Smart use of Care bundles- HII4 and SSI and NICE quality standards Manjula Natarajan Consultant Microbiologist and DIPC Deputy MD

KGHFT Medium DGH Beds Bowel cancer screening, PPCI, downs screening for the region Primary arthroplasty- Hips and knees 800/year. 76 revisions (9.5%) data General surgery including colorectal, urology, Upper GI, breast surgery-including onco-plastic surgery Obstetrics & Gynaecology

Importance of pre-op, peri-op and post op phase NICE CG New evidence had no impact on previous guidance Antibiotic coated sutures in abdominal surgery NICE SSI Evidence update June 2013 Importance of advice on wound care, antibiotics for treatment of wound infections Need to monitor SSI rates & provide feedback to stakeholders for continuous improvement through adjustment of clinical practice NICE Quality Standard 49 October 2013

High Impact Interventions HII4- DH 2011

Surveillance Patient journey- HII4, theatre ventilation validation, ward behaviours, Wound care education and management Specimen journey- Lab internal QA Surveillance- ward based, lab based, SSI, MDT and reports Also via reports from clinicians regarding incidence of infections

Aim To use HII4 as evidence of theatre practice Using this as a monitoring tool to see improvements in practice Correlate with SSI surveillance rates Use HII4 and SSI rates and MDT discussions to change practice Use presentation mode to surgeons to change practice Use ICNet to gather data for SSI and HII4 Monitor and demonstrate continuous improvement in theatre practice, compliance with NICE quality standards

HII4 During SSI module- Random & targeted Post SSI module- random HII4 Ortho- MDT based surveillance Random audit to assure practice- procedure related KGH approach to using HII4

CASE STUDIES

Breast SSI surveillance PERIOD NUMBER OF OPERATIONS NUMBER OF SSI’s PERCENT NATIONAL AVERAGE JULY- SEPT %5.2% JAN- MARCH X STAPH A1.7%4.6% APRIL- JUNE %4.6% OCT- DEC X STAPH A5.5%4.5% JAN- MARCH X STAPH A2%4.5%

Patient no TOTAL MRSA ScreenYesYES Yes Yes Yes Yes Yes Yes 100% Pre-op shower documented no Nono 0% BMI Documented % Hair removal with clippers n/a Skin prep 2% Chlorhex with 70% Alc/PI No Yes Pov/Iod No 10% Prophylactic Antibiotics AugTeicoAugNoneCefAugCefAug Cef80% Temp > 36yes No 35.6 yes 90% SATS >95% yes No 94% yes No 94% 80% Glucose < 8n/aNo 9.4 n/a No 9.2 n/a Yes % Wound dressing checked and documented yes 100% Dressing left in situ for a minimum of 48 hrs yes 100% TOTAL 80%60%70% 60%80%70%80% 70% Breast Surgery HII4, December 2013

Breast surgery SSI SSI surveillance showed evidence of MSSA infections No particular themes HII4 revealed gaps in practice Initially defensive team willing to engage change practice after viewing evidence Next SSI module showed results Face to face meeting helps

SURGICAL SITE SURVEILLANCE January 2013 To December 2013 PERIODTYPE OF SURGERYNO OF OPS NO OF SSI’sPERCENTNATIONAL AVERAGE REPORTED TO JAN 2013 TO MARCH 2013 LARGE BOWEL603 X COLIFORMS 1x PSUEDOMONAS 1 X STAPH A 8.3%12.5%ICC Consultants Surgical CMT APRIL 2013 TO JUNE 2013 #NOF HIP REPLACEMENTS x MRSA 1x MSSA 1.3% 1.2% 1.8% 1.2% ICC Consultants Surgical CMT Surgical Matron Ward Managers JULY 2013 TO SEPT 2013 C SECTIONS24014 X STAPH A 3 X GBS 3 x MIXED GROWTH 2 X COLIFORMS 1 X MRSA 1 X PROTEUS 10%8.6% ICC Consultants W&C CMT HON Ward Managers OCT 2013 TO DEC 2013 BREAST KNEE REPLACEMENTS x STAPH A 1 X Staph A 3.6% 1.5% 1.2% 1.7% Consultants Surgical CMT

We undertook HII4 to look prospectively for emergency and electives, and retrospectively at the MSSA cases. No emerging themes with surgeons or operating teams Skin prep was variable Pre-op shower not done for elective and emergency Hibiscrub for electives, wipes for emergencies introduced Wound care advice and leaflets given to patients Recommendations acted on. Rates of infection reduced in Q to 3.3% Theatre ventilation issues in June We undertook SSI for CS from July to august. 240 C Sections, 50% emergency/ elective split 10% infections, last national data was 8.6% 50% were MSSA, superficial, GP swabbed, no re-admissions. Large BMI in 60-70% of cases noted C sections and surveillance The Problem Results

SURGICAL SITE SURVEILLANCE January 2014 To December 2014 PERIODTYPE OF SURGERYNO OF OPS NO OF SSI’sPERCENTNATIONAL AVERAGE REPORTED TO JAN 2014 TO MARCH 2014 BREAST HYSTERECTOMY x Staph A 0 2% 0% 4.2% 4.5% ICC Consultants W&C CMT HON Ward Managers APRIL 2014 TO JUNE 2014 LARGE BOWEL #NOF x Coliforms 1 x ESBL %Last years NA was 12.5% Awaiting report and new NA JULY 2014 TO SEPT 2014 C SECTIONS236Strep B x 2 1 x coliform 1 x anaerobe 3.3%8.6% (National average in 2009) OCT 2014 TO DEC 2014

Trust-wide use of HII4 During SSI module- evidence to challenge and change practice Large bowel SSI module- used to change practice despite SSI rates being low Radiology and angiography- use of razors Core business in Surgery

Use of technology ICNet SSI module with NG Use of ICNet to extract HII4 data from theatre system (ORMIS in KGH)

The IC Net Dashboard

Future –HII4 on IC Net SSI module

Effective tool to reduce SSI HII4, manual or ICNet NICE compliance Evidence to change practice

Cost benefit analysis To analyse KGH data for LOS, and cost of SSI in Orthopaedics – using ICNet To achieve reduction in SSI and cost using HII4

Changing epidemiology of organisms

Acknowledgements Pam Howe- Lead Nurse, IPaC Jennie Lovell- ICN Katrina Rufea- Surveillance and Practice Development Nurse DR. Dina El-Zimaity- Consultant Microbiologist