CPD Prepare for revalidation: read this CPD article and write a reflective account http://revalidation.zone
CONTINUING PROFESSIONAL DEVELOPMENT
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Surgical site infection multiple choice questionnaire
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Read Clio Badenhorst’s reflective account on ethical practice
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Guidelines on how to write a reflective account
Prevention of surgical site infection NS754 Harrington P (2014) Prevention of surgical site infection. Nursing Standard. 28, 48, 50-58. Date of submission: March 7 2014; date of acceptance: April 28 2014.
Aims and intended learning outcomes
Abstract
Keywords
This article is aimed at nurses who care for patients during the pre, peri and post-operative periods. It is intended to provide information on the risk of developing surgical site infection (SSI) and on how it can be prevented and managed. After reading this article and completing the time out activities you should be able to: Recognise the signs and symptoms of SSI. Understand the importance of SSI audit and surveillance. Describe measures that can be taken to reduce the incidence of SSI. Explain management strategies for patients with SSI. Discuss the role of the nurse in treating patients with SSI.
Healthcare-associated infection, infection prevention and control, surgical site infection, wound care
Introduction
Surgical site infection (SSI) is a common healthcare-associated infection that can cause patients extreme pain and discomfort, resulting in prolonged hospitalisation and additional costs to the NHS. Multidisciplinary team working, combined with audit and surveillance, early recognition of signs and symptoms of infection, and implementation of evidence-based guidance are essential for reducing the incidence of SSI. Nurses caring for patients in the pre, peri and post-operative period have an important role in advising individuals about the risks associated with SSI and how infection should be managed.
Author Pauline Harrington Surgical site infection surveillance manager, Public Health England, London. Correspondence to: [email protected]
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
SSI accounts for an estimated 16% of all healthcare-associated infections (HCAIs) and can lead to increased antibiotic consumption and healthcare costs, prolonged recovery for patients, increased pain, anxiety, further risk of complications and, in some cases, death (National Audit Office (NAO) 2000, Health Protection Agency (HPA) 2012). Patients who develop SSI after discharge from hospital are at increased risk of readmission, resulting in additional costs to the NHS. Estimates suggest that it costs the NHS £700 million per year to treat patients with SSI (Adams-Howell et al 2011). SSI can be prevented with appropriate intervention, and healthcare professionals have an important role in this area. Guidance is available to assist healthcare professionals in the prevention, recognition and treatment of SSI, and should be integrated into local
50 july 30 :: vol from 28 no 48 :: 2014 ©For NURSING STANDARD / RCN Downloaded RCNi.com by ${individualUser.displayName} on Nov 25, 2015. personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
policies so that every patient undergoing surgery receives the best possible care. SSI rates are often reported using the cumulative incidence measure, which is calculated as the number of new infections divided by the population at risk over a defined period of time, expressed as a percentage. The infections included in this measure are those detected during inpatient stay or on readmission. The incidence of SSI varies widely between hospitals and between surgical categories in NHS hospitals in England (Public Health England (PHE) 2013a). This may be because of differences in case ascertainment, clinical practices and case mix. Categories with the highest degree of wound contamination have a higher incidence of infection. For example, large bowel surgery has an incidence rate for SSI of 10.6%, while categories generally considered as associated with clean wounds, such as knee and hip surgery are lower – with an SSI incidence of less than 1%. Figure 1 shows the incidence of SSI for the 17 categories of surgery available at PHE. Complete time out activity 1
Definition of surgical site infection An SSI is a wound infection that occurs following surgery. Most surgical wounds heal rapidly without complications; however, some become infected. Such infection occurs when microorganisms are introduced through the surgical incision as a result of bacteria or fungi migrating from the patient’s skin or gastrointestinal tract (microflora; endogenous infection), direct transfer from surgical instruments, equipment or hands of healthcare workers, or via the airborne route (exogenous infection) (Table 1). When the microorganism gains entry to the wound, it can multiply. The development of an SSI is influenced by the virulence of the organism and the host’s ability to resist infection. In some cases, bacteria can enter the body and travel in the blood, then deposit on prosthetic implants and multiply, causing infection. This is called haematogenous seeding (NAO 2000, Collier 2004, PHE 2013c). An SSI usually develops within 30 days of surgery – although, in some patients with a prosthetic implant, SSI can occur up to one year after surgery (PHE 2013c). Studies in
1 Make a list of the endogenous and exogenous risk factors for developing SSI. Could any of these be prevented and, if so, how? Speaking to members of the infection prevention and control team may help your decisions.
