Innovative solutions to reduce surgical site …...Innovative solutions to reduce surgical site...
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Innovative solutions to reduce surgical site infection and length of stay in high risk Cardiothoracic patients Donna Rodden, Surgical Site Infection Nurse, Cardiothoracic Department, Hammersmith Hospital, Imperial College Healthcare London Trish Dickinson, Clinical Specialist, Wound Management, Smith & Nephew, Hull UK Anna Taylor, Clinical Project Manager, Wound Management, Smith & Nephew, Hull UK Introduction A surgical site infection (SSI) may range from a spontaneously limited wound discharge within 7-10 days of an operation to a life threatening post-operative complication, such as a sternal infection after heart surgery 1 . Such infections account for approximately 16% of all hospital acquired infections and are estimated to double the length of post op hospital stay and significantly increase the cost of care 2 . Advances in surgery and anaesthesia have resulted in patients who are at higher risk of developing an SSI being considered for surgery 1 and in open Cardiothoracic surgery, the mortality associated with deep sternal infections is substantial with as many as 33% of patients dying within a year of the occurrence of such an infection 3 . In July 2008 a Surgical Site Infection Surveillance Scheme (SSISS) was launched by the Health Protection Agency (Public Health England). This enabled participating hospitals to generate reports of their data and compare their rates of SSI against a benchmark. In 2011, the Imperial College Cardiothoracic Surgery Unit found their SSI rate to be significantly higher than the national average (up to 15% compared with 4.5%). Changes to practice were implemented in a drive to reduce the incidence of SSI and an SSI Nurse was appointed to lead the prevention of SSI and to manage the surveillance data. Since April 2012, the SSI rate in the Cardiothoracic Unit has improved and has been below the national average ranging between 3-4% with the unit still planning to improve upon this. The SSI Nurse found that around 97% of all SSI incidences occurred in the high risk patient group, mostly in diabetic patients and those with a high BMI - with the SSI rate being up to 18% in the high risk group. Aim Increasing evidence is emerging to demonstrate the effect of using Negative Pressure Wound Therapy (NPWT) as a preventative tool for managing a closed incision 3 . NPWT used in this way has been found to reduce the incidence of wound infection post sternotomy in high risk obese patients 4 . Imperial College Cardiothoracic Surgery Unit evaluated the effect of using PICO™ NPWT device as the post-operative dressing on high risk patients undergoing Coronary Artery Bypass Graft (CABG) surgery. The aims of the evaluation were to assess the effectiveness of PICO with regard to reducing post- surgical complications and length of hospital stay in high-risk patients. PICO is a battery operated device which delivers continuous NPWT at -80mmHg. PICO is a single use, disposable device designed to manage surgically closed incisions and has been shown to significantly reduce SSI incidences compared to a standard dressing 5,6 . Method Working with the SSI Nurse, a Cardiothoracic surgeon agreed to evaluate the effect of using PICO as the post-operative management for those CABG patients presenting with a high risk of potential healing problems: • BMI >30 or weight >120kg • Diabetic patients or those with HbA1c >40 • Patients with renal failure or those with other co-morbidities known to have a negative effect on wound healing outcomes. An infection of the sternal wound can cause devastating consequences and from the author’s experience the leg donor site frequently suffers with wound healing issues often resulting in an extended length of hospital stay and an increased demand on NHS resources. It was decided to evaluate PICO on both the closed sternal incision and donor leg site in order to assess the impact that PICO might have not only on SSI / healing complication rates but also on the length of hospital stay. During pre-op screening, high risk patients were identified and instructions written in their notes that PICO would be required post-operatively. PICO was applied to both incision sites (see image 1) whilst the patient was still in theatre (sizes 10x30cm for the sternal site and 10x40cm for the leg donor site). Non high risk patients received a standard film dressing. From May through to December 2014, a total of 162 patients presented for CABG surgery with twenty one of these patients considered high risk and therefore managed post operatively with PICO. Results The results are summarised in the table below: In the group of patients managed with conventional dressings post-operatively (n=141), there was a 5.7% rate of SSI with five patients suffering wound healing problems at the donor site and three experiencing the same issues at the sternal incision site. The consequences of such have significant implications for the patient, clinician and related hospital resources as further surgery may sometimes be necessary; an increased hospital stay; potential return to theatre; additional use of dressings and nursing time; distress to the patient. In comparison there were no incidences of SSI or any wound healing problems experienced at both