Pauline Harrington, National Surgical site infection (SSI) surveillance manager, Public Health England, has warned that, despite significant improvements in MRSA and MSSA infections, Enterobacterales have increased and now make up the largest proportion of causative organisms across all surgical categories [30.0% in 2018/19].
At the University of Salford's Operating Theatres Conference, in Manchester, she highlighted the importance of surveillance. However, when delegates were asked if they were aware of National SSI surveillance, only a handful said they were aware of this being undertaken at their Trusts, despite this being mandated for the NHS since 1997. As this is a key performance indicator for hospital theatres, it appears there is still more work to be done in communicating SSI rates back to the perioperative teams who ultimately impact these outcomes.
Last year (2018/19) seven high outlier notifications were sent out for mandatory surveillance categories (four for knee replacement, two for hip replacement and one for repair of neck of femur).
“Patients die from SSI and we know it is avoidable,” commented Pauline. “A key factor in prevention is surveillance. By looking for SSI, you can identify the problem and address it… The purpose is to improve patient care.”
From April 2004, NHS Trusts performing orthopaedic surgery were mandated to carry out surveillance for a minimum of three consecutive months per financial year, in at least one of four orthopaedic categories: hip replacement, knee replacement, repair of neck of femur or reduction of long bone fracture. NHS hospital participation in other categories remains voluntary.
Active surveillance is undertaken by hospital surveillance staff to identify patients with SSIs during their initial inpatient stay. Hospitals are also required to have systems in place to identify patients subsequently readmitted to hospital with an SSI. SSIs identified on readmission are assigned to the hospital where the original operation took place. Other post-discharge surveillance methods are recommended, especially for short-stay procedures, but remain optional.
Pauline reported that an increasing number of Trusts are now conducting post-discharge surveillance as it gives a better overall picture of infection rates. PHE is currently developing a digital questionnaire that will help hospitals undertake this surveillance. Patients will be able to complete the questionnaire on their smart phone, via an app, and send this data back for entry on to the system, which will mean less chasing and a reduced workload for hospitals.
“If you are just relying on data for inpatient stay, you are going to miss many infections,” Pauline commented.
She added that patients with a higher BMI, in particular, are at increased risk of SSI, so there needs to be "greater efforts to tackle this prior to undergoing elective surgery".
"If it is emergency surgery, you cannot control this, but you can look at antibiotic therapy. The hospital needs to ensure that the right dosage is given to the patient, at the right time,” Pauline concluded.
