Taking a zero tolerance approach to preventable

Taking a zero tolerance approach
to preventable surgical site infections
in UK hospitals
Foreword
The UK has witnessed dramatic reductions in
the rates of Clostridium difficile (C. difficile) and
Methicillin-resistant Staphylococcus aureus (MRSA)
bloodstream infections since 2006/7, when the health
service made a concerted attempt to eradicate
avoidable cases of these difficult-to-treat and
dangerous healthcare-associated infections (HCAI).
Since the mid-2000s, there has been a significant
cultural shift in the way UK hospitals tackle infection
prevention and control, with the greatest reductions
in infection rates seen in hospitals with strong
leadership and robust performance management1.
Reducing MRSA bloodstream and C.
difficile infections has been a top priority
for most NHS Trusts, but other types of
infection have been relatively neglected1.
Many hospitals do not undertake routine
surveillance on any other HCAIs, and
even those that do until recently, then
only reported data on MRSA and C.
difficile infections1.
Surgical site infections (SSIs) impose a
substantial burden on both the patient
and the healthcare system, yet little is
known about the true rates of infection
in the UK and the cost of these infections
to the NHS. Many SSIs are unaccounted
for as the majority (up to 60%) are
superficial and present in the community
post-discharge2. Surveillance reports
from the Health Protection Agency (HPA)
underestimate the true impact of SSIs
as they generally only capture inpatient
SSIs whereas significant primary care
costs are associated with the treatment
of SSIs. What we do know is that patients
with SSIs have long unplanned hospital
stays3-5; are five-times more likely to
be readmitted after discharge, are 60%
more likely to spend time in an intensive
care unit (ICU), and twice as likely to
die as those without SSIs6. Healthcarerelated costs almost double if a patient
suffers an SSI7.
The better news is that the vast majority
of SSIs are preventable. The patient’s
Under the knife
own skin is the source of the pathogens
responsible for most SSIs8-10, so a few
basic but essential evidence-based
practices prior to and during surgery,
can significantly reduce SSI rates and, by
doing so, improve patient safety, unblock
beds, reduce readmissions, and save the
NHS a substantial amount of money.
SSIs should be moved up the
management and infection prevention
and control agenda and we should adopt
a zero tolerance approach to these
potentially preventable infections. It
is our belief that surgical teams that
are armed with their own SSI data,
have a collective focus supported by
their infection control, management
and procurement colleagues, and are
willing to make a few small changes to
their everyday surgical practice, could
significantly reduce the burden and cost
of SSIs. As has been seen in hospitals
like UCLH, removing finanacial hurdles
and adopting a ‘spend to save’ mentality
ensures that the best products and
practices with the best evidence for their
SSI reduction potential are used.
Phil Adams-Howell, Clinical Procurement Lead
Moninder Bhabra, Cardiothoracic Surgeon
Mark Enright, Research Director of AmpliPhi
Biosciences Corp and former Professor of
Molecular Epidemiology, Imperial College
Martin Kiernan, Nurse Consultant for Prevention and
Control of Infection
Shyam Kolvekar, Cardiothoracic Surgeon
Paul Trueman, Professor of Health Economics
UK hospitals
should take a
zero tolerance
approach to
preventable
SSIs
• There should be continuous hospital surveillance
and reporting of SSIs
• A nationally-agreed methodology for SSI
identification and reporting after discharge must be
developed and applied
• Every hospital should review its current practice in
relation to the prevention of SSIs
• Evidence-based approaches to the prevention of
SSIs must be implemented and complied with by all
members of the surgical team
• Hospital-level SSI data should be fed back to the
surgical teams on a regular basis, with support for
change where rates could improve
• Hospital readmission rates due to SSIs should be
monitored and reported
• A formal process for exchanging SSI data and
sharing best practice between hospitals should be
developed
Overriding all of these points is the need for a
cultural and behavioural change of mindset resulting
in a collective focus across hospital management,
clinical staff, procurement, and infection control
teams to minimise SSIs.