FIGURE 1 Cumulative incidence of surgical site infection by surgical category in NHS hospitals in England from April 2008 to March 2013 10.6
Large bowel 6.5
Bile duct, liver and pancreatic surgery
6.4
Small bowel 4.4
Coronary artery bypass graft (CABG)
4.2
Cholecystectomy 3.3
Limb amputation 2.8
Vascular
2.7
Gastric 1.6
Cranial Repair of neck of femur
1.5
Abdominal hysterectomy
1.5
Cardiac (non-CABG)
1.3
Reduction in long bone fracture
1.2
Spinal
1.1
Breast
1.0
Hip prosthesis
0.7
Knee prosthesis
0.6 0
2
4
6
8
10
12
Percentage of operations resulting in surgical site infection (Public Health England 2013b)
©Downloaded NURSINGfrom STANDARD RCN PUBLISHING july 30 :: vol uses 28 no 48 :: permission. 2014 51 RCNi.com/ by ${individualUser.displayName} on Nov 25, 2015. For personal use only. No other without Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infection control the United States have shown that there is a long-term risk of developing SSI following primary hip and knee replacements, with one quarter of infections diagnosed between two and ten years following surgery (Ong et al 2009, Kurtz et al 2010). Clinicians should bear the possibility of infection in mind when treating patients who have unresolved problems with their prosthesis. Complete time out activity 2
Clinical signs of surgical site infection, effects and classification Following surgery, patients usually experience pain, swelling and redness around the wound as part of the normal wound healing process (PHE 2013c). However, SSI may intensify these symptoms (National Institute for Health and Care Excellence (NICE) 2008). SSIs are associated with redness, heat, pain,
swelling, temperature greater than 38 degrees centigrade, purulent discharge, abscess and cellulitis directly related to the surgical wound, and dehiscence (Cutting and White 2004). A study conducted by Cahill et al (2008) investigated the long-term effect of SSI on several quality-of-life measures in patients undergoing knee and hip surgery. The results showed that SSI significantly affected patients’ mobility, independent living and psychological health. Another study conducted by Andersson et al (2010) showed that patients with deep SSI experienced physical, social, emotional and economic problems. Therefore, it is important that healthcare professionals understand the seriousness of SSI and the importance of prevention. Complete time out activity 3 Some infections may be difficult to diagnose, as there may not be obvious clinical signs
TABLE 1 Mode of infection spread
2 What information and advice might you give to a surgical patient following discharge regarding observing for signs and symptoms of SSI and how to care for the wound?
Direct physical contact (body surface to body surface) between infected or colonised individual and susceptible host. Examples of transmission: shaking hands, kissing, coitus. Examples of infections: common cold, sexually transmitted diseases. Precautions: hand hygiene, masks, condoms.
Indirect
Infectious agent deposited onto an object or surface (fomite) surviving long enough to transfer to another person who subsequently touches the object. Examples of transmission: not washing hands between patients, contaminated instruments. Examples of infections: respiratory syncytial virus, Norwalk, rhinovirus. Precautions: sterilising instruments, disinfecting surfaces in school.
Droplet
Contact, but transmission is through the air. Droplets are relatively large (>5µm) and projected up to about one metre. Examples of transmission: sneezing, coughing, during suctioning. Examples of infections: meningococcus, pertussis, respiratory viruses.
