INFECTION CONTROL
area, as may be the case in Caesarean section procedures, which creates friction and moisture around the wound site. Excessive tension on the incision is also likely to be problematic which may cause wound dehiscence and result in infection. Within the Wrightington, Wigan and Leigh NHS Trust, an audit in 2011 revealed an overall SSI rate in Caesarean section patients of 12%, higher than the 9.6% UK rate uncovered by Wloch et al (2013). In one group of patients in the audit, those with BMI>35, it was noticed that 3-4 patients per month were readmitted with wound dehiscence as a result of surgical site infection (Bullough, Wilkinson, Burns and Wan 2014). The findings prompted the Trust to
implement an improvement programme to mitigate against the risk of SSI following Caesarean section deliveries. In the first instance wound care practice was changed to help reduce the overall surgical site infection rate across all patients undergoing Caesarean deliveries. A simple transparent, film dressing (Opsite Post-Op Visible (Smith and Nephew, Hull) was introduced as the standard dressing to be used in Caesarean section patients immediately post-operatively. Dressings were to remain in place for at least 48 hours and, if possible, for up to seven days.
Table 1: Demographic data
Age (years) Mean
Median Std Min Max N
BMI (Kg/m2 <40
>=40 Mean
Median Std Min Max N
C-Section Details 1st C-Section 2nd C-Section 3rd C-Section 4th C-Section N
C-Section Type Elective
Emergency N
44 )
159 (66.5%) 80 (33.5%) 39.4 38
5.4 35 70
239 Table 2: Patient history
All patients 123 (64.7%) 60 (31.6%) 4 (2.1%) 3 (1.6%)
190 (100%)
119 (51.1%) 114 (48.9%) 233 (100%)
THE CLINICAL SERVICES JOURNAL
All patients 30.2 30
5.3 17 42
238
18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
Month 2012 2013 2014 Fig. 2a shows the number of C-Section operations per month in high BMI patients.
In order to reduce the overall infection rates and prevent readmissions in the high BMI group, a new single-use negative pressure wound therapy system (NPWT) (PICO, Smith and Nephew, Hull) was implemented for this patient group. There is an increasing body of evidence to suggest that NPWT can be effective in reducing the risk of post-operative wound complications, including SSI (Karlakki et al 2014). Studies in orthopaedic trauma,
cardiothoracic, Caesarean section, and hip and knee revision patients have demonstrated reduced wound complications in high risk patients when using negative pressure wound therapy to manage the incisions (Karlakki et al 2014). One recent study (Harris 2013) from the United States has identified that using disposable NPWT as part of a programme to reduce complications following Caesarean section procedures has had a dramatic effect on infection rates. Wrightington, Wigan and Leigh Trust
ran an initial feasibility study, introducing disposable NPWT into practice for women with BMI>35 undergoing Caesarean section deliveries. The initial experience on the first fifty patients resulted in no infections. This paper reports an analysis of the first two years experience of using PICO disposable NPWT system following Caesarean section deliveries in women with a BMI>35.
Method In order to reduce the wound infection and readmission rates in the patients with BMI of 35 or more, the PICO system was applied immediately after the surgical procedure, in theatre. PICO is a canister- free, single-use NPWT system for closed surgical incisions. It has been designed to be simple to use and to enable the patient to be mobile following surgery – the small device can fit in a patient’s pocket or bag. Each PICO kit includes two dressings and provides the entire seven day therapy for a patient with no need for additional components, such as canisters, to manage fluid from the incision. The innovative dressing has an airlock layer to ensure negative pressure is distributed across the dressing and also a silicone wound contact layer to enable gentle removal of the dressing. With the fluid handling capacity of 300mls across both bacteria proof dressings in the PICO kit, the therapy will continue to manage and protect the incision until removal. In all cases, the NPWT system was applied in theatre onto closed wounds, following suturing. PICO therapy was applied in theatre immediately following the operation and was left in situ for one week only. Midwives had undergone wound management training and education on the application and management of the PICO therapy. Post-discharge surveillance was
It is essential that we do all we can to help minimise the risk of infection for patients undergoing Caesarean section procedures.
APRIL 2015
Number of patients
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
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