Infection prevention


Mr. Bond Smith added that maintaining normothermia (36o


C or above) is also important


for SSI prevention, yet it is often poorly implemented. Before educating the surgical team at large,


in Oxford, about normothermia, the original audit into pre-operative normothermia demonstrated that none of the patients were normothermic at the time of knife to skin. There have been significant efforts to drive improvement in this area. “Once the patient falls below 36o


C, it is


extremely difficult to raise their temperature back up, so we have to think about normothermia,” he commented. Ensuring normoglycaemia is also important


in preventing SSIs – even in non-diabetics, he explained. Glycaemic control between 6-8mmol/L should be achieved. Glycaemic levels can become elevated due to the stress of the operation, but the anaesthetist should work to bring this down, he asserted. “There is a lot of evidence to support this, but anaesthetists are concerned that that they will make the patient hypoglycaemic. Therefore, they need lots of sampling,” he commented. Triclosan impregnated sutures can also


have an impact. NICE evaluated 31 randomised controlled trials that included over 14,000 patients


and found that Triclosan impregnated sutures reduced SSI rates by up to 30%. In the Oxford HPB department, the introduction of these sutures led to an additional reduction of over 20%..


Care bundle strategy Ultimately, the evidence shows that surgical care bundles can make a significant difference. Tanner et al’’s systematic review and cohort meta- analysis of 8,515 patients (2015) showed that the SSI rate for the bundle group was 7% compared to 15.1% in the standard care group. The SSI strategy, shown in Figure 1, is a simple care bundle that has been tried and tested at the Oxford University Hospitals NHS Foundation Trust.. According to Mr. Bond Smith, the results


have been “extraordinary”. There has been a significant reduction in SSI rates, a significant reduction in length of stay, significant cost savings, and it has ensured ‘a sustainable solution’ for healthcare. Many surgeons are unaware of their own


SSI rates, so Mr. Bond Smith suggested initially auditing the rates, for a period of a couple of months, and presenting the surgeons with the data. “Typically, their SSI rate will be double what they think it is, and double what the literature posts,” he commented. In the acute surgery department, the SSI rate


Suggested SSI Reduction Strategy


1 Ensure clipping NOT shaving of the patient. 2 The correct antibiotics are given at the correct time.


3 Normothermia (36o C or above).


4 2% Chlorhexidine skin preparation. 5 Glycaemic control between 6-8mmol/L.


DO THE OPERATION


6 Wash wound with aqueous povidone-iodine. 7 Close wound in layers (Triclosan sutures). 8 Skin closure using Monocryl Plus and Dermabond.


Figure 1


was audited for at least 30 days, for open, ‘dirty’ laparotomy, and was found to be 40%. One year later, following the implementation of the eight- point care bundle, this was reduced to just 4%. The length of stay was reduced by two days and the Trust has now saved “millions of pounds”.


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June 2023 I www.clinicalservicesjournal.com 21


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