SSI: using root cause analysis

Healthcare-associated infections cost the NHS approximately £1 billion per annum. (National Institute for Health and Clinical Excellence 2012) The 2011 Hospital Infection Society Point Prevalence Survey findings suggest that pneumonia, urinary catheter and surgical site infections (SSI) remain the most frequently detected hospital-acquired infections (HAIs) with SSI constituting 9.5% of HAIs detected. (HPA 2012) According to the Health Protection Agency, ‘a surgical site infection occurs when micro-organisms get into the part of the body that has been operated on and multiply in the tissues’ (Health Protection Agency 2012). Patients with wound infections following surgery are five times more likely to be re-admitted to hospital and have longer intensive care and general admission periods, which also impacts on the allocation of resources to other patients. (Pexton and Young 2004) Patients with SSI have double the mortality rate than those without. From a surgeon’s perspective, ‘a deep wound infection is a serious and preventable complication with substantial associated costs’; patients can endure months of inpatient stay and wound revisions. One patient described his experience of an organ/space wound as ‘changing who I am. There is the huge financial strain on me and my family from my being in hospital for months… the stress is very difficult to cope with… I am not sure of anything other than this is going to take a long time to sort out’. Often it is by focusing on fine tuning processes or reallocating resources at lower levels of interventions (Huczynski and Buchanan 2001) that root cause analysis (RCA) can contribute to broader safety and quality initiatives, although larger scale changes can arise directly via the RCA process if the recommendations and/or actions are reported effectively (Pexton and Young 2004).

Root cause analysis

At the author’s Trust, all deep, organ/space SSIs will trigger RCA. RCAs are well established investigation processes which gather, interrogate and provide solutions for contributory factors, root causes and ‘active learning’ from the problem. The National Patient Safety Agency (NPSA) has a wide range of tools available for RCA. Initially, a five-page document for SSI RCA was adapted for Trust use. However, completing the RCA was time consuming. Multi-disciplinary input was rarely sought, and summary recommendations were not implemented or publicised which was frustrating for the individuals undertaking the review and completing the paperwork. For these reasons, the decision was made to review and implement recommendations via the following process: