Infection prevention
Care Bundles While SSI care bundles can have a significant impact, they can also be challenging to implement – as with any change within the healthcare setting. Getting everyone ‘on board’ is crucial. Mr Giles Bond-Smith, lead consultant HPB and emergency surgeon, at the Oxford University Hospital NHS Foundation Trust, discussed the ‘practical implementation of care bundles’ – sharing his insights into achieving sustained improvement. “The challenge with SSI is the fact that it is multimodal – there is the patient’s physiology; they may be malnourished, and they may have a complex medical history including cancer,” he explained. Following liver and pancreatic cancer surgery, for example, surgical site infection can delay the patient from receiving vital post-operative chemotherapy, which is key to improving outcomes and length of survival. “That’s why it is vital that we get it right first
time (GIRFT),” he asserted. Mr Bond-Smith emphasised that multidisciplinary teams have a vital role to play in driving improvement in SSIs – not just the surgeon. There needs to be collaboration with infection prevention and control, microbiology, the anaesthetist, the scrub team, the surgeon, the critical care team, as well as procurement. Procurement needs to understand what is
trying to be achieved with the patient cohort – to understand the business case, through cost-based analysis, and this must be based on the whole patient journey and outcomes. “With any clinical improvement, if you do
not look at the whole journey and the financial planning, it is difficult to get anywhere. On paper, it may look expensive, but when you look at the ‘whole circle’, the initiative is cost effective – if you prevent just one deep incisional SSI after HPB surgery, the cost is justified,” said Mr Bond- Smith. Steps for improvement need to be easy to understand and implement, as well as being bespoke to the specialty, he advised. “People are not going to engage if you make it difficult or complex for them. It must not be time consuming to implement and the bundle must be simple, evidence based, cost effective, and sustainable,” he explained. Mr Bond-Smith added that improving SSI also has the added benefit of reducing the impact on the environment – a patient with an SSI consumes more hospital resources and will have more journeys to hospital, generating additional CO2
emissions and needless use of
water. It can therefore support other board- level objectives – such as helping to achieve the Net Zero target for the NHS.
Implementation When implementing a care bundle, Mr Bond-Smith emphasised that is important that “you do not tell the surgeon how to do the operation itself”. “You can influence the patient’s journey up
to the point of knife to skin; but let the surgeon do the operation their way. When it comes to wound closure, that’s when you step back in, so the patient leaves the theatre in a safe, robust, evidence-based, sustainable manner,” Mr Bond- Smith continued. The secret to achieving successful implementation, he found, was the development of six simple steps: Step One: The first step is to conduct 1-2 months of SSI surveillance, for all operations, to identify the true local 30-day SSI rate – the rates are “always higher than you think”, Mr Bond- Smith pointed out. “As a surgeon, I took responsibility for this – I assessed every wound, at the time of discharge and 30 days later. You need this audit to understand the scale of the problem,” he commented. Step Two: The next step is to disseminate this information. Step Three: Once the problem has been identified and the data collected, it is important to involve all key stakeholders to solve the problem. “The whole team needs to come together
to implement a tried and tested bundle,” commented Mr Bond-Smith. He explained that it is important to build a multidisciplinary team to solve the problem and to give each member just 1-2 roles each. The care bundle should have no more than 10 points. The Liver and Pancreatic SSI reduction bundle, at the Oxford University Hospital NHS Foundation Trust, includes just eight points:
1 Clip, don’t shave (but only if hair removal is necessary and do it outside of the theatre).
2 Correct antibiotic at the correct time. 3 Normothermia (36o
C or above).
4 2% Chlorhexidine gluconate in 70% Isopropyl alcohol skin prep.
5 Glycaemic control between 6-8mmol/L DO THE OPERATION
6 Wash the wound with aqueous povidone- iodine. (This coincides with the ‘pause for gauze’/safety check)
7 Close the wound in layers, using Triclosan sutures.
8 Subcuticular skin closure with Monocryl Plus and Dermabond.
At the Oxford University Hospital NHS Foundation Trust, each point is carried out by just one person and every point in the bundle is evidence based. Mr Bond-Smith pointed out that, although the WHO Checklist has helped improve compliance with the requirement to give the antibiotic at the right time, what exactly is the right antibiotic? Each year, this is evaluated with the IP&C and microbiology teams to see whether the bioflora has changed and to review prophylatic antibiotics accordingly. Over the course of 10 years, there have been several changes to ensure optimal antibiotic stewardship. Step Four: Staff should be allowed to get
used to their role in the SSI reduction bundle – avoiding the temptation to make changes. This is essential to enable the initiative to become embedded and normalised. It is also important to assess the compliance rate. At the Oxford University Hospital NHS Foundation Trust, an audit reported over 95% adherence to the bundle
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