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The Limeolder-Folder


Like managing the data, determining what was and what wasn't a SSI was also strangely difficult. Armed with definitions and classifications from the Health Protection Agency (HPA) (now Public Health England), I would set out on the units and wards, visiting every patient and examining every chest, leg and radial wound that there was to see. In those days, the Mepore dressings would be taken down on Day 2 and the wound was left exposed. So many wounds to see and for each and every incision, I would carefully date and document the appearance .

In those days, no one would tell me if there was a patient readmitted for a wound infection or if VAC therapy was needed for Mr Jones in Bed 5. It was all done by thorough beside review. In the hospital corridor, the herd of SpRs would scatter when I headed in their direction, charging after the one I wanted to query an SSI with.

Armed with my 'Limeolder-folder' (so called, because my wonderful Australian colleague had selected the most lurid, bright green folder for our surveillance work because it was 'fun') and the HPA protocol, I wanted everything to have a binary outcome, Yes or No. I saw the colourful lime-coloured folder as ironic for our surveillance team, because we wanted everything to be black or white. But the path was not straight. Things came up which confused me: the new tissue viability nurse was using the word 'purulent' to describe the amount of exudate (ie. heavy), as opposed to meaning the type of exudate (thick, cloudy, coloured discharge for infection)**. The infection control nurse argued that 'cellulitis, arising from leg incision [not evident prior to surgery]' was 'not a wound infection, it was cellulitis'. The SHOs would delight in writing 'wound infection' on any Day 3 surgical wound with serous discharge**.

There were other pitfalls to accuracy, as I saw it. 'Fat necrosis' or liquidised fat, aka diathermy's calling card. Yellow, globular discharge which looks exactly like pus (or urban myth, created by colleagues to refute HPA criterion 1: purulent discharge??); or a culture positive result from a wound infection was always dubbed an infection, even without clinical signs of infection or the all-important HPA 'host response': pus cells, polymorphs or WBC. And if the definitions were tricky, don't even get the cardiac surveillance nurse started on the classification difference between HPA 'superficial incisional, deep incisional, organ and space SSI' and the rest of the cardiac world's simple superficial or deep approach.

I can honestly say that, having earnestly represented HPA and later PHE definition and classification for cardiac SSI surveillance, my colleagues have laughed, jumped up and down, picked ourselves up/brushed ourselves off and celebrated buy-in probably more than any other areas auditing anywhere, ever, in the history of audit and surveillance. What once was a job that people did for three or maybe six months ticking boxes frantically, is now a role that colleagues stay with or develop professionally from, taking on more senior roles. I still like a dichotomous outcome (though in my heart, I know wound burden would be better represented as a continuum). But SSI surveillance turned out to be a lot more like the Limeolder than I ever thought it would be.

*It would be years before I would take more than four days off at a time so as not to miss any patients. Does surveillance encourage habit-forming behaviour? Yes.

** Leading to an unfortunate and unnecessary volume of SSI queries

***Leading to a constant worry that I was under-reporting SSI

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