of the patient’s body.

Dr Kelly said: “My concern is sometimes that we tolerate that. The life of most medical directors I know is just filled with trying to police poor behaviour, which is a real pity because so much of the strategy work just goes out the window.”

Building on enhanced recovery programmes can be a way of rolling out changes without too much disruption, suggested Dr Kelly. “Once everyone’s up to adherence, that’s when you widen out the spectrum of measures you use,” he said.

Seeing variation means we do have an ethical responsibility to do something about it, where that variation in practice impacts on outcomes

Standardising clinical protocols to reflect best practice in a particular field was a particularly contentious area, the group had found. Mel Burden, infection control nurse specialist at Royal Devon & Exeter Foundation Trust, said there had been a point blank refusal from surgeons to use the same dressings and sutures for breast surgery.

She said: “When I worked at [private hospital provider] Nuffield, surgeons were told ‘this is what we’ve got, this is what you’ll use’, whereas in our acute trust it’s almost as if they’ve got a shopping list and each surgeon will have a folder with their preferences.”

Paul Kavanagh-Fields, divisional director of nursing in the surgery department at Aintree University Hospitals FT, suggested theatre hierarchies presented another barrier to consistent practice.

“There’s still that subordinate mentality in a theatre environment and that’s what we need to challenge as opposed to accept, because maybe that’s the better thing for the patient.”

Mike Durkin, NHS England’s director of patient safety, agreed staff at all levels needed to highlight areas of concern. He said: “Seeing variation means we do have an ethical responsibility to do something about it, where that variation in practice impacts on outcomes. Just get on with it – just change.”

Healthy competition

Ms Chiwera said Guy’s had managed to achieve medical buy-in when it standardised dressings for paediatric cardiac surgery in 2010. Infections have subsequently dropped from 47 in the year the policy took effect, to one so far in 2016.

I think it’s really around working together collaboratively and saying ‘this is a problem we have and what can we do at every stage of the patient’s journey?’ Once we say: ‘We want to improve, here are the reasons why’, people will want to do it

“You have to find ways of getting people on board,” she said. Surgeons initially regarded the focus on SSIs as an implicit criticism of their care, but the trust emphasised the need to think about SSIs in the round. For example, had they washed before going into theatre, was post-operative care good enough, and were patients receiving sufficient information before being discharged?

Ms Chiwera said: “I think it’s really around working together collaboratively and saying ‘this is a problem we have and what can we do at every stage of the patient’s journey?’ Once we say: ‘We want to improve, here are the reasons why’, people will want to do it.”

Ensuring that procurement has some clinical input is very important, said Ms Kenny, adding: “Some trusts have done that and – if the stats are to be fully believed – have fantastic outcomes.”

Morecambe Bay’s nurse procurement group has saved £150,000, said Ms Smith, and is now working with community services to try to spread the saving across the wider healthcare economy. The trust’s medical director is leading a medical procurement group and “there’s really healthy competition going on at the moment” between acute and community clinicians, she said.

Ms Middleton highlighted the work being done by the recently established NHS Clinical Evaluation Team to identify the best clinical products for nurses to buy and use. She said: “I’m really pleased to see that nursing is taking a lead on that. I think that could have a massive impact on standardisation but it also could be really interesting to see the work they come up with, [though] I think it’ll be slow and a long time before we get through everything.”

There would always need to be some local variation when it came to procurement decisions, Ms Kenny pointed out. She said: “Local hospitals have different populations with different needs, and local variations as well as a national focus on standardisation is really important.” Surgical teams need to be listened to, she stressed.

The group were also asked to consider the difference between SSIs and wound complications. Did their trusts differentiate between types of wound complications, such as seromas and haematomas, or was that an under-reported area?

Ms Burden confirmed that only SSIs that fitted nationally set criteria would be reported, meaning “the wound complications just get brushed under the carpet” and a full root cause analysis was not carried out. She added: “It’s an area that should possibly be focused on to see what could change there.”

Jerome McCann, consultant intensivist at Warrington and Halton Hospitals FT, referred to the Matching Michigan project – a quality improvement programme to reduce central venous catheter bloodstream infections. Based on a US model, it saved 1,500 lives over 18 months when used in England.

Its success, Dr McCann said, was based on defining a central line infection and noting the bacteraemia in a database. However, wound infections proved slightly trickier, he said, adding: “I’m not sure there is a definition, it’s probably not easy to define. Because of that, it will make it more difficult I think, to create a database or some sort of system of auditing.”

