Surgery can be traumatic enough for a patient without an infection setting them back weeks, months, or even disabling them for a lifetime. LINLEY BONIFACE* of the Health Quality & Safety Commission backgrounds the national campaign to prevent surgical site infections and the role that nursing plays.
A patient coming in for a hip replacement expects to be leaving in days, not bedridden for weeks or months.
Between two and five per cent of people having inpatient surgery in New Zealand develop a surgical site infection (SSI), which can have a devastating impact on patients and their families.
SSIs make up about 17–20 per cent of healthcare associated infections in developed countries. They’re the second most commonly reported healthcare associated infection after infections of the urinary tract, and are among the most common adverse events experienced by hospital patients.
Many of these infections are considered preventable, which is why healthcare associated infections, including SSIs, have been chosen as the second focus area for New Zealand’s national patient safety campaign.
Open for better care is being coordinated nationally by the Health Quality & Safety Commission and implemented locally by district health boards (DHBs) and other health providers.
The commission is coordinating New Zealand’s first national quality improvement programme aimed at preventing SSIs. The programme will concentrate first on reducing infections developed during total hip and knee replacement surgery and will then move on to infections following cardiac bypass grafting and caesarean sections.
The national Surgical Site Infection Surveillance Programme is being delivered by a joint lead agency – Auckland and Canterbury DHBs – in partnership with the commission. DHBs around the country are helping to develop a consistent, evidence-based approach to preventing SSIs.
Margaret Drury, infection prevention and control advisor at Hawke’s Bay DHB, is a member of the steering committee of the commission’s SSI surveillance programme group. She has been working on SSI prevention since 2009.
‘Nurses care for their patients and hate it when someone develops an infection,” says Drury.
“A surgical site infection should make us ask, ‘Where have our processes failed?’”
Devastating impact on patients
In her nursing career, Drury has seen first-hand the terrible impact an SSI can have on patients. “Implanting a piece of metalware in a joint is foreign to the body, so infections after a hip or knee replacement tend to have more serious consequences,” she says.
“Patients who develop a serious SSI may face a long hospital stay, have a line in delivering antibiotics for six to eight weeks, and be left with a permanent disability. If someone has to have a joint taken out because of an infection, it sometimes isn’t possible to replace the joint. A patient without a ball and socket joint in the hip will be left with one leg shorter than the other and will always have trouble walking. I’ve seen it happen, and it is life-changing for the patient.
“An infection can also be devastating for the patient’s family. They may be in serious financial hardship because of the loss of income, the need for extra childcare, and the cost of making regular trips to the hospital. It puts everyone under a great deal of pressure.”
SSIs following joint replacements are strongly associated with increased morbidity and mortality. Patients with an SSI have a two to 11-fold increased risk of death compared to post-operative patients without an SSI. A patient who develops an SSI after hip replacement surgery will have at least 2–3 times the length of hospital stay of non-SSI patients.
The risk of developing an SSI is explained to patients when they sign the consent form for their operation. Drury says patients are usually reasonably accepting when first told they have an infection but may become angry and upset later on, particularly when they realise they may have to deal with the consequences of an SSI for the rest of their life.
Drury says she will never forget an older male patient she cared for many years earlier. He expected to be in hospital for five days to have a hip replacement operation but ended up spending the best part of six months in hospital after developing a serious infection that didn’t respond to antibiotics.
Independent and accustomed to spending most of his times outdoors, the patient had to put his life on hold while healthcare staff battled to control his infection. He lived in a rural area some distance from the hospital, so it was difficult for his family to make regular visits to see him. Eventually his prosthesis had to be removed, leaving him with a permanent disability.
SSIs costly in time, resources and emotional input
Infections also take a toll on the health system’s resources. A patient with an SSI costs about twice as much to care for as a patient without an infection, while an SSI following a hip or knee replacement costs three or four times as much as the original surgery.
An SSI following open heart surgery extends the length of hospital stay by an average of 32 days, at an average cost of $45,000 per patient.
Superficial infections are usually discovered within a week, but a patient with a deeper, more serious infection in a joint may not return to hospital until 30 days after the original surgery.
“Orthopaedic patients are usually in and out within a week, but nurses often form an amazing bond with patients who require longer-term care because of an infection. They can see the frustration and emotions involved, so they put their heads down and work hard to do everything they can to support that patient,” says Drury.
A proposal to implement a hospital-associated infection surveillance system in New Zealand was first developed in the early 1990s. Another surveillance proposal was put forward in the late 1990s, but resource constraints prevented both proposals from going ahead.
