We asked some of our Cardiac SSI members two questions -
Post your thoughts/answers on the Online Forum page
Martin Still, Lead Nurse for Infection Prevention and IV Resource Service
Brighton & Sussex University Hospitals NHS Trust
1. What national programme(s) and/or hospital pressures do you think will shape SSI surveillance over the next few years?
In terms of national agenda, these links are useful:
2. How can the Cardiac SSI Network help shape the direction and/ or support members for the future?
I think the cardiac SSI network can demonstrate sharing of best practices for the Getting It Right the First Time strategy. Are we aligned with them? However, at the last meeting, we heard how variations in practice were not associated with outcomes leading to variations that may be acceptable.
Carlos Morais, Clinical Nurse Specialist in Surveillance
Royal Brompton & Harefield NHS Foundation Trust
1.What skills do you think surveillance nurses need?
Surveillance Nurses, in my view, should have a wide range of skills, knowledge, and experience. The healthcare experience and/or previous academic training in a healthcare discipline would be important, as it provides the Surveillance Nurse with a solid foundation and understanding of the impact of surveillance in healthcare outcomes. The IT knowledge including the ability to generate reports, data management and being proactive in learning and adapting to new software are also essential tools. The human and personal skills are equally important, due to the nature of this type of work which requires autonomous and responsible individuals, confident in decision-making and the ability to persuade and negotiate with a wide range of people. Good organisational skills are also important in a view to chase the Surveillance objectives and goals using a variety of methods and exploring solutions.
2. What do you like best about working in surveillance?
I like working in the field of healthcare Surveillance because of the opportunity to explore strategies to identify, design and implement solutions. In the field of cardiac surveillance the most important aim is to reduce SSIs in cardiac surgery, which has a significant impact on the patient. I find the opportunity to drive and encourage change and supporting the implementation of solutions and ideas exciting. Every day is different and I enjoy the satisfaction of being able to have a positive impact on the outcomes of the patients.
Melissa Rochon, Quality & Safety Lead for Surveillance
Royal Brompton & Harefield NHS Foundation Trust
1. From your perspective, what do you think is making (or has made) the biggest difference to reducing SSI rates at your hospital?
I think endoscopic vein harvest (EVH) has reduced donor (leg and radial) SSI at our centre, without a doubt! SSI in legs following CABG surgery can drive the overall SSI rate to above the national benchmark. It is a shame this information isn't collected by Public Health England - our own analysis for BHIS (Brompton Harefield Infection Score - a predictive model for CABG SSI) suggests EVH is one of the most persuasive interventions to reduce SSI in this patient group.
I feel multidisciplinary working and clinician engagement is also crucial to low SSI rates. The Photo at Discharge (PaD) scheme has also been really valuable for patients and carers, and we have also found that standardising the approach to managing digital images generally has been useful. We have taken many ideas away from the Cardiac SSI Network as well - like placing the drain sites a bit further away from the central incision if it is safe to do so (also, if the patient is not too short of stature or with high BMI) to leave the central dressing undisturbed when drains are removed Day 1 or Day 2.
2. You mention PaD, which received Patient Safety and OneTogether Awards. Any tips for others who are thinking about entering their SSI projects?
Within the quality improvement approach, it is important to promote projects to reduce SSI internally and externally, and also to celebrate successes! My blog for ICHP on the application process for awards can be found here. Patient Safety, RCNi and Nursing Times Awards all offer categories for teams to showcase their work to reduce SSI and improve patient safety. Good luck!
Elizabeth Silva, SSI Audit Clerk
St Bartholomew Hospital
1. What is the best bit about your job, working in surveillance?
I love my Job as a Surveillance Clerk because it pretty much gives me the best of both worlds. I get to sit at a desk for part of the day dealing with the clerical side of the job, such as drafting presentations on surveillance and doing statistics on SSI rates, to let the trust staff and patients know where we are at in terms of SSI. It is something I love to do, I've always been a bit of a Math nerd. And then I get to spend the other part of my day speaking with both patients and relatives on how to look after the surgical wound to minimize the risk of infections, what to look out for in terms of symptoms of infection, and how to contact us if they have any wound issues. And it is very rewarding to see patients at ease when you engage with them, as you can see they feel more empowered and more confident when they go home in terms of looking after themselves once I have spoken to them.
2. Why do you attend the Cardiac SSI Network Meetings?
Surgical Site infection is a measure of the quality of how we are doing our job here at BHC. I take extreme pride in being a part of the process and being able to contribute to the best outcomes for our patients. I love coming to meet all the lovely Cardiac SSI Network members as there is always something new we can learn from each other. I always come back refreshed with new ideas to share with my colleagues here at the BHC that will improve our patient care, and that is always valuable. Plus we always have a good time together!