We have seen a real change in the way people report and work across boundaries in order to understand and move forward, and it feels healthy, it feels good

Dr Kelly said there was also a problem with “lost reporting” of complications that did not fit the definition of reportable incidents, or happened after a patient was discharged. He said: “Some of these incidents occur out of the hospital setting and the big significant ones may result in readmissions, but I have no idea if my wounds get looked at by the midwives or the health visitors, or may end up needing some GP input – they never come back to me.”

Ms Kenny posited that staff may not report incidents that do not fit neatly into the definition of an SSI if they are unsure what the outcome would be. She described it as: “I don’t know what it is I’m telling you I want you to do, so I’m less likely to report it.”

It was widely agreed that incident investigations must not be carried out in a finger-pointing way. Morecambe Bay holds a patient safety summit every Wednesday morning with all the senior nurses and doctors to discuss individual patient stories and reflect on what can be done to prevent incidents occurring again.

Ms Smith said this had helped to share lessons across the trust, speak openly about incidents, and encourage self-reporting. She said: “We have seen a real change in the way people report and work across boundaries in order to understand and move forward, and it feels healthy, it feels good.”

It is equally important to let staff know where incidents they reported were unavoidable, said Ms Smith. She said: “We often find that [in] some of the incidents that are reported by people they couldn’t have done anything differently, and it’s important to feed that back. Sometimes things go wrong and it is unavoidable.”

Systematically holding staff briefings before and after surgery is a crucial component of success, according to the World Health Organisation’s surgical safety checklist, said Dr Durkin.

He said: “The key thing that actually improved the whole process was the reflection bit – the pre-briefing and post briefing, which is just de rigueur in most high-risk industries.”

Utilising data

Could data be used more effectively to pinpoint specific areas of concern? Ms Kenny recalled a talk she had recently attended by someone who was developing an app looking at post-surgical outcomes for surgeons. Information was fed back in a way that allowed clinician-based outcomes data to be collated.

She said: “It was just a really interesting concept – the data gathered by the app became a real competition in a positive way; even juniors were wanting to see their data, wanting to hear back about the patients they’d dealt with.”

It was also seen to be important that data was not just collected for its own sake, but acted upon, and added to only if it proved to be illuminating

Dr Kelly agreed there was an appetite for this kind of data, calling it a “necessary evil for revalidation and for appraisals” but concluding “it drags us in the wrong direction”. He said: “I think competition can drive improvements very well if it’s all in the open” but he worried that it would be received negatively if individuals felt they were being singled out for blame. When it came to improving care, he said, “much of the challenge is in opening up conversations better”.

It was also seen to be important that data was not just collected for its own sake, but acted upon, and added to only if it proved to be illuminating.

Dr Kelly said: “All we seem to do is add to this ever-increasing data burden that no-one ever goes back to.” For example, information from nursing admission bundles for incidents such as falls and pressure damage were “never referenced on the ward round”.

Bringing together data gathered by the medical and nursing staff was felt to be a challenge. Ms Burden said: “We still have nursing care plans and documentation at the end of a patient’s bed and the clinicians never look at what the nurses write, and vice versa. So if I, in infection control, want them to do something, we end up writing it in both sets of notes so that everyone can see it. It is about marrying it all together, having one set of notes.”

Dr Durkin said two upcoming national programmes would tackle clinical variations. One, The Model Hospital, stems from Lord Carter’s report into hospital efficiency and is aimed at helping trusts to compare their organisations with the most productive.

We’re all swimming in the same stream, but we’re not aligned in our swimming stroke

The second piece of work would look at population health and, combined with sustainability and transformation plans, help with “marrying up whole pathway approaches to not just save money but be more effective in the delivery of care”, said Dr Durkin. Together, these programmes would provide “huge data against which we can start to look to improve”, he added.

Ms Kenny highlighted the need to ensure that information was also shared with care teams in the community, asking: “What does the key [discharge] communication look like? Does it exist?”

It was also crucial, she stressed, to share information with patients in a way that allows them to be a partner in their own care. She said: “I truly think that people realise how stretched the NHS is, and they want to know how they can help make their care journey more cost efficient, or better for them, and easier for us.”

Allowing patients to take more responsibility for their own outcomes could be applied in relatively straightforward ways. For example, she said: “We have kitchens on wards and you can’t make a cup of tea yourself – you have to wait for someone to do a tea round. What does that promote?”

Dr Durkin used a swimming analogy to summarise the need to work collaboratively on the challenges that lie ahead. “We’re all swimming in the same stream, but we’re not aligned in our swimming stroke. The finance director has the same goal – to release sufficient money to reinvest, to improve what we do. We underestimate how much we really need to work together in terms of the finance side, he said.

“Nobody’s got the answer on the business case for safety, we’ve been trying this for 10 years now. We will get there, but it will only be when we start to align all our strokes.”