Under the knife
Executive Summary
SSIs have been relatively neglected in the
country-wide quest to reduce rates of C. difficile
and MRSA bloodstream infections. It is time to
take action and adopt a zero tolerance approach
to these preventable, costly and potentially
serious infections.
• SSIs can be potentially life-threatening
post-operative complications that
currently account for around 1 in 7
HCAIs11
• SSIs are estimated to affect at least
5% of patients undergoing a surgical
procedure in England and Wales12
However, since most hospitals do
not undertake routine surveillance
on SSIs1, and many SSIs present and
are managed in the community, it
is likely that any estimates based
on hospital surveillance are a gross
underestimation of the extent of the
problem2
• SSIs have a major impact on both the
sufferer and healthcare provider6,13–14.
Individuals who develop an SSI typically
spend an additional 7–10 days in
hospital3-5; they are 60% more likely
to spend time in ICU, five times more
likely to be readmitted to hospital after
discharge, and twice as likely to die as
those uninfected after their surgery6
• Healthcare-related costs almost
double if a patient suffers an SSI7.
Conservative estimates suggest that
Under the knife
the average cost per SSI to the NHS is
approximately £320015, however, some
SSIs (e.g. those developing after limb
amputation) have been estimated to
cost the NHS in excess of £6000 per
infection5
• Emerging evidence suggests that the
patient’s own skin is the source of most
of the pathogens involved in SSIs8-10,
suggesting that a greater focus on
skin antisepsis may have a substantial
impact on infection rates
• Studies have demonstrated that the
incidence of SSIs varies widely between
hospitals and between surgeons16,17.
Surgical teams that know their SSI
rates are often able to reduce them
through the implementation of a range
of basic, relatively inexpensive infection
prevention measures
• The role of leadership within Trusts in
terms of championing SSI reduction
cannot be overstated. The importance
of HCAI reduction in general has to
be driven through all levels of the
organisation by these key players. This
will be integral to the adoption of best
practice and a culture where HCAI
avoidance is of paramount importance
to patient outcomes
• The Department of Health (DH)
has recently updated its evidencebased High Impact Intervention care
bundle for the prevention of SSIs18.
This includes recommendations for
screening and decolonization, skin
disinfection, and the use of prophylactic
antibiotics and surgical dressings
• The DH care bundle, for the first
time, emphasizes the importance of
skin preparation in the prevention of
SSIs and now recommends the use
of 2% chlorhexidine gluconate and
70% isopropyl alcohol solution, based
on a substantial body of evidence
suggesting this to be the optimal agent
for pre-surgical skin antisepsis9, 19-26
• Establishing the cost-effectiveness of
different infection control strategies
or new technologies is challenging,
since timely and accurate data on
local SSI rates is lacking, there is no
formal process to identify or monitor
SSIs presenting in primary care,
and randomized controlled trials
are expensive and often impractical.
Nevertheless, ‘headroom’ or
‘threshold’ analyses can be adopted
which determine how much can be cost
effectively invested in the prevention of
an infection. These analyses are largely
supportive of greater investment in
prevention to avoid the costs of an SSI
to the NHS, the wider UK economy
and the unnecessary suffering to the
patient and their family
SSIs: the size of the problem
SSIs are wound infections that occur
after an invasive surgical procedure.
They range from a limited wound
discharge to a potentially life-threatening
post-operative complication such as
a sternal infection after open heart
surgery1. SSIs account for around 1 in
7 HCAIs in acute hospitals in the UK,
and are the third most common type of
HCAI after urinary tract infections and
pneumonia (Figure 1)11.
The National Institute for Health
and Clinical Excellence (NICE) has
estimated that approximately 5% of all
surgical procedures undertaken in the
UK are associated with a SSI12. Limb
amputations and bowel procedures
carry the greatest risk of developing an
SSI, however, vascular surgery, gastric
surgery and cholecystectomy are all
associated with SSI rates in excess of
5%27 (Table 1). Since the majority of
SSIs present in the community postdischarge, it is highly likely that hospitalbased surveillance studies significantly
underestimate the true extent of the
problem2.
SSIs have a major impact on both the
sufferer and the healthcare provider
(Figure 2)6,13,14. Individuals who develop
an SSI typically remain in hospital for
an additional 7–10 days3-5; they are 60%
more likely to spend time in an intensive
care unit, five times more likely to be
readmitted to hospital once discharged,
and twice as likely to die as those
uninfected after their surgery6. Other
poor clinical outcomes associated with
SSIs include unsightly scars, persistent
pain and itching, restriction of movement
– particularly when over joints – and a
greatly reduced quality of life14, 28.
Figure 1
Types of HCAI across acute hospitals
13
20
Urinary tract
Surgical site
Skin & soft tissue
22
1 in every 7
HCAI is a
surgical site
infection
14
14
Bloodstream
Pneumonia
Gastrointestinal
Other
10
7
Table 1
SSI by category of surgical procedure
Category
SSI rate %
Abdominal hysterectomy
2.4
Bile duct, liver, pancreas
12.3
Chlolecystectomy
5.8
Gastric surgery
9.7
CABG
4.3
Hip prosthesis
3.1
Knee prosthesis
1.7
Limb amputation
15.6
Vascular surgery
7.5
Figure 2
SSIs impose a substantial burden on the
individual and on the healthcare budget
1 in 7
5 times
1 in 7 of all hospital aquired
infections are SSIs
Patients with SSIs are 5 times more
likely to be readmitted to hospital
60%
Patients with SSIs are 60% more
likely to spend time in ICU
twice
Patients with SSIs are twice
as likely to die
QoL
Health-related quality of life may be
significantly impaired
Under the knife
THE FOCUS OF
INFECTION
Since skin-dwelling bacteria such as staphylococci are
an important cause of SSIs – even in patients undergoing
contaminated procedures such as colorectal surgery37 – it is
imperative that skin antisepsis is optimised before surgery.
Under the knife
Fungi
5.2 0.6
Other bacteria
0.4
Acinetobacter spp.
Anaerobic cocci
Pseudomonads
2.0 1.8
Anaerobic baccilli
3.7 3.0
Streptococcus spp.
4.6
Pseudomonas
aeruginosa
8.9
Enterococcus spp.
21.8
M
S
S 19.3
11.7
A
Coagulase-negative
Staphylococci
The Health Protection Agency has recently reported that
staphylococci are by far the most common cause of SSIs in
the UK, accounting for almost 50% of the micro-organisms
responsible for SSIs (Figure 3)35. Staphylococcus aureus,
which is a normal component of human nasal microflora,
can lead to serious invasive infections such as septic
arthritis, osteomyelitis, pneumonia, mediastinitis, meningitis,
septicaemia and endocarditis36. Staphyloccus epidermidis,
which is the most common organism found on the skin, has
emerged as a frequent cause of HCAIs and is particularly
pathogenic in immunocompromised individuals such as those
receiving immunosuppressive therapies, neonates and patients
with indwelling devices and prosthetic implants36.
M
R 17.4
S
A
Enterobacteriaceae
Normal skin contains crevices, grooves, hair follicles and
sebaceous glands, all of which act as reservoirs for bacterial
breeding31. A single cm2 of skin can harbour as many as a
million aerobic bacteria32, with the type and density of the
micro-organisms determined by anatomical location, local
humidity, and the amount of sebum and sweat produced, as
well as host factors such as hormonal status and age33,34.
Figure 3
Micro-organisms causing SSIs (% of all organisms)
Staphylococcus
aureus
Infection prevention measures have historically been focused
on asepsis of healthcare professionals and the environment29.
Emerging evidence, however, suggests that the patient’s own
skin is the source of most of the pathogens involved in SSIs8–10.
Each time the skin is breached, patients are at risk of
contamination from their own skin flora30.