the donor and sternal site with PICO usage. Wound healing challenges (not SSI related) in the conventional dressing group occurred in 38 patients-one of which was at the sternal site (see image 2) and 37 at the donor site thus illustrating the authors’ pre-evaluation concerns. Such challenges at the leg donor sites mainly referred to the management of exudate levels from ‘leaky legs’ (see image 3). In the PICO group of patients however, there were no wound healing issues (see image 4). The average length of hospital stay for patients receiving conventional dressings was 12.5 days in comparison to patients receiving PICO having a reduced hospital stay of 5.4 days - a significant reduction in hospital stay of seven days. To illustrate this, a bed on the cardiothoracic unit costs £550 per night thus demonstrating an initial saving of £3850 per patient for hotel costs alone. Image 1: PICO in situ May-Dec 2014 Standard Dressing PICO Total cases 141 21 Total SSI 8 (5.7%) 0 Sternum 3 0 Donor 5 0 Healing problems non SSI 38 (26.9%) 0 Sternum 1 0 Donor site 37 0 Average LOS (days) 12.5 5.4 Image 2: A sternal incision site (conventional dressing) that developed wound healing challenges Image 3: A leg donor site (conventional dressing) which broke down nine days post-op Image 4: Example of a sternal incision site post PICO Discussion/Conclusion The introduction of PICO NPWT has had a positive effect on outcomes for those patients at highest risk of developing problems with wound healing post-operatively. No complications of SSI or wound healing issues at either incision site were experienced when PICO was utilised. The positive effects are so compelling that the SSI Nurse developed a care pathway (see image 5) to ensure that all high risk patients undergoing CABG surgery have both the sternum and donor incision site managed with PICO. This pathway is currently being implemented throughout the Cardiothoracic Unit and is expected to provide even stronger data in the future to further demonstrate the effectiveness of incision management with PICO. References 1. NICE 2008 Surgical Site Infection https://www.nice.org.uk/guidance/cg74/chapter/introduction. 2. Protocol for Surveillance of Surgical Site Infection 2013 Public Health England Surgical Site Infection Surveillance Service Version 6. 3. Karlakki S Brem M Giannini S Khanduja V Stannard J Martin R 2013 Negative pressure wound therapy for management of the surgical incision in orthopedic surgery Bone Joint Res 2:276–84. 4. Grauhan O Navasardyan A Hofmann M Muller P Stein J Hetzer R 2012 Prevention of post sternotomy wound infections in obese patients by Negative Pressure Wound Therapy. The Journal of Thoracic and Cardiovascular Surgery 145(5):1387-92. 5. Selvaggi F Pellino G Sciaudone G Corte A Candilio G Campitiello F Canonico S 2014 New Advances in Negative Pressure Wound Therapy (NPWT) for Surgical Wounds of Patients Affected with Chron’s Wound Healing - Disease Surgical Technology International XXIV 1-7 6. Bullough L Burns S Wilkinson D 2014 Reducing infection rates in caesarean section patients with BMI of 35 or more: a 138 patient evaluation Poster Presentation EBCOG. ™Trademark of Smith & Nephew © Smith & Nephew March 2015 57214 Poster presented at STSC Conference 2015. This poster was supported by restricted medical grant from Smith & Nephew. Cardiothoracic PICO Pathway Revision PICO indicated PICO indicated PICO indicated PICO indicated PICO indicated Standard care Primary Pre-Assessment BMI >30 or >120kg Diabetic or HBA1C >40 Pico Score of >12 Smoker Non-Smoker AND Pico score of < 12 AND Non-diabetic AND HBA1C < 40 NHS Trust Imperial College Healthcare PICO contraindications Patient Suitability? Is PICO a suitable treatment for the patient being considered? - Will the patient be concordant with the therapy? - Will the patient remove and/or interfere with the dressing and/or device? - Will PICO be acceptable to the patient? Considerations for PICO use Wound Site Is the wound location suitable for treatment with PICO? - Avoid sites with pins and/or external fixation. - Will it be possible to achieve and maintain a seal? - Can the port can be located in an area which will minimise the risk of pressure damage? - Consider routing of tubing to avoid risks of pressure damage and entanglement - Consider proximity of stoma sites - Consider application technique over joints Should you have any queries please contact: Donna Rodden, Surgical Site Infection Nurse, Bleep: 5933 or Mobile: 07977 620454 Smith & Nephew Product Advice Line: 0800 590173 or [email protected] CABG Procedure Do not use PICO if any of the contraindications for PICO use are applicable: • Do not use on patients with malignancy in the wound bed or the margins of the wound (except for palliative care to enhance quality of life). • Do not use on patients with previously confirmed and untreated osteomyelitis. • Do not use on patients with non-enteric and unexplored fistulas. • Do not use on necrotic tissue with eschar present. • Do not use over exposed arteries, veins, nerves or organs. • Do not use on exposed anastomotic sites. • Emergency airway aspiration • Pleural, mediastinal or chest tubing drainage • Surgical suction Image 5: Imperial College Healthcare - Cardiothoracic PICO Pathway
Transcript of Innovative solutions to reduce surgical site …...Innovative solutions to reduce surgical site...
