The time is now: we must act to reduce surgical site infections
Responding to the latest State of the Nation Report on Surgical Site Infections from Mölnlycke, the company’s General Manager for UK & Ireland, Nick Rothwell, presses home the need for urgent reform that will save lives.
With the NHS doing all it can to reduce the risks to the public from Covid-19, the vital role of infection prevention in improving health outcomes has never been higher in the public consciousness or on the political agenda. As elective care resumes across the country, now is an opportune moment to reflect on how we can work together to support the health service in minimising the risks from other forms of healthcare associated infections, such as surgical site infections (SSIs).
Gaining a true understanding of the scale of the challenge we face from SSIs and the burden they place on the health system was the primary reason that Mölnlycke developed our new report, Time to Act: A State of the Nation report on Surgical Site Infections in the UK. The report provides the fullest possible picture of SSI rates in the UK, and their impact on patients, clinicians and the NHS. In understanding how to reduce the impact of SSIs, we reviewed the best practice taking place from within the UK and around the world.
The report finds that the challenges we face in reducing SSIs cannot be solved by just policymakers or clinicians alone, they need to be met by collective action from across the health system. From industry to clinicians, from Royal Colleges to patient associations, we all need to act, and play our part in reducing the risk of SSIs across the UK.
The cost of SSIs to patients and the National Health Service
When a patient gets an infection after a surgical procedure, it can have a significant impact on their lives and the lives of their families. They may be forced to spend many months in hospital, and undergo additional surgical procedures. Some patients may be forced to give up their work, and subsequently experience serious financial hardships. While deaths from SSIs are mercifully rare, mortality rates are still too high and over one third of deaths in patients with SSIs were directly attributable to the infection.[i]
We also know there is a significant financial cost to the NHS of SSIs. There is no agreed figure of the total cost of SSIs to the NHS, but we know that the financial impact is considerable. Each SSI is estimated to cost just over £10,000 per person, with deep-incisional SSIs costing a staggering £100,000 per patient[ii]. An SSI can also significantly increase the cost of a particular surgery, doubling them in some instances. There are also the damages that may be paid as a result of legal action against clinical negligence. At a time when NHS budgets are under extraordinary pressures from the challenges of Covid-19, the financial burdens of SSIs are one cost that we should not seek to bare.
The National Picture of SSI rates
But what is the extent of the problem across the country? The picture across all surgeries is, unfortunately, far from clear. One of the difficulties in estimating the true impact of SSIs is the current methods by which they are reported across the four nations of the UK. Nationwide surveillance and data capture for the number of SSIs only began in 1997 with the introduction of voluntary submissions of data from NHS trusts in orthopedic surgery. Mandatory reporting for SSI rates in orthopedic surgery was first introduced in 2005[iii], and many trusts now voluntarily report rates for over 13 other surgical categories.[iv] This is of course a welcome development, and has greatly supported hospital trusts in benchmarking their own performance for some surgical categories, but much more needs to be done to expand the surveillance into other surgical areas, beyond orthopaedics. Without a full understanding of the scale of any problem, we will never know how it can be solved.
Time to act on infection prevention
Policymakers, who have done much to tackle the growing risk of antimicrobial resistance, with the publication of the 5-year plan for antimicrobial resistance, must now do more to tackle specific healthcare associated infections, such as SSIs. We urgently need to raise the level of understanding and prioritisation of SSIs amongst policymakers. The Time to Act report calls the Government to convene a Preventable Infections Taskforce, bringing together experts from across all four nations, to produce a UK-wide strategy for further reducing all healthcare associated infection rates. Furthermore, the next AMR Strategy needs to recognise the importance of reducing SSIs, setting a clear and deliverable target to reduce SSIs across all surgical specialties within the lifetime of the 5-year AMR plan, and, subsequently, for the 20-year plan.
However, the fight to reduce SSIs will never receive the political support it truly needs without a full understanding of the scale of the problem we face in all four nations of the UK. National reporting for SSIs is still nowhere near as robust as it should be. Data sets, whilst increasing each year, are still not of a high enough quality, nor as comprehensive as the scale of the challenge demands. That is why we now need mandatory SSI reporting for all surgical procedures in each of the UK’s four nations. Without this baseline, we will never be able to set national benchmarks against which further action can be taken at a hospital and system level.
A collaborative approach to SSI reduction
The Time to Act report shows that despite the challenges we face with national data collection, when we take a collaborative approach to SSI prevention within a surgical team or across hospital trusts, we can develop highly effective interventions to help drive down SSI rates. Led by the Northumbria Healthcare NHS Foundation Trust, the Quality Improvement for Surgical Teams (QIST) programme has brought together 30 trusts from across England and the British Orthopaedic Association to drive forward improvements in patient care. By introducing small, targeted changes to care pathways, such as whole body washing and nasal gel treatments, the QIST programme expects to improve patient outcomes whilst supporting savings of up to £6.3 million to hospital trusts across the country since its launch in 2013.
Another successful national intervention is Getting It Right First Time (GIRFT), an NHS Improvement programme delivered in partnership with the Royal National Orthapaedic Hospital NHS Trust. GIRFT is designed to improve the quality of care within the NHS by reducing unwarranted variations, and has done much to reduce SSIs by engaging frontline clinicians in the data collection process and exploring variation in surgical practice and outcomes for a wider range of procedures and specialties. One of the key recommendations made by the GIRFT programme is for Trusts to review their own surgical units’ deep SSI rates and introduce a multi-disciplinary approach to reduce infection risk pre-, inter- and post-operatively – as seen to great effect in Ashford and St Peter’s Hospitals NHS Trust.
Minimising the risk of SSIs from the board to the ward
Adopting a collaborative approach within hospitals, from the ‘board to the ward’ can also drive considerable improvements in patient care. Our report highlights a number of case studies show that if we can raise the profile of infection control within the hospital and adopt best practice measures across the patient’s surgical journey, trusts can drive significant improvements in SSI rates. That is why we have called for compulsory training and education programmes for healthcare professionals at all levels on the importance of infection prevention, and reducing SSIs. At a time where strain is being felt across the NHS, we also need NHS managers to listen to evidence based arguments from their clinical teams about what equipment they feel is needed to best deliver safe, high quality care.
As hospitals continue to increase elective care in the coming months, they must do so under the significant additional pressures of Covid-19. The added burden of SSIs is one which, through a collaborative approach across the health system, from Westminster to hospital wards, we can go without. It is time to act, for our patients, for our healthcare professionals, and for the NHS.
To read and download your copy of Time to Act: A State of the Nation report on Surgical Site Infections in the UK click here.
[i] P. Astagneau et. al. Morbidity and mortality associated with Surgical Site Infections: Results from the 1997-1999 INCISO surveillance. The Hospital Infection Society. 2001. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11461127.
[ii] Getting It Right First Time. GIRFT SSI National Survey. 2019. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/08/SSI-Report-GIRFT-APRIL19e-FINAL.pdf
[iii] Health Protection Agency. Mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery. October 2005. Available from: https://webarchive.nationalarchives.gov.uk/20140722031003/http://www.hpa.org.uk/Publications/InfectiousDiseases/SurgicalSiteInfectionReports/0510MandatorySurveillanceofSSIinOrthopaedicSurgery/
[iv] Public Health England. Surveillance of surgical site infections in NHS hospitals in England. December 2019. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/854182/SSI_Annual_Report_2018_19.pdf