Evidence-based solutions:
changing the SSI landscape
Many factors have been identified that
contribute to the risk of SSIs; some of
them are modifiable while others are not
(Figure 4). Increasing age, underlying
medical conditions, obesity and smoking
have all been shown to increase the
risk of SSIs12. More complex surgical
procedures and prolonged operations are
also considered important risk factors12,
as are the number and virulence of
micro-organisms present on the skin36.
Studies have demonstrated that the
incidence of SSIs varies widely between
hospitals and between surgeons16,17,
suggesting that working practices
play a critical role in the prevention of
these infections. Surgical teams that
are equipped with their post-operative
infection data are often able to reduce
their surgical site infection rates38,
suggesting that more could be done
to improve infection control in routine
surgical practice. Unfortunately, many
UK hospitals do not routinely collect SSI
data or provide feedback on SSI rates to
the surgical staff, thereby missing vital
opportunities to monitor infection rates
and assess the outcomes of any changes
to infection control practices.
Evidence-based guidelines for
preventing SSIs
Several evidence-based clinical
guidelines have now been produced
with the aim of minimizing the risk of
SSIs in UK hospitals12,39. The Department
of Health has recently revised its High
Impact Intervention care bundle to prevent
surgical site infections, and included
evidence-based recommendations for
pre-operative, intra-operative and postoperative care (Table 2). Unfortunately,
studies suggest that compliance with
recommended guidelines for prevention
of SSIs is often sub-optimal40, and
many operating theatre rituals that
are conducted in the name of infection
prevention lack any supporting evidence
in the literature41.
Figure 4
Factors contrbuting to risk of SSi
PATIENT FACTORS
Age
Obesity
Underlying illness
SURGICAL
PROCEDURE
Type
Duration
Technique
MICROORGANISMS
Number
Virulence
Under the knife
Table 2.
Department of Health’s High Impact Intervention No. 4 – care bundle to prevent
surgical site infection18.
Pre-operative phase
1. Screening and
decolonization
• Patient has been screened for MRSA using local
guidelines. If found positive they have been decolonized
according to the recommended protocol prior to surgery
2. Pre-operative
showering
• Patient has showered (or bathed/washed if unable to
shower) pre-operatively using soap12
3. Hair removal
• If hair removal is required, it is removed using clippers
with a disposable head (not by shaving) and timed as
close to the operating procedure as possible42,43
Intra-operative phase
1. Skin preparation
• Patient’s skin has been prepared with a 2%
chlorhexidine gluconate and 70% isopropyl alcohol
solution and allowed to air dry26. If the patient has
sensitivity to this solution, povidone-iodine application
should be used
2. Prophylactic
antibiotics
• Appropriate antibiotics were administered within 60
minutes prior to incision44 and only repeated if there is
excessive blood loss, a prolonged operation or during
prosthetic surgery
3. Normothermia
• Body temperature is maintained above 36°C in the perioperative period12
4. Incise drapes
• If incise drapes are used, they are impregnated with an
antiseptic12
5. Supplemented
oxygen
• Patients’ haemoglobin saturation is maintained above
95% (or as high as possible if there is underlying
respiratory insufficiency) in the intra- and postoperative stages (recovery room)12
6. Glucose control
• A glucose level of <11 mmol/L has been maintained in
diabetic patients (this tight blood glucose control is not
yet considered relevant in non-diabetic patients)45
Post-operative phase
1. Surgical
dressing
• The wound is covered with an interactive dressing at the
end of surgery and while the wound is healing12
• Interactive wound dressing is kept undisturbed for a
minimum of 48 hours after surgery12 unless there is
leakage from the dressing and need for a change
• The principles of asepsis (non-touch technique) are
used when the wound is being re-dressed
2. Hand hygiene
• Hands are decontaminated immediately before and after
each episode of patient contact using the correct hand
hygiene technique (use of the WHO’s ‘5 moments of
hand hygiene’ or NPSA ‘Clean your hands’ campaign is
recommended)
Under the knife
The health
economic
evidence for
preventing
SSIs
Establishing health economic
arguments in relation to
the burden of SSIs and the
potential costs and benefits
associated with their
reduction requires the use of
accurate and timely estimates
of local infection rates, the
cost of those infections and
good quality data generated
from randomized controlled
trials on the effectiveness of
different strategies
or new technologies. This,
unfortunately, is not as easy
as it may seem.
