Reducing Surgical Site Infection in the Paediatric Neurosurgical Patient
The Children's Hospital Westmead
Abstract
Surgical Site infections (SSIs) are the second most common type of adverse event occurring in hospitalised patients.
This project, led by the Neurosurgical Department at The Children’s Hospital Westmead (CHW), was established in 2007, to reduce surgical site infections (SSI) in children admitted for insertion of ventriculoperitoneal (VP) shunts and insertion of external ventricular drains (EVDs).
A protocol was developed in conjunction with the stakeholders, following extensive evidence-based research. The protocol was designed using the concept of ‘bundle of care’, where an individual component is known to reduce the risk of surgical site infections, but when all components of the protocol are followed in unison the risk of surgical site infection is further reduced.
Since implementation of the protocol, there has been a significant reduction in the surgical site infection rate from 7.5 % to 1.4 %, with the incidence rate in 2008 currently at zero %.
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Presented by Gabrielle O’Grady. |
Aim
To reduce the incidence of surgical site infection in the paediatric patient admitted for insertion of VP shunts and EVDs from 7.5 % to zero % within 12 months.
Nature of the Problem
Surgical Site infections are the second most common type of adverse event occurring in hospitalised patients (Brennan et al. 1991).
They are known to increase mortality, readmission rate, length of stay and cost for patients who incur them (Kirkland et al. 1999).
A medical record review of 34,133 charts revealed a significant opportunity for improvement in surgical site infection prevention (Bratzler et al. 2005).
Although the infection rate in patients admitted for insertion of VP shunts and EVDs at CHW was 7.5 %, not considered excessively high, it was felt that any SSI was unacceptable.
Extent of the Problem
Infection rate data (positive cerebral-spinal fluid cultures or positive wound swabs) provided by the Neurosurgical Clinical Program Coordinator was reviewed.
A patient chart review was undertaken by the Project Officer, who identified that there were significant issues surrounding prophylactic administration of IV antibiotics.
A review of dressing protocols identified varying protocols regarding dressing change and type of dressings used.
In the baseline period (July to December 2006) the surgical site infection rate in children admitted to CHW for insertion of VP shunt and EVDs was 7.5 %. These patients were readmitted for a total of 149 days, requiring 17 unplanned returns to theatre.
Strategic Importance
This activity contributes to the NSW Health Strategic Direction of creating better experiences for people using health services.
The project directly relates to this strategic direction as it is in line with patient safety within a quality framework, it focuses on improving clinical practice and reduces the risk of infection in healthcare settings.
The project positively impacts on key performance measures of NSW Health’s statewide program, ensuring high quality healthcare in NSW. It has the potential to impact on and reduce unplanned/unexpected hospital readmissions within 28 days.
Planning and Implementing Solutions
The Project Team met with stakeholders to review and identify the current practice. A review of the medical literature was performed to identify the evidence to practice gap.
The review showed that the following care components can reduce the incidence of surgical site infection:
- Appropriate use of prophylactic antibiotics - this included correct choice of antibiotic, correct prophylactic dose of antibiotic; correct timing of antibiotic-prior to skin incision and cessation of antibiotic at 24 hours, unless otherwise clinically indicated.
- Hair removal within the anaesthetic bay - it was identified that removing hair in the anaesthetic bay greatly reduced the amount of small hairs floating around the theatre, lowering the risk of potential wound contamination.
- Use of double gloving - evidence suggested that if surgeons were double gloved it would decrease the likelihood of glove puncture, thus reducing the risk of surgeon or patient contamination.
- Wound irrigation with hydrogen peroxide prior to closure - this was already a practice that all neurosurgeons followed.
- Soaking shunts in gentamicin prior to insertion - this was already a practice that all surgeons previously followed to ensure that contamination of the shunt is minimised as much as possible.
- Antibiotic impregnated shunts for high risk patients - these patients included low birth weight neonates and patients with a prior history of CSF infection.
- Post-operative dressing protocol - this protocol was developed in conjunction with the neurosurgeons and was documented on the protocol checklist so that all staff has easy access to it.
The agreed components were combined as a ‘bundle of care’. This approach works on the knowledge that when each individual evidence-based component is followed we can reduce the incidence of SSIs, but when all components are implemented together, it can further reduce the incidence of surgical site infection.
A range of stakeholders, including anaesthetist, neurosurgeons and nursing staff were engaged to participate in the project. An extensive consultation was also completed to seek input from expert departments, such as Microbiology and Pharmacy, to ensure their involvement.
A protocol checklist was developed that included each of the evidence-based components and this was placed into the patients notes pre-operatively. Each stakeholder follows the protocol checklist at various stages in the patient journey. On discharge, the information is entered into a database, where compliance to the protocol is measured.
All patients included in the project that are readmitted to CHW are reviewed and discussed with the Head of Neurosurgery. If a positive CSF culture or wound swab is confirmed, then that patient would be categorised as having acquired a surgical site infection.
Outcomes and Evaluation
The information on the protocol checklist is entered into the database once the patient has been discharged and results are measured using process measures and outcome measures.
Any positive CSF cultures or wound swabs are reviewed. This is then entered into the database and is compared to the number of patients that have been treated by following the protocol. To date, the incidence of surgical site infection has reduced significantly from 7.5 % to 1.4 %. In 2008, the rate of SSIs stands currently at zero %.
Any non compliance to the protocol is measured and the information is collated. To date, the main non-compliance is hair removal in the anaesthetic bay. Overall, compliance to the protocol has been over 85 % since project commencement in March 2007.
Sustaining Change
The protocol is now embedded into regular practice by all relevant staff, evident through the high compliance to the protocol and the reduced infection rate. Any non-compliance is discussed at the Neurosurgical Team Meetings to ensure continued support of the project. An information brochure has been designed for all new staff members, outlining the main aspects of the project.
The Neurosurgical Department is currently looking at implementing the protocol as policy.
With only one documented infection in the last 15 months, no reported SSIs in 2008 and high compliance to the protocol, it is evident that the success achieved by the project is sustainable.
Future Scope
Building upon the learning experience of the project in neurosurgery, a similar project involving bundling care components together has recently commenced in the Cardiac Surgery Department. The Orthopaedic Department has also agreed to implement a similar project for their patients. This protocol could also be applied to any other healthcare settings performing similar procedures.
References
- Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, and Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I, New England Journal of Medicine1991(324);6:370-376.
- Kirkland KBH, Briggs JP, Trivette SLH, Wilkinson WEH, Sexton DJH. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs, Infect Control Hosp Epidemiol 1999(20):725-30
- Bratzler DW, Houck PM, Richards C, Steele L, Dellinger P. Fry DE, Wright C, Ma A, Carr K, Red L. Use of Antimicrobial Prophylaxis for Major Surgery: Baseline Results From the National Surgical Infection Prevention Project, Arch Surg 2005(140):174-182.
Contact
Co-ordinator, Service Improvement Unit
The Children's Hospital at Westmead
Phone: 02 9845 2093