Philippa Clark, Tissue Viability and Surgical Site Surveillance Nurse
Royal Papworth Hospital NHS Foundation Trust
1. In your role, what would you like to do less of/spend less time on?
In my role as SSI nurse, I would like to spend less time looking at spreadsheets! Not my favourite part of the job but it is necessary to ensure the correct information is captured and the data fields are as complete as possible. Also needed to examine trends in the occurrence of SSI. In my Trust, we have created our own electronic database to collect and record the criteria as specified by PHE surveillance protocol. Some of the information is pulled across from our hospital systems and some information is manually inputted by the SSI team e.g. the criteria for SSI or ward visits. I can then pull an excel spreadsheet at the end of every quarter with this information on. This is then is double checked with a list of patients sent from our audit department to ensure we haven’t missed anyone.
2. In the year ahead, what targets or goals do you have for surveillance (or even what would you like to have more time to spend on!)
This year, our focus is getting the basics right – again! We have been carrying out SSI surveillance in CABG patients for 9 years and have brought our rates down considerably. However, there is still room for improvement! We are going through a time of great change and are facing challenges within our Trust, as are all my friends in SSI and the NHS as a whole. I feel we need to refocus our attention on getting the basics right again so we are looking at our patient pathway, updating patient information, and raising SSI prevention on the shop floor, and hopefully these efforts will benefit our patients even more.
Liz Shaughnessy, Senior Sister & Ward Manager
Essex Cardiothoracic Centre
1. In your experience, what is the biggest challenge to improving practice or introducing change to reduce SSI rates?
Striving to ensure that the quality of care we deliver is continually improving is of the utmost importance in health care and reducing surgical site infections is high on this agenda.
The impact that a wound infection can have on a patient can be devastating and cannot be underestimated.
Having worked in cardiothoracic surgery for more than 15 years I truly believe that it is about getting the basics right, every time and ensuring patients are well informed to understand how to look after their wound.
2. The work to reduce SSI across the patient pathway involves many staff groups! Do you have any tips on how to communicate effectively with so many staff?
Ensuring staff are aware of what is expected and engaging them is vital. On Chelmer ward (the Cardiothoracic Surgical ward at the Essex Cardiothoracic Centre) we use newsletters, emails, ELearning, Team days, competitions, quizzes and awareness weeks to raise the profile of issues such as wound infection prevention. Ensuring that all staff understand the impact a wound infection can have on a patient's life can assist to ensure they adhere to policies and procedures, and ensure the care they deliver is of the highest standard.
I have found the Cardiac SSI Network a great resource and support system to aid in the challenge of reducing surgical site infections.
Lilian Chiwera, Surveillance Team Leader
Guys & St Thomas' NHS Foundation Trust
1. Many of us will have heard you speak passionately on SSI at conferences and specialist days and showing amazing reductions in SSI rates for improved patient safety. What would you say are the key features of a successful surveillance programme?
Wow, thank you for this amazing compliment, I can't hide it, I love SSI surveillance and the benefits it brings for patients (grinning!) A lot of people think surveillance is all about data collection, but I am sure you'll all agree that it goes beyond just collecting data, it has always been and will always be about the patients.
Some important but not exclusive points linked with success:
High passion for patient safety & PATIENCE!
Ensure others understand what SSI surveillance is all about and promote collaborative working (spread the passion)
Have clear strategies on how the programme should be executed and involve senior leadership (Be S.M.A.R.T)
Identify SSI leadership and /or local champions at onset
Seek to understand other people's views not just your own
Use available evidence to direct potential improvement initiatives, e.g. below:
In summary, everyone needs to remember to put patients at the centre of everything they do!
2. Sometimes, our work gets incredibly stressful or you have a meeting where you feel there was more blame than learning being bandied about. Do you have any advice for those times when rates are high but morale is low?
You have to empathise with frontline staff considering they often work under stressful conditions, but that's not an excuse particularly if there are lapses in care. I always say to myself, "Seek first to Understand, then to be Understood" (Dr Stephen Covey). It's important to understand reasons why staff can often come across as 'defensive'. They may be signalling potential system problems that need us to look beyond 'current' high rates of infection for example. At the end of the day, surveillance is all about finding opportunities for continuous quality improvement and not necessarily just blaming each other; everyone needs to constantly be reminded of that.