Estimating the rate of SSIs
There are huge variations in the
published literature relating to SSI
rates depending on the population
being studied, the types of surgical
intervention, the definitions used, the
surveillance approaches taken, and
the time periods over which rates are
measured. We also know that many
SSIs are unaccounted for as the majority
(up to 60%) are superficial and present
in the community post-discharge2.
Surveillance reports from the Health
Protection Agency (HPA) underestimate
the true impact of SSIs. In their review
of SSI rates in Europe, Leaper et al
Table 4
Even with superficial SSIs the costs can be substantial
Surgical procedure
Extra length of stay
Extra cost per SSI
Limb amputation
21.2 days
£6161
Small bowel surgery
12.9 days
£3313
Vascular surgery
11.4 days
£3749
Coronary artery bypass graft
10.8 days
£3138
Hip prosthesis
8.9 days
£2586
Knee prosthesis
8.6 days
£2499
Open reduction of long bone fracture
8.4 days
£2441
Large bowel surgery
7.8 days
£2267
Abdominal hysterectomy
2.8 days
£814
(2004) reported rate variations ranging
from 1.5% to 20%, with 1.1–2.8% of
‘clean’ surgeries and 2.6–20% of ‘dirty’
surgeries associated with an SSI4.
Coello et al (2005) reported an SSI
rate of 4.2% across more than 67,000
surgical procedures undertaken in the
UK between October 1997 and June
2001, with rates as low as 1.9% for knee
prostheses and as high as 14.3% for
limb amputations5. In its 2008 surgical
site infection clinical guideline, NICE
estimated that at least 5% of all surgical
procedures undertaken in the UK are
associated with a SSI12.
Estimating the cost of SSIs
In their seminal work on the socioeconomic burden of hospital-acquired
infections, Plowman et al (2000)
estimated that the average cost per SSI
to the NHS was approximately £1600
(1995–1996 costs)3. The majority of
these costs result from incremental
days spent in hospital, with both Coello
et al and Leaper et al estimating an
average incremental length of stay of
approximately 10 days per SSI (Table
4)5. This translates into an average
cost per SSI of approximately £3200
(2010 costs)4, although estimated
SSI costs have ranged from £814 for
abdominal hysterectomy to £6161 for
limb amputation (Table 4). Using an
average cost of ~£3,500 per infection, it
has been estimated that SSIs currently
cost the NHS in the region of £700 million
per year4. If one were to adopt a more
conservative estimate of the cost of
treating infections of £800, at the lower
end of the range reported by Coello et al,
then this would still equate to a cost of
around £160 million per annum.
Studies such as these rarely account for
the cost of primary care consultations
and the many SSIs that are managed
outside the hospital setting. Neither do
they account for the cost to the patient or
to society as whole for the loss of income
or work productivity associated with
extended hospital stays and subsequent
morbidities. Opportunity costs associated
with ‘bed blocking’, the cancelled
admissions of other patients, and the
cost of readmitting patients with an SSI
are also not factored into these figures,
suggesting that the estimated total cost
of SSIs based on the studies outlined
above are no more than just the ‘tip of
the iceberg’.
Estimating the effectiveness of
management strategies
There are significant difficulties
associated with undertaking controlled
clinical trials of different management
strategies or new technologies in the
prevention of SSIs. Large sample sizes
are needed for randomized controlled
studies, requiring the involvement of
multiple study centres, which makes
controlling for confounding practices
extremely difficult. ‘Headroom’ or
‘threshold’ economic approaches are
often used in the absence of robust
effectiveness data, whereby an estimate
is made of how effective a strategy would
need to be in order to break even or save
money. The approach is illustrated below.