Airborne
Transmission via aerosols (airborne particles
CONTINUING PROFESSIONAL DEVELOPMENT
Page 60
Surgical site infection multiple choice questionnaire
Page 61
Read Clio Badenhorst’s reflective account on ethical practice
Page 62
Guidelines on how to write a reflective account
Prevention of surgical site infection NS754 Harrington P (2014) Prevention of surgical site infection. Nursing Standard. 28, 48, 50-58. Date of submission: March 7 2014; date of acceptance: April 28 2014.
Aims and intended learning outcomes
Abstract
Keywords
This article is aimed at nurses who care for patients during the pre, peri and post-operative periods. It is intended to provide information on the risk of developing surgical site infection (SSI) and on how it can be prevented and managed. After reading this article and completing the time out activities you should be able to: Recognise the signs and symptoms of SSI. Understand the importance of SSI audit and surveillance. Describe measures that can be taken to reduce the incidence of SSI. Explain management strategies for patients with SSI. Discuss the role of the nurse in treating patients with SSI.
Healthcare-associated infection, infection prevention and control, surgical site infection, wound care
Introduction
Surgical site infection (SSI) is a common healthcare-associated infection that can cause patients extreme pain and discomfort, resulting in prolonged hospitalisation and additional costs to the NHS. Multidisciplinary team working, combined with audit and surveillance, early recognition of signs and symptoms of infection, and implementation of evidence-based guidance are essential for reducing the incidence of SSI. Nurses caring for patients in the pre, peri and post-operative period have an important role in advising individuals about the risks associated with SSI and how infection should be managed.
Author Pauline Harrington Surgical site infection surveillance manager, Public Health England, London. Correspondence to: [email protected]
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
SSI accounts for an estimated 16% of all healthcare-associated infections (HCAIs) and can lead to increased antibiotic consumption and healthcare costs, prolonged recovery for patients, increased pain, anxiety, further risk of complications and, in some cases, death (National Audit Office (NAO) 2000, Health Protection Agency (HPA) 2012). Patients who develop SSI after discharge from hospital are at increased risk of readmission, resulting in additional costs to the NHS. Estimates suggest that it costs the NHS £700 million per year to treat patients with SSI (Adams-Howell et al 2011). SSI can be prevented with appropriate intervention, and healthcare professionals have an important role in this area. Guidance is available to assist healthcare professionals in the prevention, recognition and treatment of SSI, and should be integrated into local
50 july 30 :: vol from 28 no 48 :: 2014 ©For NURSING STANDARD / RCN Downloaded RCNi.com by ${individualUser.displayName} on Nov 25, 2015. personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
policies so that every patient undergoing surgery receives the best possible care. SSI rates are often reported using the cumulative incidence measure, which is calculated as the number of new infections divided by the population at risk over a defined period of time, expressed as a percentage. The infections included in this measure are those detected during inpatient stay or on readmission. The incidence of SSI varies widely between hospitals and between surgical categories in NHS hospitals in England (Public Health England (PHE) 2013a). This may be because of differences in case ascertainment, clinical practices and case mix. Categories with the highest degree of wound contamination have a higher incidence of infection. For example, large bowel surgery has an incidence rate for SSI of 10.6%, while categories generally considered as associated with clean wounds, such as knee and hip surgery are lower – with an SSI incidence of less than 1%. Figure 1 shows the incidence of SSI for the 17 categories of surgery available at PHE. Complete time out activity 1
Definition of surgical site infection An SSI is a wound infection that occurs following surgery. Most surgical wounds heal rapidly without complications; however, some become infected. Such infection occurs when microorganisms are introduced through the surgical incision as a result of bacteria or fungi migrating from the patient’s skin or gastrointestinal tract (microflora; endogenous infection), direct transfer from surgical instruments, equipment or hands of healthcare workers, or via the airborne route (exogenous infection) (Table 1). When the microorganism gains entry to the wound, it can multiply. The development of an SSI is influenced by the virulence of the organism and the host’s ability to resist infection. In some cases, bacteria can enter the body and travel in the blood, then deposit on prosthetic implants and multiply, causing infection. This is called haematogenous seeding (NAO 2000, Collier 2004, PHE 2013c). An SSI usually develops within 30 days of surgery – although, in some patients with a prosthetic implant, SSI can occur up to one year after surgery (PHE 2013c). Studies in
1 Make a list of the endogenous and exogenous risk factors for developing SSI. Could any of these be prevented and, if so, how? Speaking to members of the infection prevention and control team may help your decisions.