Sammra Ibrahim, Lead Surgical Care Practitioner
Barts Heart Centre
1. As an SCP, what do you think about the practice of double skin prep - a first prep with unscrubbed personnel (just before WHO), followed by a second skin prep by scrubbed personnel?
We already practice double skin prep….Pre Surgical Wash (PSW) and have been for years. The SCP does the first skin prep for the patient, which is a non-sterile social wash (4% chlorhexidine soaked sponge), before the checklist, and then the patient gets the routine sterile prep from scrubbed personnel.
2. What are you looking forward to in 2018, in terms of SSI reduction initiatives or plans?
(We are) looking for a more robust SSI “bundle” protocol for the Trust which will target where we are failing as a unit to keep SSI rates to zero, ok at least a minimum! Change of practice, especially mindset as many professionals are very set in their way and changes are hard/long in accepting and maintaining. To be able to share experiences with other institutions and compare practice and results to help understand where and what needs targeting in order to make a difference in rates of SSI.
Kate Turkentine, Surgical site surveillance nurse
Bristol Royal Infirmary
1. You undertake different types of surveillance at your centre. From your perspective, are there different challenges or considerations for undertaking surveillance in the cardiac group?
The difference within our centre is the volume of Adult cardiac operations undertaken which takes up a significant amount of our workload.
The things we have taken into consideration are the different risks associated with this category for the incidence of surgical site infection. We have found each category will have different factors affecting their infection rates or incidence of infection. Each category we are involved in will engage with our data differently, if at all!
We considered how we could feedback and manage improvement in adult cardiac by implementing a steering group specifically for surgical site infections, which started as soon as we began to collect data and feedback results just over a year ago. This focused individuals and split up recommendations and actions to start to improve infection rates. Although slow to start with, we are now taking some positive steps to improve standards and make changes to patient care and outcomes following cardiac surgery in relation to infection. Mainly around incision management.
Good collaborative working with all professionals has been extremely important such as close links with tissue viability nurses within cardiac surgery and the surgeons themselves.
2. Do you have any advice for someone starting SSI surveillance at their hospital?
Advice is, be realistic. It is quite a slow process to start with due to the timeframes within PHE and their reports being published.
It has taken us over 12 months to even see a small improvement in our infection rates. Think about the whole patient journey from pre-op to discharge and break it down into components that are manageable for surveillance. Get the right people engaged, there is no point in collecting data just for the sake of it. It has to be feedback and recognised and actioned on.
Get organised, depending on how many people are working with you or if you are managing this alongside other jobs.
We have good links with theatre staff, ward nurses and tissue viability. Once you have started to build up your results the most important message is how the trust is improving and benchmarking itself against itself in each category.
Be consistent, the best thing for any data collection programme is the same people gathering and looking at the data over a period of time. This makes your results much more robust.
Mr Shahzad Raja, Cardiac Consultant
Royal Brompton & Harefield NHS Foundation Trust
1. What has been your experience of having SSI surveillance nurse at your hospital site?
The presence of a dedicated SSI surveillance nurse enabled us to evaluate our surgical practice and led to major changes throughout the trust. These included the implementation of a trust-wide surveillance service and clinical practice interventions which saw SSI rates fall by almost two thirds. The SSI surveillance nurse ensured that the true rates and cost of surgical site infections were regularly communicated to all stakeholders resulting in a dedicated multidisciplinary approach to reduce SSI rates as well as the cost of care.
2. From your perspective, what three interventions would you suggest are useful in reducing SSI rates?
The three key interventions that are useful to reduce SSI rates are:
Establishment of an effective Surveillance Service to identify baseline SSI rates and evaluate surgical practice particularly with a view to reducing SSI rates.
Employ targeted interventions in line with best evidence guidelines for SSI reduction.
Promote multidisciplinary working through a strong Surgical Site Infection Surveillance leadership as well as ensure patient education about the identification of SSI with a view seeking early advice and treatment particularly once in the community after discharge from the hospital.
Sarah Battaglia, Clinical Nurse Specialist in Wound Care
University Hospitals Bristol NHS Foundation Trust
1. Do you think there is a role for negative-pressure therapy for clean, closed cardiac surgical wounds?
I do indeed. There has been recent and growing interest in the use of NPWT on closed incisions post-operatively to prevent surgical site infections and other wound complications in high-risk patients.
A consensus document by the World Union of Wound Healing Societies (WUWHS) (2016) identified that the evidence surrounding the use of NPWT on the closed incision shows early promise in being able to reduce the incidence of incisional complications.
A number of retrospective and prospective studies have been carried out over recent years which have shown a clear benefit of using INPWT in reducing the risk of SSI. A number of these relate to sternal incisions following cardiac surgery.
