INFECTION CONTROL
was an important lesson to have learned about delivering behaviour change. “The team were disappointed that the
SSI rate had not reduced, despite all their efforts to increase compliance with best practice. However, the findings generated a lot of excitement over the impact of patient warming on the wards, before surgery.” Prof. Tanner revealed that patient
warming was the one factor that stood out in reducing SSIs. Patients who had no pre-op warming had a superficial SSI rate of 22%. For patients that were pre-op warmed, the superficial SSI rate was 0%. “Lots of people from other hospitals
visited us to learn from our work and told us that they would like to conduct good, high quality, post-discharge surveillance, but they had concerns,” said Prof. Tanner. She explained that if a Trust performs high quality surveillance, its infection rates inevitably show an increase. Trusts are therefore concerned that these figures will be reported to the Health Protection Agency (HPA), who will label them as ‘outliers’, and they will be penalised. “‘Surely this cannot be right?’ we
questioned.We realised we needed to look at the national surveillance systems in place – if we are reporting our infection rate figures, we do not want to be compared unfavourably with others that are conducting surveillance in a different way,” she continued. The team therefore sent out
questionnaires to all the acute Trusts in England – a total of around 156 – to establish how they collected their surveillance data. Of the 107 Trusts that responded, two-thirds conducted post- discharge surveillance. However, 30 Trusts said they did not send all the data to the HPA. So what didn’t they send? Prof. Tanner pointed out that some Trusts did not send post-discharge data and only sent mandatory data. In short, there was significant variation in the amount and type of data being sent to the HPA. Reflecting on these findings, Martin
Kiernan was reported to have shared some encouraging thoughts: ‘The fact that post-discharge surveillance is being performed, but not reported, means that Trusts are conducting this surveillance for themselves – not because they have to meet the demands of the HPA, but because they want to know what is going on in their Trusts to make improvements.’ However, the findings also presented challenges that needed to be addressed.
‘Apples and oranges’ “We found that you cannot compare apples and oranges,” said Prof. Tanner. “There were many inconsistencies and variations in the data collection methods and quality of surveillance being carried
NOVEMBER 2012 THE CLINICAL SERVICES JOURNAL 41
‘Concerns have been raised that some staff groups are not formally trained to undertake cleaning duties and are poorly motivated to do it, with many feeling that this should not be part of their duties.’
out across Trusts. It was impossible to benchmark this data. Ten per cent of the Trusts said that they only presented in- patient data to the HPA; 10% did not report ‘superficial’ data, and 10% used a different definition of SSI. There were several different data collection methods used which had a huge impact on SSI rates.” The team therefore looked at all the
Trusts that said they undertook post- discharge surveillance and separated them into ‘high quality’ and ‘low quality’. For those Trusts that conducted high quality surveillance, the infection rate for knee surgery was found to be six times higher than the HPA’s figures – suggesting that official figures for SSIs are not an accurate reflection of incidence. At this time, the lead on surveillance
highlighted the importance of considering the impact on patients of SSIs. “Until this point, our work had been all about rates, numbers and costs, but where were our patients in all of this?” said Prof. Tanner.
Patients’ experiences of SSIs The team therefore decided to conduct patient interviews with people who had experienced deep wound infections.* “The first surprise we had was that
patients were not always aware that they had experienced an infection,” Prof. Tanner commented. “One patient responded that they ‘hadn’t had an infection’, but, on further investigation, they had been readmitted, had their wound reopened by a surgeon and had been given three cycles of antibiotics.” In fact, 9 out of 17 patients with deep
wound infections did not know that they had had an SSI. Patients were not always
informed by staff, while the significance of the infection, in some cases, was reported to have been ‘underplayed’ by the clinician treating the patient. “One nurse said to a patient with a
deep wound infection: ‘It is nothing to worry about – it’s not MRSA’,” said Prof. Tanner. “This contrasts with what patients said: ‘I cannot cope’; ‘There was a stage when I just wanted to die. I was in utter despair.’ Another said: ‘My children woke up in the middle of the night screaming.’” She also pointed out that there were
financial implications for patients – those patients that had been in work at the start of the surgery were all on reduced pay. They struggled to pay the mortgage and experienced financial hardship. Patients also talked about the lack of
support and help in the community. They felt frightened and isolated, and talked about going from ‘pillar to post’ to find someone who would diagnose their developing symptoms. Prof. Tanner read out another patient’s account, highlighting the problems patients face after being discharged: “I felt ill and couldn’t keep food and
drink down. The GP said: what do you expect you have had major surgery. I thought I was going mad. Perhaps I was supposed to feel like this? My husband was at his wits end and didn’t know what to do. He called NHS helpline and they said to buy some anti-sickness tablets from the chemist.We rang the hospital and they weren’t very helpful.We rang the ward and they said ‘she has been discharged so there is nothing we can do’. After 3-4 days I was getting really bad pains in my stomach and I’d felt like I’d
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