INFECTION CONTROL
• Themes identified fromvariances (for example non-compliance with the Trust antibiotic prophylaxis policy or outbreaks of SSI associated with one particular theatre) are addressed and when a number of deep wound infections are recorded an action plan is developed with the steering group for wound prevention. A number ofTrusts have successfully implemented changes via similar multidisciplinary meetings, charged with ensuring best practice, resource alignment, and strategy/policy actions. (Jakeman 2010)
Dehisced laparotomy wound caused by infection at the site of the incision.
the Trust electronic reporting system for transparency and learning. RCAs are completed more quickly because the IPCT has access to the majority of information (e.g. overall SSI surveillance data, antimicrobial stewardship audit/pilot information, hand hygiene and cleaning audits, building work programmes etc) and systems (including the theatre, infection control, intensive care and surgical databases).
• The SSI RCA formhas been streamlined. Standard information now includes a picture of the infected wound; details of operation and operators; a summary of the main findings; a short narrative of details relating to key care concerns; and microbiology and biochemistry graphs. Good practices and variances are identified (these are often already known). The Saving LivesHigh Impact Intervention care bundle to reduce SSI score is also included (see Box 1).
• The IPCT works with surgical team colleagues for input on the additional points (see review points below) before the formis uploaded to the Trust’s incident reporting system.
Review points for SSI RCAs According to guidelines, (Healthcare Infection Control Practices Advisory Committee 1999) the development of infection is believed to be linked to three principal factors:
Risk = number x virulence of
of Infection of pathogens the organism resistance of the host
Subsequently the RCA process below incorporates these key areas:
1 Review: measures to reduce number of pathogens • Exacting surgical technique (including surgical scrub competency, de-scrub and re-scrub if moving between incisions, any revision/repair or difficulties encountered during the procedure, careful closure of the skin, drain placement and management).
• Environment: cleaning and decontamination, theatre ventilation, building projects specific to time period/theatre and or ward concerned.
• Infection prevention promotion: e.g. education for staff and patients.
2 Review: measures to reduce the spread of virulent bacteria • Appropriate microbiological and biochemistry requests with timely review, appropriate antibiotic therapies (Jordan and Riddle 2012) and communications.
• Infection prevention and control precautions for resistant organisms.
• Risk assessment e.g. remote or pre-existing infection (including urinary tract infection, leg ulcer, etc), managed and communicated effectively.
Dehisced mastectomy wound, demonstrating sloughy tissue in the closure layers.
26 THE CLINICAL SERVICES JOURNAL
3 Review: factors which may compromise patient and/or wound status • Body habitus, WorldHealth Organization (WHO) surgical
Box 1: Care bundle to prevent surgical site infection
Pre-operative phase Screening and decolonisation: Patient has been screened for MRSA using local guidelines. If found positive they have been decolonised according to the recommended protocol prior to surgery. Pre-operative showering: Patient has
showered (or bathed/washed if unable to shower) pre-operatively using soap. Hair removal: If hair removal is
required, it is removed using clippers with a disposable head (not by shaving) and timed as close to the operating procedure as possible.
Intra-operative phase Skin preparation: Patient’s skin has been prepared with 2% chlorhexidine in 70% isopropyl alcohol solution and allowed to air dry. Prophylactic antibiotics: Appropriate antibiotics were administered within 60 minutes prior to incision and only repeated if there was excessive blood loss, a prolonged operation or during prosthetic surgery. Normothermia: Body temperature is
maintained above 36˚C in the peri- operative period. Incise drapes: If incise drapes are
used they are impregnated with an antiseptic. Supplemented oxygen: Patients’ haemoglobin saturation is maintained above 95% (or as high as possible if there is underlying respiratory insufficiency) in the intra and post operative stages. Glucose control: A glucose level of
<11 mmol/L has been maintained in diabetics patients (this tight blood glucose control is not yet considered relevant in non-diabetic patients).
Post-operative phase Surgicaldressing: The wound is covered with an interactive dressing at the end of surgery and while the wound is healing. Interactive wound dressing is kept
undisturbed for a minimum of 48 hours after surgery unless there is leakage from the dressing and need for a change. The principles of asepsis (non touch
technique) are used when the wound is being redressed. Hand hygiene: Hands are
decontaminated immediately before and after each episode of patient contact using the correct hand hygiene technique.
NOVEMBER 2012
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