Simple, and relatively inexpensive, steps to implement care bundles can have a dramatic impact on rates of surgical site infection. The Burden of Infection Symposium provided an insight into the latest evidence and guidance around best practice, as well as offering expert advice on ‘overcoming the challenges of change’. Louise Frampton reports.
Surgical site infections (SSI) are among the most reported healthcare-associated infections (HCAIs). They have an adverse economic impact on hospitals, as well as on the patient. In addition, they are responsible for increasing the length of stay for patients – resulting in social and economic loss to the patients and family. To further theatre teams’ understanding of SSIs, their associated socio-economic burden, the risk factors, and guidelines for prevention, the J&J Institute and Ethicon recently held a ‘Burden of Infection Symposium’, at its Pinewood Campus in Wokingham, UK.
The symposium opened with a powerful account from a patient on the devasting impact of SSI – reminding clinicians of the human cost to patients. Following surgery for fibroids, the patient contracted an infection which developed into necrotising fasciitis. She described the immense pain associated with this “flesh eating disease” and how the “black dot above her wound” led to seven surgical interventions, nine blood transfusions and being in the hospital for two months.
“I never imagined that [the surgery] would turn into that. But if it can happen to me, it can happen to anyone. I have gone from survivor to patient advocate, to put a face to the harm… One surgical site infection is one too many… I want surgeons to know that they don’t just hold one person’s life in their hands; they hold a family in their hands; they hold a community in their hands. If you can add another layer of protection for the patient, why wouldn’t you?” she exclaimed.
Having placed the focus firmly on the patient, the symposium went on to provide an insight into SSI definitions, the evidence base, and clinical guidelines. Professor Leaper, an Emeritus professor of surgery with University of Newcastle Upon Tyne and Clinical Sciences at the University of Huddersfield, previously chaired the NICE guideline development group on SSI. He gave a stark reminder that healthcare-associated infections can prove fatal. Against a backdrop of increasing antimicrobial resistance (AMR) and a lack of new antibiotics in our armoury, prevention has become more important than ever
There has been significant progress in reducing Meticillin-resistant Staphylococcus aureus (MRSA), in the UK, but Meticillinsusceptible Staphylococcus aureus (MSSA) remains a problem. He added Coagulase-negative staphylococci/Meticillin-Resistant Staphylococcus epidermidis (MRSE) is also problematic in orthopaedic and other prosthetic surgery.
A key message of the session was the importance of prevention rather than cure – antibiotics can have significant side effects, including renal damage and problems with coagulation. However, there has also been a historic failure to ‘preserve’ new antibiotics that have entered the market, though injudicious prescribing. This means that some infections are becoming fatal, once again, through antimicrobial restistance (AMR).
In a world without effective antibiotics, chemotherapy and transplantation will become “too risky”. Furthermore, some surgical procedures may also become high risk – Prof. Leaper warned that there could be a significant increase in deep incisional infections, following colorectal surgery, for example. In joint replacement surgery, untreatable infection could also lead to devasting amputations.
“Antibiotic stewardship is simple, but it is a team effort. The right antibiotic must be administered at the right time, at the right dose, for the right length of time,” Prof. Leaper commented.
In particular, he emphasised that simple clinical markers – such as white blood cell count and temperature – should guide the length of the course of antibiotics when treating infections, to avoid unnecessary prolongation. He said that resistance with antiseptics, on the other hand, was “not a concern” – although it was prudent to continue surveillance in this area and to avoid overuse/misuse
Prof. Leaper went on to tackle the misconception that SSI is just about the surgeon’s ‘skill’. In the UK, there is now a focus on prehabilitation/ optimisation prior to surgery, Getting it Right First Time (GIRFT), Enhanced Recovery After Surgery (ERAS), and a move towards day case surgery.
Important patient optimisation factors to reduce the risk of SSI include:
- Weight loss in obese patients (with a BMI greater than 30).
- Optimisation/management of diabetes.
- Optimisation of nutrition prior to surgery.
- Smoking cessation and optimisation of chronic obstructive airways disease (COPD)
“This makes a huge difference to outcomes,” he asserted.
Prof. Leaper went on to discuss the categorisation of surgical wounds. The US Centers for Disease Control’s definition of SSI (shown below), is most commonly used:
- Reported by a surgeon (!)
- 30 days (1 year prosthetics)
- Purulent discharge or abscess
- Isolated organisms
- 1+ Celsian signs
- Wound separation or need for drainage
“The definition is around 30 years old and needs revisiting,” said Prof. Leaper.
In particular, he thinks the premise of SSI being ‘reported by a surgeon’ is especially problematic. In addition, presentation at 30 days or one year for prosthetics is “probably not long enough for surveillance”, while not all SSIs have a “purulent discharge”, he commented.
One of the challenges around gaining an accurate picture of the true rates of SSI is the fact that patients are often treated as day cases; if there is an infection, it is likely to materialise after the patient has left the hospital. Consequently, many SSIs go unreported in the national statistics. Despite the burden placed on primary care, clinicians in this setting are not always trained to recognise or optimally treat SSIs. However, the impact on the acute sector is also significant – SSIs can lead to increased length of hospital stay (7–10 days), as well as doubled mortality, while patients with an SSI are 60% more likely to spend time in the intensive care unit and five times more likely to be readmitted.
The cost for healthcare providers is generally reported to be around $400+ [£346+] for a superficial incisional infection, to $50,000+ [£43,305+] for an organ/deep space SSI. However, there are also indirect costs to the patient and their family, which need consideration, such as the loss of productivity and functional capacity. Prof. Leaper emphasised that superficial SSIs are common and, although they may be ‘superficial’, they still cause problems for patients – including delaying their return to work, for example
Prof. Leaper went on to highlight some research which calculated the ‘real-world economic cost of SSIs after colorectal surgery’. This included analysis of databases for IBM MarketScan, Medicaid and Medicare, and involved a total of 107,665 patients, between 2014-2018.
The study revealed a 24% SSI rate – yet only three-quarters were recognised by eight weeks. The true cost of SSI was calculated to be >$100,000 [>£86,598] for deep incisional/ organ space SSIs at 6 months, with accurate surveillance.1 Surveillance of SSI is an integral part of organisational infection prevention and control activities, but unless post-discharge surveillance is carried out in a robust manner, the data may be inaccurate and misleading. As part of a paper, co-authored with Judith Tanner and Martin Kiernan, Prof. Leaper called for more accurate definitions and intensive recording. Outpatient reviews, questionnaires, telephone follow-up, patient diaries (patient reported outcome measures) and patient surveillance using mobile phones are just some of the tools that can be utilised. While accurate postdischarge surveillance methodology is critical, it is also costly and requires investment, he commented.2
Other key areas for discussion included the ongoing challenges around wound definitions. Prof. Leaper showed a number of wound images and invited the audience to consider “is it an SSI or dehiscence?” For example, the wound may have broken down, but what if the swab shows there is no microbiological growth? He pointed out that the breakdown of the wound may be due to dehiscence and not SSI. Therefore, a better term is required, in his view, such as “surgical site outcome” or “wound complication”
An important message from Prof. Leaper’s presentation was the fact that it takes significantly lower levels of microorganisms to develop an SSI when an implanted prosthesis is involved. When a biofilm forms on the prosthetic, the infection can prove especially challenging – “persister cells” in established biofilm resist the host-defences, antibiotics, and antiseptics, but still provoke inappropriate inflammatory responses. He went on to highlight guidelines for SSI prevention, including those published by WHO and NICE, as well as explaining the various levels of evidence quality available. Level one evidence (i.e. best quality) includes patient warming (64% reduction in SSIs), use of 2% Chlorhexidine gluconate in 70% Isopropyl alcohol for preoperative skin preparation, clipping of hair and not shaving, administering prophylactic antibiotics within 60 minutes of incision, perioperative glucose control, and use of (antimicrobial) Plus Sutures for wound closure when absorbable sutures are appropriate.
It is worth noting that NICE also concludes, in its Medical Technologies Guidance (2021), that Plus Sutures achieve a cost saving by an average of £13.62 per patient, following a reduction in SSI.
Ultimately, NICE supports the “pooling of best practice into care bundles” and the efficacy of this approach is well supported by the evidence.3
“Care bundles really work,” Prof. Leaper concluded.
Care Bundles
While SSI care bundles can have a significant impact, they can also be challenging to implement – as with any change within the healthcare setting. Getting everyone ‘on board’ is crucial. Mr Giles Bond-Smith, lead consultant HPB and emergency surgeon, at the Oxford University Hospital NHS Foundation Trust, discussed the ‘practical implementation of care bundles’ – sharing his insights into achieving sustained improvement
“The challenge with SSI is the fact that it is multimodal – there is the patient’s physiology; they may be malnourished, and they may have a complex medical history including cancer,” he explained.
Following liver and pancreatic cancer surgery, for example, surgical site infection can delay the patient from receiving vital post-operative chemotherapy, which is key to improving outcomes and length of survival.
“That’s why it is vital that we get it right first time (GIRFT),” he asserted.
Mr Bond-Smith emphasised that multidisciplinary teams have a vital role to play in driving improvement in SSIs – not just the surgeon. There needs to be collaboration with infection prevention and control, microbiology, the anaesthetist, the scrub team, the surgeon, the critical care team, as well as procurement.
Procurement needs to understand what is trying to be achieved with the patient cohort – to understand the business case, through cost-based analysis, and this must be based on the whole patient journey and outcomes.
“With any clinical improvement, if you do not look at the whole journey and the financial planning, it is difficult to get anywhere. On paper, it may look expensive, but when you look at the ‘whole circle’, the initiative is cost effective – if you prevent just one deep incisional SSI after HPB surgery, the cost is justified,” said Mr BondSmith.
Steps for improvement need to be easy to understand and implement, as well as being bespoke to the specialty, he advised.
“People are not going to engage if you make it difficult or complex for them. It must not be time consuming to implement and the bundle must be simple, evidence based, cost effective, and sustainable,” he explained.
Mr Bond-Smith added that improving SSI also has the added benefit of reducing the impact on the environment – a patient with an SSI consumes more hospital resources and will have more journeys to hospital, generating additional CO2 emissions and needless use of water. It can therefore support other boardlevel objectives – such as helping to achieve the Net Zero target for the NHS.
Implementation
When implementing a care bundle, Mr Bond-Smith emphasised that is important that “you do not tell the surgeon how to do the operation itself”.
“You can influence the patient’s journey up to the point of knife to skin; but let the surgeon do the operation their way. When it comes to wound closure, that’s when you step back in, so the patient leaves the theatre in a safe, robust, evidence-based, sustainable manner,” Mr Bond-Smith continued.
The secret to achieving successful implementation, he found, was the development of six simple steps:
Step One: The first step is to conduct 1-2 months of SSI surveillance, for all operations, to identify the true local 30-day SSI rate – the rates are “always higher than you think”, Mr Bond-Smith pointed out.
“As a surgeon, I took responsibility for this – I assessed every wound, at the time of discharge and 30 days later. You need this audit to understand the scale of the problem,” he commented.
Step Two: The next step is to disseminate this information.
Step Three: Once the problem has been identified and the data collected, it is important to involve all key stakeholders to solve the problem.
“The whole team needs to come together to implement a tried and tested bundle,” commented Mr Bond-Smith. He explained that it is important to build a multidisciplinary team to solve the problem and to give each member just 1-2 roles each. The care bundle should have no more than 10 points.
The Liver and Pancreatic SSI reduction bundle, at the Oxford University Hospital NHS Foundation Trust, includes just eight points:
1 Clip, don’t shave (but only if hair removal is necessary and do it outside of the theatre).
2 Correct antibiotic at the correct time.
3 Normothermia (36o C or above). 4 2% Chlorhexidine gluconate in 70% Isopropyl alcohol skin prep.
5 Glycaemic control between 6-8mmol/L
DO THE OPERATION
6 Wash the wound with aqueous povidone-iodine. (This coincides with the ‘pause for gauze’/safety check)
7 Close the wound in layers, using Triclosan sutures.
8 Subcuticular skin closure with Monocryl Plus and Dermabond.
At the Oxford University Hospital NHS Foundation Trust, each point is carried out by just one person and every point in the bundle is evidence based
Mr Bond-Smith pointed out that, although the WHO Checklist has helped improve compliance with the requirement to give the antibiotic at the right time, what exactly is the right antibiotic? Each year, this is evaluated with the IP&C and microbiology teams to see whether the bioflora has changed and to review prophylatic antibiotics accordingly. Over the course of 10 years, there have been several changes to ensure optimal antibiotic stewardship
Step Four: Staff should be allowed to get used to their role in the SSI reduction bundle – avoiding the temptation to make changes. This is essential to enable the initiative to become embedded and normalised. It is also important to assess the compliance rate. At the Oxford University Hospital NHS Foundation Trust, an audit reported over 95% adherence to the bundle for the whole year.
Step Five: The next step is to reassess the 30-day SSI rate. The HPB department at Oxford University Hospital NHS Foundation Trust saw a 60% reduction in SSIs.
Step Six: Finally, it is important to report the success back to the team, to ensure everyone is aware and that everyone receives recognition for their efforts.
The success of this simple bundle approach has now been replicated across multiple specialties at the Trust. Orthopaedics, for example, moved from being an outlier, prior to the bundle, to an SSI rate below 1% following the implementation of a bundle. Spine surgery already had a very low SSI rate, below the national average, and the department was initially sceptical that this could be reduced even further. However, they successfully halved their SSI rate to 1.4%.
“When we talk about ‘zero SSIs’, it is tough. But I think it is achievable,” Mr Bond-Smith asserted. He added that it is “not a passive process” and team members turn over. But there are also challenges around 30-day surveillance – it can be labour intensive and costly.
Surveillance needs to be carried out by the same person to avoid inconsistencies in identifying and classifying SSI, and there needs to be quarterly reports to identify any unexpected changes.
To address the surveillance challenge, Johnson and Johnson has developed a digital solution that allows patients to give feedback, in real time, if they have any concerns.
“If there is an issue, you want ‘early eyes on it’,” he explained. The digital solution provides the team with an early warning of any problems and avoids inappropriate prescribing of antibiotics in primary care, due to incorrect assessment of the wound by the GP, for example.
Procurement
Gary Welch, director of procurement and supply chain, at Oxford University Hospital, went on to discuss the topic of ‘Procurement for the Patient’. He commented that the mission for procurement departments should be about supporting clinicians and ensuring better patient care; it shouldn’t be solely about price reductions.
Some of the key challenges currently facing healthcare include money, staffing and the backlog. There are also issues around supply chain disruption and inflation, meeting the demands of an ageing population, and problems concerning ‘flow’ – caused by pressures on social care.
“Procurement should be working with the rest of the Trust to tackle some of these problems; not spending £100k on an SSI is just one example where cost savings can be achieved,” he commented
Gary Welch gave an insight into some of the ways in which the Oxford University Hospital procurement team has helped with the mission to improve patient care, while also achieving savings, through the procurement of innovative solutions. This included the introduction of a solution to enable patients to self-administer IV antibiotics at home. The latter released 2,000 bed days per annum and freed £630,640 in financial benefits.
The device also improved efficiency, reduced the demands on staffing, and helped with the hospital’s response to COVID. He revealed that other value-based procurement projects include: beds to reduce the incidence of healthcare-acquired pressure ulcers, antibacterial sutures to reduce SSIs, 3D surgical guides, and spinal robot-assisted surgery to improve the safety and accuracy of surgery.
“It is important to make the best commercial decisions. However, first and foremost, the conversation must be: ‘how can we use procurement to transform patient care by working with our clinical colleagues?’ We need to be part of the team delivering patient care,” he concluded.
Ultimately, the Burden of Infection Symposium provided delegates with some useful tools and insights to help drive improvement in their own surgical departments. Sharing this knowledge with colleagues, provided a valuable opportunity for surgical teams to reflect and discuss how these proven tools and strategies might be applied and adapted in their own Trusts and specialties. It is hoped that, by exchanging knowledge and best practice, in this way, outcomes for patients can be improved, unnecessary costs associated with SSI can be reduced, and extra capacity may be freed – at a time when the NHS is facing some of its greatest challenges while tackling the backlog
References
1 Leaper DJ, Holy CE, Spencer M, Chitnis A, Hogan A, Wright GWJ, Po-Han Chen B, Edmiston CE Jr. Assessment of the Risk and Economic Burden of Surgical Site Infection Following Colorectal Surgery Using a US Longitudinal Database: Is There a Role for Innovative Antimicrobial Wound Closure Technology to Reduce the Risk of Infection? Dis Colon Rectum. 2020 Dec;63(12):1628-1638. doi: 10.1097/ DCR.0000000000001799. PMID: 33109910; PMCID: PMC7774813.
2 Leaper D, Tanner J, Kiernan M. Surveillance of surgical site infection: more accurate definitions and intensive recording needed. J Hosp Infect. 2013 Feb;83(2):83-6. doi: 10.1016/j. jhin.2012.11.013. Epub 2013 Jan 13. PMID: 23332350.
3 Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015 Jul;158(1):66-77. doi: 10.1016/j.surg.2015.03.009. Epub 2015 Apr 25. PMID: 25920911
