PE R IOPE RAT IVE PRACT ICE
section (CS) surgeries. She has been at the heart of SSI surveillance for more than 11 years. During this time, she has worked with well-respected healthcare leaders, surgeons, and multidisciplinary teams, and persuaded them the benefits of accurate data collection.
Changing and change management It is testament to Lillian’s approach and tenacity that the Trust has changed its approach and can be considered an exemplar in reducing risk of SSIs. Originally, when she began prospective SSIS in 2009, she was warned not to expect positive results as challenging long held views can be a lengthy battle. She expanded on her original remit of engaging surgeons in SSI surveillance and explaining the importance of this patient safety initiative.
Lillian said: “I have always believed that
all HCPs have one common call; to give safe care to every patient they encounter. This was my mindset when approaching colleagues at the outset. I refused to think that anyone was unapproachable, and instead took the view that different situations may impact different behaviours at any given time.
“I kept an open mind and I was patient.
When trying to engage surgeons as SSIS champions, if someone did not respond positively at first, I tried again another time. I never gave or took an excuse, and I believe this is what made the difference to my whole SSI surveillance career.”
Change management is key to successful
SSI surveillance and SSI prevention. Collection of robust data is important, but this data must be utilised to inform surgical practice otherwise it becomes a wasted exercise. Another key factor, Lillian found, was good engagement with clinical teams and identification of local champions to act as change agents. She said: “During my experience, SSI prevention changes have been data driven, meaning that having systems for robust data collection are also key.”
Creating an SSI surveillance programme
One of the main SSI prevention measures that was introduced, as part of the SSI surveillance and prevention programme, was the standardisation of skin preparation in theatres. This followed the publication of the Darouiche paper3
in 2010, which suggested
that alcoholic skin preparations are superior to aqueous based skin preparation agents. ChloraPrep was first introduced in adult cardiac surgery in August 2010 following a series of SSI detailed investigation meetings. During initial meetings with a ChloraPrep representative and the infection control surveillance team leader, SSI prevention evidence was thoroughly discussed, which
Figure 1. SSI rates before and after implementation of ChloraPrep. (Data courtesy of Guy’s and St Thomas’ NHS Foundation Trust).
was also backed by the newly published guidance from the Department of Health (DH)4
on high impact interventions. To
get the right buy in, current SSI data was presented to surgeons, alongside the proposed quality improvement plan. When a consensus was reached to introduce the product, the respective theatre management team arranged for their teams to be trained on ChloraPrep, with a detailed plan being provided and records being kept for audit purposes. Good communication was retained from the beginning, to make sure any new staff received appropriate training, with retraining scheduled for current staff at regular intervals.
Challenging inconsistencies in care provision
Since the initial launch in 2010, the Trust has gone on to standardise skin preparation for all surgical specialties in line with evidence-based SSI prevention recommendations. Skin preparation in many other directorates was driven by theatre sisters who had been keen to standardise this in theatres for some time. Before standardising practice, use of skin preparation in theatres was dependant on surgeon choice. One of the issues with this was inconsistencies with care provision between patients presenting with the same condition or requiring the same procedures. Skin preparations were also contained in reusable bottles, which meant there was a high risk of cross contamination. Lillian said: “This intervention was therefore welcomed by many theatre colleagues. This evidence-based SSI prevention intervention is endorsed by the latest SSI guidelines from the World Health Organization (WHO) and the National Institute for Health and Care Excellence (NICE).” 5
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Data-led institutional change and the benefits of ChloraPrep The team employed targeted interventions in line with NICE evidence-based guidelines for SSI reduction. This gave an opportunity to standardise practice along a patient’s journey to improve quality, safety and efficiency, in line with organisational targets. A strong SSIS leadership and adoption of a multidisciplinary collaborative led to successful reduction of SSI rates for covered surgical specialties. The NICE ‘SSI Quality Standard (QS) 49’ enabled the team to further reduce SSI incidence at a time when they believed they had reached the irreducible minimum for some specialties. Such was the success, that in 2017 the team from Guy’s & St Thomas’ NHS Foundation Trust presented to the NICE shared learning database, their findings.6 They set out that SSI surveillance at the Trust started as a patient safety initiative using established local protocols in line with National Institute for Health and Care Excellence (NICE) recommendations. Lillian said: “This is how we have demonstrated reductions in SSI rates across a number of specialties since introducing ChloraPrep, as part of our SSI prevention package. One area where we have shown significant SSI reductions is Caesarean section (CS). This started in February 2011.”
Inpatient and readmission C-section SSI rates The introduction of ChloraPrep and other SSI prevention measures were championed by a consultant obstetrician and a midwifery practice lead in obstetric theatres. A roll out programme was agreed and training for staff delivered by ChloraPrep and the SSI local champion. The inpatient/readmission SSI incidence reduced from: 4% (January
OCTOBER 2020
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