Photo at Discharge (PaD): Improving information to patient and carers reduces readmission for incisional surgical site infection

APIC 2019 Annual Conference, Philadelphia, PA.
Reducing Risk of Readmissions for SSI: Photo at Discharge Scheme




SSIs are a devastating and costly post-operative complication. The risk of SSIs is well-known from high-quality studies and prospective surveillance, with approximately 1 in 25 patients affected following cardiac surgery. In the U.K., the national surveillance service reported a significant reduction in SSIs in this particular patient group over the last five years. However, in contrast to this trend, the report found that cardiac SSIs detected on readmission have increased slightly (1.3% to 1.8%) over the same period.

Reducing avoidable, non-emergency SSI readmissions is high on the national agenda; however, studies demonstrating successful patient-centered interventions for use in the transition between healthcare settings are limited.

This session will introduce colleagues interested in SSI prevention strategies to the photo at discharge (PaD) scheme to reduce the risk of SSI readmission. PaD is an award-winning, innovative, simple (not simplistic) idea with outstanding patient impact. Providing surgical patients with a color photo of their own surgical wound on the day of discharge improves the patient experience, and links wound information shared between acute and community settings. PaD associated with a significant reduction in risk of readmission for SSI, attributable bed days and SSI costs. In turn, capacity is released for elective admissions and associated revenue for hospitals using the low-cost PaD scheme.

Participants will explore how a PaD can positively influence readmission rates at their facility and get strategies and techniques for implementing this scheme at the facility.

  • Upon completion, participants will be able to identify factors which may influence risk of readmission for SSI and traditional strategies to mitigate these risks.

  • Participants will be able to describe the benefits of the Photo at Discharge to the patient, healthcare works and organizations as an infection prevention strategy.

  • Participants will be able to define the quality and performance metrics associated with reducing the risk of surgical site infection and examine implementation strategies for PaD in their healthcare setting.

Project Objectives: This information appears on the NICE sharing database
  • To improve documentation/information and photo assessment of surgical wound at the time of discharge, for the patient, carer(s) and healthcare providers

  • To improve patient experience of discharge and infection prevention advice

  • To provide a tool or prompt to seek medical attention at the earliest opportunity if the wound shows signs of surgical site infection (SSI) or deterioration

  • To reduce the incidence of readmission for incisional SSI

  • To implement solutions to findings from root cause analysis of SSI

Reasons for implementing your project:

Root cause analysis of incisional SSI highlighted the lack of documentation on the appearance of the wound at the time of discharge (both in medical notes and in information provided to the patient/carer) and secondly, a delay in seeking treatment and/or community management of a deteriorating wound.

Our Trust spent over £1.6 million over a three year period managing readmissions for surgical site infection. We used indirect patient involvement (i.e. postal questionnaire) to determine if our patients found the PaD initiative useful.

Feedback indicates the majority of patients find the scheme 'very useful', finding the photo 'reassuring and comforting' during the recovery period as well as providing them with a follow-up mechanism to report concerns (Rochon et al, 2016).

The PaD scheme is in line with NICE guidance on providing information to patients and carers to reduce SSI. Over a two year period, we are able to demonstrate a significant reduction in readmissions for SSI and associated 'costs avoided'. We believe PaD is readily transferable to other surgery types and is a novel strategy to address the 'substantial disease burden' of post-discharge SSI (Wolberg et al, 2016).

How did you implement the project?

We used the Institute for Health Improvement (IHI) Model for Improvement and small iterative tests of change using Plan-Do-Study-Act cycles.

At the end of 2014, the surveillance nurses undertook the PaD scheme, in order to scale up and sustain improvement, all staff nurses required PaD training.

Costs were avoided by modifying in-house resources: PaD uses an existing database with site wide licences. The colour print out costs 7p. Staff time did not meet criteria for 'additionality' (McMahon and Sin, 2015), as the time to assess and document the wound is part of standard discharge practice.

Key findings:

At our hospital, improving the wound care information and advice to patients and carers is associated with a 90% reduction in readmission for SSI (proportion of total readmission for incisional SSI no-PaD 95% [n=37] total minus proportion total readmission for incisional SSI PaD[2]). Total 39 incisional SSI May 2014- February 2016 period.

We calculate the cost avoided by the reduction is £196,202 per annum (average cardiac SSI readmission cost is £25,164). To monitor this, we maintained prospective, continuous SSI surveillance by trained personnel using the Public Health England 2013 protocol. In addition, we monitored monthly compliance with PaD scheme (maintaining >90% compliance since January 2016).

These results exceed expectations and have the multiple unexpected benefits: staff receiving PaD training (includes use of photography for wound assessment & documentation, clinical governance issues, consent and privacy and dignity) have skills readily transferable for other uses, including photo documentation for pressure ulcers, other wound types etc.

The photo upload on to the electronic patient record (EPR) helps with remote multidisciplinary review of wounds, improves continuity for care and may contribute to antibiotic stewardship as photos improve the sensitivity of SSI detection (Sanger et al. 2016).

Key learning points:
  • Use quality improvement approach including key stakeholders, iterative changes and feedback regularly

  • In line with the Quality Improvement approach, start small

  • Feedback from patients/carers and staff using electronic patient record (EPR) will help drive spread


Melissa Rochon


Quality and Safety Lead for Surveillance 


Royal Brompton & Harefield NHS Foundation Trust

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