FIGURE 1 Cumulative incidence of surgical site infection by surgical category in NHS hospitals in England from April 2008 to March 2013 10.6
Large bowel 6.5
Bile duct, liver and pancreatic surgery
6.4
Small bowel 4.4
Coronary artery bypass graft (CABG)
4.2
Cholecystectomy 3.3
Limb amputation 2.8
Vascular
2.7
Gastric 1.6
Cranial Repair of neck of femur
1.5
Abdominal hysterectomy
1.5
Cardiac (non-CABG)
1.3
Reduction in long bone fracture
1.2
Spinal
1.1
Breast
1.0
Hip prosthesis
0.7
Knee prosthesis
0.6 0
2
4
6
8
10
12
Percentage of operations resulting in surgical site infection (Public Health England 2013b)
©Downloaded NURSINGfrom STANDARD RCN PUBLISHING july 30 :: vol uses 28 no 48 :: permission. 2014 51 RCNi.com/ by ${individualUser.displayName} on Nov 25, 2015. For personal use only. No other without Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infection control the United States have shown that there is a long-term risk of developing SSI following primary hip and knee replacements, with one quarter of infections diagnosed between two and ten years following surgery (Ong et al 2009, Kurtz et al 2010). Clinicians should bear the possibility of infection in mind when treating patients who have unresolved problems with their prosthesis. Complete time out activity 2
Clinical signs of surgical site infection, effects and classification Following surgery, patients usually experience pain, swelling and redness around the wound as part of the normal wound healing process (PHE 2013c). However, SSI may intensify these symptoms (National Institute for Health and Care Excellence (NICE) 2008). SSIs are associated with redness, heat, pain,
swelling, temperature greater than 38 degrees centigrade, purulent discharge, abscess and cellulitis directly related to the surgical wound, and dehiscence (Cutting and White 2004). A study conducted by Cahill et al (2008) investigated the long-term effect of SSI on several quality-of-life measures in patients undergoing knee and hip surgery. The results showed that SSI significantly affected patients’ mobility, independent living and psychological health. Another study conducted by Andersson et al (2010) showed that patients with deep SSI experienced physical, social, emotional and economic problems. Therefore, it is important that healthcare professionals understand the seriousness of SSI and the importance of prevention. Complete time out activity 3 Some infections may be difficult to diagnose, as there may not be obvious clinical signs
TABLE 1 Mode of infection spread
2 What information and advice might you give to a surgical patient following discharge regarding observing for signs and symptoms of SSI and how to care for the wound?
Direct physical contact (body surface to body surface) between infected or colonised individual and susceptible host. Examples of transmission: shaking hands, kissing, coitus. Examples of infections: common cold, sexually transmitted diseases. Precautions: hand hygiene, masks, condoms.
Indirect
Infectious agent deposited onto an object or surface (fomite) surviving long enough to transfer to another person who subsequently touches the object. Examples of transmission: not washing hands between patients, contaminated instruments. Examples of infections: respiratory syncytial virus, Norwalk, rhinovirus. Precautions: sterilising instruments, disinfecting surfaces in school.
Droplet
Contact, but transmission is through the air. Droplets are relatively large (>5µm) and projected up to about one metre. Examples of transmission: sneezing, coughing, during suctioning. Examples of infections: meningococcus, pertussis, respiratory viruses.
Airborne
Transmission via aerosols (airborne particles