Within the Bristol Heart Institute, we have recently introduced the application of incisional negative pressure wound therapy (INPWT), applying post sternal closure in our high risk patient group. We are using the Brompton & Harefield Infection Score (BHIS) to score all CABG surgery patients pre-operatively. Those in the high risk group are sent to theatre with PICO INPWT.
This practice has only recently been introduced and is being audited, as part of a larger intervention package aimed at reducing SSI’s within our centre.
2. How do you feel about antimicrobials/antiseptics for a surgical wound with early evidence of infection?
There has been much work around the use of antimicrobials/antiseptics and their use on both surgical and chronic wounds.
Used appropriately I believe they can have a place. However, care needs to be taken to closely monitor the wound and change treatment plans accordingly.
Failure to monitor their use may put patients at risk, though equally if there is a culture of fear regarding the use of these agents some patients may be at risk of untreated infection which could progress to sepsis (Newton, 2010).
The attached documents shed interesting light on this topic:
Carly Baker, Cath Lab Nurse Manager
University Hospital Coventry and Warwickshire (UHCW)
1. As Cath Lab manager, what three basic principles do you like to see for reducing the risk of infection implant device infection?
As a Cath Lab Nurse Manager (and background as an Infection Prevention Practitioner!) there are three basic principles I like to see for reducing the risk of infections to patients:
An Excellent Aseptic Technique - You are only as good as your aseptic field.
Good monitoring and management of blood glucose.
Active management of patient's core temperature.
2. Do you use active or passive warming devices to reduce the risk of infection in your patient group?
UHCW Cath Lab use active warming of our patients, using a Bear Hugger to maintain patients core temperature.
Sandra Hutton, SSI and TV specialist nurse for cardiac surgery
Oxford University Hospitals NHS Foundation Trust
1. What are the benefits of belonging to the Cardiac SSI Network?
Belonging to this network has been a fantastic opportunity for support and to develop many aspects of my post. Through the network, I have met members who work in different nursing disciplines such as infection and prevention, tissue viability, pre-admission etc. that all undertake Cardiac SSI surveillance. These members have a collective wealth of knowledge and experience they are willing to share and offer support which I have really appreciated.
At the network meetings there are many excellent informative presentations from both clinician’s and industry along with less formal open discussions. I have found the learning opportunities at these network meetings fantastic for developing changes in our practice. I took the opportunity to visit a network member at their Cardiac centre. This has given me ideas on how I can move our service forward.
2. How do you feel your role as a surveillance nurse contributes to patient care?
The leading part of my role is SSI surveillance. The predominant aim of the role is not just to monitor rates of SSI’s but to reduce incidences. SSI’s can be devastating, life-threatening and costly for patients and their families and expensive for the health service provider both financially and bed days required. I believe my SSI surveillance is a vital role within our service to improve our patient care.
I strive to meet and monitor every post cardiac surgical patient. During this time I assess the surgical sites and advise and educate the patients on discharge wound management, infection prevention and observing wounds for signs infection. All patients are given my contact details if they have any concerns after discharge and if indicated I provide the opportunity for the patient to attend a wound clinic with a surgical registrar present. The wound clinic has been successful in picking up superficial SSI’s in a timely manner before deteriorating further in some cases.
Within this role, I teach new members of nursing staff within cardiac directorate wound management and how to observe surgical sites for infection. I am very visible in the clinical areas to support the clinical staff and the patients requiring treatments for an SSI.
Helen Saraqi, Infection prevention and control nurse
Great Ormond Street Hospital for Children NHS Foundation Trust
1. We are excited to be focusing on paediatric cardiac surgery, adult cardiac and implant device surveillance in 2018. What do you find most useful at the Network meetings?
All aspects of the network meetings are engaging and beneficial - the case study presentations, the review and discussion of national programmes, networking and sharing experiences of challenges; triumphs and future plans.
2. The Network offers an opportunity to collaborate on papers, poster and presentations. Is this something you are interested in?
I am a dually qualified nurse (Adults and Paediatrics). The majority of my career has been working in Cardiac intensive care at Great Ormond Street Hospital where I have been involved with all aspects of caring for children who pass through Cardiac intensive care including patients on interventional cardiac catheter, ventricular assisted device, and surgical pathways. I have always had a keen interest in all aspects of infection prevention and control and had the opportunity to transition into this role in 2014; within this role, I have continued involvement and interest in Cardiac SSIS. I am interested and would be willing to be involved in collaboration in presentations, posters or papers
Christina Bannister, Nurse Care Manager
University Hospital Southampton NHS Foundation Trust
Patient Liaison Representative for the Society of Cardiothoracic Surgery in GB & Ireland
1. As the Patient Liaison Representative for the Society of Cardiothoracic Surgery in GB & Ireland, is there a part of the patient pathway or journey that you feel may need more attention or support to reduce the risk of SSI?