Example of ‘headroom’ approach:
application to a hypothetical hospital
Number of procedures conducted per
annum which present a risk of SSI =
10,000
Rate of surgical site infections = 5%
Estimated cost of surgical site infections
= £3,500
Burden of SSI to the hospital
Expected number of SSIs = 500
Estimated total cost to the hospital =
£1,750,000
• Assume a new technology to help
prevent the incidence of SSI is
made available at a cost of £10 per
procedure. If this were used in all
surgical procedures then the cost to
the hospital = £100,000
• To break even, the hospital would need
to reduce the number of infections by
29 (derived from the additional cost of
technology, £100,000, divided by the
cost of an infection, £3,500)
• This equates to reducing the rate
of infection from 5% to 4.71%. Put
another way, this also equates to an
absolute risk reduction of 0.29% or a
relative risk reduction of 5.8%.
SSIs are costly to the NHS with
healthcare-related costs almost doubling
if a patient suffers an SSI and yet they
are relatively low in cost to prevent.
‘Headroom’ or ‘threshold’ analyses
can be adopted which determine how
much can be cost effectively invested
in the prevention of an infection. These
analyses are largely supportive of
greater investment in prevention to avoid
the costs of an SSI to the NHS and the
unnecessary suffering to the patient.
Under the knife
Case study 1
IMPROVING SSI
RATES AFTER
CARDIOTHORACIC
SURGERY
The latter three factors cannot be
modulated easily, but it was postulated
that as patients undergoing non-elective
10
Under the knife
>
Consultant-led prep procedure
>
Additional initial prep with
chlorhexidine in the anaesthetic
room
>
Increased drying time
>
More glove changes
• Increased use of barrier drapes
>
Antibiotic-impregnated drapes for
chest
>
Additional drapes used for legs
• Isolation of operative sites
>
No interchange of instruments
>
Additional separating drapes
2
0
Apr-Jun 2007
• Improved skin preparation and
protection measures
4
Jan-Mar 2007
With antiseptic showers on the
morning of surgery and the night
before if possible
6
Oct-Dec 2006
>
Additional
SSI-reduction
procedures
introduced
8
Jul-Sep 2006
With a greater focus on social
hygiene
10
Apr-Jun 2006
>
12
Jan-Mar 2006
• Improved patient preparation
Figure 5
SSI rates before and after the introduction of a
range of additional SSI reduction procedures.
Apr-Jun 2005
In 2006, after relatively stable SSI rates of
around 2%, rates increased significantly
during two consecutive quarters (Figure
5). No obvious pattern of infection
could be identified in terms of surgical
or scrub teams, theatre use or microorganisms involved. A detailed audit of
all CABG patients over 1 year (N=540)
was therefore undertaken using logistical
regression analysis of over 50 preoperative and intra-operative variables
captured in the hospital’s database,
and four independent risk factors for
SSIs emerged: non-elective surgery,
peripheral vascular disease, chronic
obstructive pulmonary disease (COPD)
and renal dysfunction.
surgery were frequently in hospital for a
week or longer prior to their operation,
their skin colonization may have altered
unfavourably with “hospital-acquired”
micro-organisms. This prompted a range
of evidence-based procedural changes
aimed at prevention of SSIs by improving
skin preparation. Changes implemented
included:
Jan-Mar 2005
The Wolverhampton Heart and Lung
Centre is one of the busiest cardiac
surgery unit in the West Midlands. It
was the first purpose-built integrated
cardiac unit in the UK and, since opening
in 2004, has conducted more than 5200
cardiac operations – an average of 864
operations each year. The Centre has an
active and ongoing infection surveillance
programme and it collects and reports
SSI data to the Health Protection Agency
(HPA) every quarter.