Innovative solutions to reduce surgical site infection and length of stay in high risk Cardiothoracic patientsDonna Rodden, Surgical Site Infection Nurse, Cardiothoracic Department, Hammersmith Hospital, Imperial College Healthcare LondonTrish Dickinson, Clinical Specialist, Wound Management, Smith & Nephew, Hull UKAnna Taylor, Clinical Project Manager, Wound Management, Smith & Nephew, Hull UK
Introduction A surgical site infection (SSI) may range from a spontaneously limited wound discharge within 7-10 days of an operation to a life threatening post-operative complication, such as a sternal infection after heart surgery1. Such infections account for approximately 16% of all hospital acquired infections and are estimated to double the length of post op hospital stay and significantly increase the cost of care2.
Advances in surgery and anaesthesia have resulted in patients who are at higher risk of developing an SSI being considered for surgery1 and in open Cardiothoracic surgery, the mortality associated with deep sternal infections is substantial with as many as 33% of patients dying within a year of the occurrence of such an infection3.
In July 2008 a Surgical Site Infection Surveillance Scheme (SSISS) was launched by the Health Protection Agency (Public Health England). This enabled participating hospitals to generate reports of their data and compare their rates of SSI against a benchmark.
In 2011, the Imperial College Cardiothoracic Surgery Unit found their SSI rate to be significantly higher than the national average (up to 15% compared with 4.5%). Changes to practice were implemented in a drive to reduce the incidence of SSI and an SSI Nurse was appointed to lead the prevention of SSI and to manage the surveillance data.
Since April 2012, the SSI rate in the Cardiothoracic Unit has improved and has been below the national average ranging between 3-4% with the unit still planning to improve upon this.
The SSI Nurse found that around 97% of all SSI incidences occurred in the high risk patient group, mostly in diabetic patients and those with a high BMI - with the SSI rate being up to 18% in the high risk group.
Aim Increasing evidence is emerging to demonstrate the effect of using Negative Pressure Wound Therapy (NPWT) as a preventative tool for managing a closed incision3. NPWT used in this way has been found to reduce the incidence of wound infection post sternotomy in high risk obese patients4.
Imperial College Cardiothoracic Surgery Unit evaluated the effect of using PICO™ NPWT device as the post-operative dressing on high risk patients undergoing Coronary Artery Bypass Graft (CABG) surgery.
The aims of the evaluation were to assess the effectiveness of PICO with regard to reducing post- surgical complications and length of hospital stay in high-risk patients.
PICO is a battery operated device which delivers continuous NPWT at -80mmHg. PICO is a single use, disposable device designed to manage surgically closed incisions and has been shown to significantly reduce SSI incidences compared to a standard dressing5,6.
Method Working with the SSI Nurse, a Cardiothoracic surgeon agreed to evaluate the effect of using PICO as the post-operative management for those CABG patients presenting with a high risk of potential healing problems:
• BMI >30 or weight >120kg• Diabetic patients or those with HbA1c >40• Patients with renal failure or those with other co-morbidities known to have a negative effect on wound healing outcomes.
An infection of the sternal wound can cause devastating consequences and from the author’s experience the leg donor site frequently suffers with wound healing issues often resulting in an extended length of hospital stay and an increased demand on NHS resources.
It was decided to evaluate PICO on both the closed sternal incision and donor leg site in order to assess the impact that PICO might have not only on SSI / healing complication rates but also on the length of hospital stay.
During pre-op screening, high risk patients were identified and instructions written in their notes that PICO would be required post-operatively. PICO was applied to both incision sites (see image 1) whilst the patient was still in theatre (sizes 10x30cm for the sternal site and 10x40cm for the leg donor site). Non high risk patients received a standard film dressing.
From May through to December 2014, a total of 162 patients presented for CABG surgery with twenty one of these patients considered high risk and therefore managed post operatively with PICO.
ResultsThe results are summarised in the table below:
In the group of patients managed with conventional dressings post-operatively (n=141), there was a 5.7% rate of SSI with five patients suffering wound healing problems at the donor site and three experiencing the same issues at the sternal incision site. The consequences of such have significant implications for the patient, clinician and related hospital resources as further surgery may sometimes be necessary; an increased hospital stay; potential return to theatre; additional use of dressings and nursing time; distress to the patient.
In comparison there were no incidences of SSI or any wound healing problems experienced at both the donor and sternal site with PICO usage.
Wound healing challenges (not SSI related) in the conventional dressing group occurred in 38 patients-one of which was at the sternal site (see image 2) and 37 at the donor site thus illustrating the authors’ pre-evaluation concerns. Such challenges at the leg donor sites mainly referred to the management of exudate levels from ‘leaky legs’ (see image 3). In the PICO group of patients however, there were no wound healing issues (see image 4).
The average length of hospital stay for patients receiving conventional dressings was 12.5 days in comparison to patients receiving PICO having a reduced hospital stay of 5.4 days - a significant reduction in hospital stay of seven days. To illustrate this, a bed on the cardiothoracic unit costs £550 per night thus demonstrating an initial saving of £3850 per patient for hotel costs alone.
Image 1: PICO in situ
May-Dec 2014 Standard Dressing PICOTotal cases 141 21
Total SSI 8 (5.7%) 0Sternum 3 0Donor 5 0
Healing problems non SSI 38 (26.9%) 0
Sternum 1 0Donor site 37 0
Average LOS (days) 12.5 5.4
Image 2: A sternal incision site (conventional dressing) that developed wound healing challenges
Image 3: A leg donor site (conventional dressing) which broke down nine days post-op
Image 4: Example of a sternal incision site postPICO
Discussion/ConclusionThe introduction of PICO NPWT has had a positive effect on outcomes for those patients at highest risk of developing problems with wound healing post-operatively. No complications of SSI or wound healing issues at either incision site were experienced when PICO was utilised.
The positive effects are so compelling that the SSI Nurse developed a care pathway (see image 5) to ensure that all high risk patients undergoing CABG surgery have both the sternum and donor incision site managed with PICO.
This pathway is currently being implemented throughout the Cardiothoracic Unit and is expected to provide even stronger data in the future to further demonstrate the effectiveness of incision management with PICO.
References1. NICE 2008 Surgical Site Infection https://www.nice.org.uk/guidance/cg74/chapter/introduction. 2. Protocol for Surveillance of Surgical Site Infection 2013 Public Health England Surgical Site Infection Surveillance Service Version 6. 3. Karlakki S Brem M Giannini S Khanduja V Stannard J Martin R 2013 Negative pressure wound therapy for management of the surgical incision in orthopedic surgery Bone Joint Res 2:276–84. 4. Grauhan O Navasardyan A Hofmann M Muller P Stein J Hetzer R 2012 Prevention of post sternotomy wound infections in obese patients by Negative Pressure Wound Therapy. The Journal of Thoracic and Cardiovascular Surgery 145(5):1387-92. 5. Selvaggi F Pellino G Sciaudone G Corte A Candilio G Campitiello F Canonico S 2014 New Advances in Negative Pressure Wound Therapy (NPWT) for Surgical Wounds of Patients Affected with Chron’s Wound Healing - Disease Surgical Technology International XXIV 1-76. Bullough L Burns S Wilkinson D 2014 Reducing infection rates in caesarean section patients with BMI of 35 or more: a 138 patient evaluation Poster Presentation EBCOG.™Trademark of Smith & Nephew © Smith & Nephew March 2015 57214 Poster presented at STSC Conference 2015.
This poster was supported by restricted medical grant from Smith & Nephew.
Cardiothoracic PICO Pathway
Revision
PICO indicated PICO indicated PICO indicated PICO indicated
PICO indicated
Standard care
Primary
Pre-Assessment
BMI >30 or >120kg
Diabetic or HBA1C >40
Pico Score of >12 Smoker
Non-Smoker AND Pico score of < 12 AND Non-diabetic AND HBA1C < 40
NHS TrustImperial College Healthcare
PICO contraindications
Patient Suitability? Is PICO a suitable treatment for the patient being considered?- Will the patient be concordant with the therapy?- Will the patient remove and/or interfere with the dressing and/or device?- Will PICO be acceptable to the patient?
Considerations for PICO use
Wound Site Is the wound location suitable for treatment with PICO?- Avoid sites with pins and/or external fixation. - Will it be possible to achieve and maintain a seal?- Can the port can be located in an area which will minimise the risk of pressure damage?- Consider routing of tubing to avoid risks of pressure damage and entanglement- Consider proximity of stoma sites- Consider application technique over joints
Should you have any queries please contact:
Donna Rodden, Surgical Site Infection Nurse, Bleep: 5933 or Mobile: 07977 620454
Smith & Nephew Product Advice Line: 0800 590173 or [email protected]
CABG Procedure
Do not use PICO if any of the contraindications for PICO use are applicable:
• Do not use on patients with malignancy in the wound bed or the margins of the wound (except for palliative care to enhance quality of life). • Do not use on patients with previously confirmed and untreated
osteomyelitis.• Do not use on patients with non-enteric and unexplored fistulas.• Do not use on necrotic tissue with eschar present.• Do not use over exposed arteries, veins, nerves or organs.• Do not use on exposed anastomotic sites.• Emergency airway aspiration • Pleural, mediastinal or chest tubing drainage• Surgical suction
Image 5: Imperial College Healthcare - Cardiothoracic PICO Pathway