It’s very important for patients and their relatives/carers to be aware of infection issues – education and knowledge is a big part of the pathway that ensures a safe operative journey. Good basic hygiene and hand washing is key to reducing the risk of SSI. All patients should understand the need for pre-operative anti-microbial washing which again will reduce their risk post-operatively.
Post-operatively; quality education will enable patients and their carers to recover quickly, by being able to spot issues with their wounds early, for example redness etc and highlighting these with the GP or Practice Nurse. The use of the Photo at Discharge scheme encourages patients to take ownership of checking their wounds post-operatively and having a discharge baseline to guide them.
2. You are also an Ambassador for Heart Valve Voice. Infective endocarditis affects approximately 1 in 120 patients, do you think infection prevention for SSI for patients includes enough detail on the signs and symptoms of this type of organ/space SSI, and if not, what would you advise to include as information?
It’s very important for all patients undergoing valve surgery or who have valve disease to be aware of the risks related to infective endocarditis. I always talk to patients and their relatives about maintaining good dental hygiene and attending the Dentist regularly, as bacteria entering the bloodstream during teeth cleaning & dental procedures can be a source of infection. Again education is key to raising awareness of having a healthy lifestyle; any break within the skin can allow organisms to enter the body which could lead to infective endocarditis. It is very important that all valve disease patients look after themselves and treat any issues early, therefore preventing problems before they occur.
Ms Rashmi Yadav, Cardiac Consultant
Royal Brompton & Harefield NHS Foundation Trust
1. What are your thoughts on targeting patients at higher risk of SSI with a different intervention(s)?
Our work with the care bundle approach in reducing SSI has shown a targeted approach to be highly effective, both in terms of clinical efficacy and cost. Using the BHIS score to risk stratify patients allows limited resources to be focused on those patients at highest risk of SSI. In my experience, a targeted approach is a way forward to reducing the morbidity of coronary artery bypass surgery in the most vulnerable patients.
2. Do you think like orthopaedic surgery, cardiac surveillance should be mandatory in the Public Health England scheme?
Surgical site infections, particularly sternal wound infections cause significant morbidity and also increase mortality in the patients who unfortunately develop it. A mandatory surveillance programme will impact positively on patient outcomes and I would strongly support this approach.
Lisa Butcher, Lead Nurse and Manager for Infection Prevention and Control
Oxford University Hospitals Foundation Trust
1. Particularly deeper SSI are associated with theatres. What would basic assurances would you seek for root cause analysis?
As an Infection Prevention and Control Nurse, the assurances I would be looking for would be seeing that the NICE surgical site infection guidelines had been followed during all stages of the patient’s journey. In addition I would want to know what the cleaning was like in theatre, what is theatre etiquette and culture like, have we got too many people in theatre? Too many reps visiting? I would want reassurance that the Air Handling Units are having verification audits undertaken and remedial work carried out. I would review Datix reports of failings with sterile services or any issues that have been reported under the category of infection control issues. The theatre staff also always have an opinion of why we have SSI and they are worth talking to in order to gain an understanding of any changes in theatres, it might be new dressings, dodgy drapes or new staff. However, my top tip is to get into theatres and just watch and ask questions…you learn a lot from just being there!
2. Do you have any tips for business cases for surveillance resources?
I don’t have top tips but whatever you want to change has to have demonstrable improved patient outcomes, often needs to be cost neutral or be a cost saving. Don’t try and submit a business case without doing thorough homework- it just gets rejected and is totally demoralising. Talk to people that have experience in doing business cases would be my suggestion.
Dr. Sumita Pai, Consultant Microbiologist
Royal Papworth Hospital NHS Foundation Trust
1. Could you describe your role of clinical microbiologist in SSIs?
The microbiologist works in close collaboration with surgeons and the tissue viability team in managing each SSI case individually, to ensure the overall SSI rate is kept within national expectations. A systems approach is important and includes several components, including the interpretation of the significance of bacteria grown from samples and tailoring the management decisions accordingly. We also help classify the infections, monitor the overall rate of SSIs and contribute to policy-making decisions. We work with our colleagues to ensure that all antibiotic treatment adheres to the principles of antimicrobial stewardship.