Results: A rapid decrease in SSI rates
was evident (Figure 5), with a return
to baseline levels in the two quarters
subsequent to the infection control
changes. Levels have remained stable
and low since the changes have been
implemented.
With thanks to Mr Moninder Bhabra,
Cardiothoracic Surgeon, Wolverhampton
Heart and Lung Centre, New Cross
Hospital, Wolverhampton, West Midlands
for providing the information for this case
study.
Case study 2
REDUCING
SSIs THROUGH
COMMITMENT AND
TEAMWORK:
10-YEAR RESULTS
FROM UCLH
A SSI prevention bundle was
implemented, CVC/procedure packs were
developed, and new products including
catheter securing devices, ChloraPrep
pre-operative skin antiseptic, advanced
dressings and needle-free access devices
were introduced. Having a ‘spend to
save’ mentality ensured that the best
Figure 6
A ten-year commitment to reducing
bacteraemias at UCLH
Alcohol-based
hand gel for hand
hygiene begins
HA
Moving average
APC = Antibiotic Prescribing Committee
Health Care
Commission (HCC)
inspection
20.0
Transfer to new hospital building
Wound
surveillance
begins
Hand hygiene
target raised
to 100%
Renal unit moves to a
different trust (the Royal
Free Hospital)
MRSA screening of surgical
patients begins (culture)
MRSA molecular screening
of surgical patients begins
15.0
Statlock device
for peripheral
IV lines
IV care bundle starts
Hand hygiene
audits begin
10.0
MRSA screening
of all ellective
admissions
APC
5-2010
10-2010
7-2009
2-2009
12-2009
1-2007
6-2007
11-2007
4-2008
9-2008
8-2006
3-2006
5-2005
10-2005
7-2004
2-2004
12-2004
4-2003
9-2003
6-2002
1-2002
11-2002
8-2001
3-2001
5.0
Month
Provision of statistics by Annette Jeanes,
DIPC UCLH.
Results: A dramatic, 10-fold reduction in
all bacteraemias has been achieved since
2000 (Figure 6). The project is ongoing
and SSI rates remain low.
With thanks to Mr Phil Adams-Howell,
UCLH Clinical Procurement Lead,
University College London Hospitals NHS
Trust Headquarters, London, for providing
the information for this case study.
Under the knife
11
Number of new bacteraemias
CA or OHA
5-2000
Since 2000, over the past 10 years,
projects have been initiated with the
aim of reducing SSIs across the Trust.
A range of new products, procedures
and changes to surgical practice were
introduced (Figure 6) in consultation with
key stakeholders such as the infection
control and microbiology departments,
clinical users, the procurement
department, commercial partners and
the purchasing hub.
products with the best evidence for their
SSI reduction potential were introduced,
with infection control kept high on the
Trust’s agenda throughout that period
decade. Our experience highlighted the
importance of the role of the DIPC and
team as clinical leaders and drivers in
the early stages, as well as leadership
from the Chief Executive and Chief Nurse
resulting in the promulgation of a culture
where the reduction of HCAI is always a
priority. The role of the Chief Executive
and Chief Nurse within the Trust in terms
of championing SSI reduction cannot
be overstated. The importance of HCAI
reduction in general was driven through
all levels of the organisation by these
key players. The holding to account of
Divisional/General Managers, Medical
Directors and Departmental Sisters/
Charge Nurses was integral to the
adoption of best practice and a culture
where HCAI avoidance was of paramount
importance to patient outcomes.
10-2000
The University College London Hospitals
NHS Foundation Trust (UCLH), situated
in the heart of London, is one of the
most complex NHS Trusts in the UK,
serving a large and diverse population.
The Trust provides acute and specialist
services, and, in 2010, had contracts with
more than 150 Primary Care Trusts. The
hospitals that make up the trust, which
include University College Hospital, the
National Hospital for Neurology and
Neurosurgery and the Heart Hospital,
see over 500,000 outpatients and admit
over 100,000 patients each year.
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The development of the Under the Knife report was initiated and funded by: