INFECTION CONTROL


improve the management of post- operative wounds following Caesarean sections, the Trust has witnessed a notable improvement in patient outcomes. This analysis reports on a case series of 239 women with BMI>35 who underwent Caesarean section procedures. A baseline audit conducted by the Trust suggested that they were experiencing 3-4 patient readmissions as a result of wound complications prior to the introduction of the steps described herein. Furthermore, applying data derived from the national audit, we would anticipate around almost 20% (~45 of these women) might be expected to experience a surgical site infection. In the case audit findings reported here, we identified only one infection in the PICO group. The one patient who developed the wound infection in this evaluation also had diabetes, which according to Wloch et al (2013) correlates with a higher than normal wound infection rate of 15.6% in Caesarean section patients. This not only has important patient benefits but also economic implications for the Trust. The recent study by Jenks et al reported an average cost per SSI following Caesarean section procedures of approximately £3,700. Based on the predicted number of 45 infections, discussed above, the Trust could have expected to incur a treatment cost of around £165,000 had they not implemented the protocols described herein. In addition to the clinical and economic


benefits the changes to practice described have also resulted in meaningful patient benefits. Infections following Caesarean sections can be painful and traumatic for women at a time when they want to focus on caring for their newborn. The avoidance of these is therefore a highly desirable outcome. Other authors have also noted how NPWT provides a ‘stenting’ effect at the surgical incision and anecdotal reports from women treated with PICO suggest that it provides women with a degree of security that their surgical incision is being supported.


Limitations of the study The authors are keen to highlight the limitations of the findings reported herein. The findings are derived from an audit of routinely collected data. Such an approach also faces challenges of missing data as was the case in the current analysis. It is also important to note that we compared our findings to historic controls also reported from routine data. As such, this cannot be considered a comparative study. It is also true that other variables may have changed over the course of the 2-3 years during which new post-operative wound management protocols were put in place and that these too may have contributed to


46 THE CLINICAL SERVICES JOURNAL


100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0


79 (51%)


35 (45%)


Elective Emergency


76 (49%)


43 (55%)


<40


>=40 Body Mass index (kg/m2 ) Fig. 4 The number of patients with BMI above and below 40, per operation type. Table 3 Breakdown of expected costs for high risk patient group


Item PICO


Re-admissions (assuming 3 per month prior to study) Total


Savings Annually


If using Jenks et al (2014) estimated cost of SSI = £3,716 per patient episode. *average of 7.97 patients with high BMI per month


any improvements identified. However, while these are all shortcomings of the current evaluation, it should also be noted that the data presented are derived from routine data on patients managed in a real world setting. The patients treated were not subject to eligibility criteria as might be the case in a clinical trial and treatment reflected day-to-day practice in the hospital. In light of this, it could be argued that the findings should be more readily reproducible than a clinical trial.


Conclusion


It is essential that we do all we can to help minimise the risk of infection for patients undergoing Caesarean section procedures. One way to do this is to identify criteria which may deem a patient at higher risk of wound complications either due to their body weight or their relative health at the time of surgery. The next step is to get all staff to buy in to the process. In this case, tissue viability, infection control, obstetricians, midwives and ward managers were all involved in the changes being implemented. For the majority of patients negative pressure wound therapy may not be necessary; however, for the high risk patients it would appear that this should be considered as an alternative to traditional dressings.


This study demonstrates that using PICO NPWT on closed incisions in high


risk patients can potentially reduce wound complications, readmission rates and may reduce the overall incidence of wound breakdown in this vulnerable patient group. In addition, the positive impact on the patient and families’ well-being during a very important time in their lives cannot be ignored. More importantly, this project identified the need for improved staff education, a better understanding of wound care issues and encouraged all staff to take ownership of this problem. The additional cost of the dressing is significantly off set by the reduction in re-admission rate suggesting this protocol is extremely cost effective. The authors point out that this evaluation is not a randomised trial but a case series/evaluation intended to show a reduction in wound infection when utilising a new therapy. The numbers are not high enough to show significance. Despite this, however, there are encouraging indications that the therapy may have a beneficial role to play in the incision management of high risk patients.


Conflict of interest:


This work was not funded by Smith and Nephew; however, support was provided by the company in relation to training and education of staff in the application of the therapy. Assistance was also provided in writing up the results of the evaluation. ✚


APRIL 2015


Previous Protocol New Protocol £0


£133,776 £133,776


£11,476* £0


£11,476 £122,300


Number of patients (% of patients)


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