The new national surveillance programme aims to identify SSI cases using consistent definitions between hospitals. The programme provides nurses and other health professionals with access to information to drive practice change and continuous quality improvement, as well as contributing to national and international efforts to improve patient safety.
Eight DHBs were involved in the initial phase of the programme, which is being progressively rolled out to other DHBs that carry out hip and knee surgery. As part of the programme, infection prevention and control nurses buddy each other.
Consistent best practice makes the difference
Deborah Jowitt, a senior advisor at the commission, says many people have been doing great work in reducing SSIs in their own DHBs, but until now they had been doing it in isolation.
“A national programme gives a consistent standardised approach to definitions, data collection, analysis and reporting. The result will be really robust data that can be used as the basis for making improvement suggestions.”
Target CLAB Zero, a collaborative project between the commission and Counties Manukau DHB to prevent the bloodstream infection Central Line Associated Bacteraemia (CLAB), illustrates how successful national patient safety projects can be. The project reduced the number of hospital patients developing CLAB in New Zealand ICUs from between four and six patients per month from January to March 2012 down to almost zero.
Programmes that are similar to New Zealand’s new national surveillance programme have reduced the numbers of SSIs in the United States, parts of Europe, England, Scotland, and Australia.
Drury says there are many simple interventions that can help reduce the risk of SSIs.
“Giving the right antibiotic at the right time, using the right skin preparation before surgery, keeping patients at the appropriate temperature and watching their glucose levels – it can all make a big difference.”
At Hawke’s Bay Hospital, patients are given a skin preparation to use as a wash for two days before surgery. On the day of surgery, staff give the patient a packet of wipes to wash with, especially around the surgical area. They’re prepped with the skin “paint” – chlorhexidine and alcohol – again before surgery, when they’re on the operating table. “It’s about creating an optimum area to make the incision in,” says Drury.
“Best practice approaches might be as simple as remembering to record weight and height so the anaesthetist in theatre knows what the patient’s BMI is, so that if he has a larger BMI he’ll get an increased dose of antibiotics.”
Many DHBs already use part of the “bundle” of surgical care best practices, but Drury says the aim is to ensure a consistent approach across the country.
For more information about Open for better care, go to: www.open.hqsc.govt.nz
*Linley Boniface is communications advisor for the Health Quality & Safety Commission
Best practice approaches that can help reduce SSI rates include:
- appropriate choice of antibiotic
- appropriate weight-based dosing with the antibiotic
- administering the antibiotic within the hour before the incision is made
- removing hair before surgery with clippers rather than by shaving
- using an appropriate alcohol-based surgical field skin antisepsis
- maintenance of perioperative normothermia for colon surgery
- maintenance of perioperative glucose control prior to cardiac surgery
- mainenance of high hand hygiene standards.
World Health Organisation’s Five Moments for Hand Hygiene
- Before patient contact.
- Before a procedure.
- After a procedure or body fluid exposure risk.
- After patient contact.
- After contact with patient surroundings.
Good hand hygiene critical
Hand hygiene is also critical to reducing infections in post-operative care. Scientific evidence shows that microbes that cause infections are most frequently spread between patients via the hands of health care workers.
Health care workers’ hands can be contaminated even after seemingly clean procedures – such as taking a pulse, blood pressure reading or temperature – as well as touching a patient’s hand, shoulder, or groin.
Since 2012, all New Zealand DHBs have carried out observational audits to measure their compliance with the Five Moments for Hand Hygiene (see box). The latest data shows hand hygiene in New Zealand has significantly improved since all 20 DHBs began actively participating in the Hand Hygiene New Zealand programme.
The national quality improvement programme aims to reduce healthcare associated infections by improving hand hygiene practices in the country’s health care facilities. Each DHB has a local hand hygiene programme that includes auditing and reporting of hand hygiene compliance to a national hand hygiene database three times a year.
Drury says old habits can be a reason some health care staff fail to perform hand hygiene when necessary.
“When I trained as a nurse, we were trained to wash our hands but the consequences of not doing it weren’t drilled into us the way they are today,” she says.
“The other barrier is busyness. Sometimes staff – especially more senior medical staff – don’t see the consequences of what they do. They don’t see that by touching a bed, they contaminate their hands. They might get distracted, or they might have just given a patient some bad news, and washing their hands to prevent the spread of infection might not be uppermost in their minds.”
At Hawke’s Bay Hospital, Drury and her colleagues take a positive, supportive approach to encouraging good hand hygiene. “Coming down heavy only puts people’s backs up,” she says. “Simple measures such as the appropriate hand hygiene signage and gels at point of care can help to spread the message that small changes can make a big difference to patient safety.”