Barriers and facilitators for surgical site infection surveillance for adult cardiac surgery in a high-income setting: an in-depth exploration.

BACKGROUND: Surgical site infection (SSI) surveillance aims to facilitate a reduction in SSIs through identifying infection rates, benchmarking, triggering clinical review and instituting infection control measures. Participation in surveillance is, however, variable suggesting opportunities to improve wider adoption. AIM: To gain an in-depth understanding of the barriers and facilitators for SSI surveillance in a high-income European setting. METHODS: Key informant interviews with 16 surveillance staff, infection prevention staff, nurses and surgeons from nine cardiac hospitals in England. Data were analysed thematically. FINDINGS: SSI surveillance was reported to be resource intensive. Barriers to surveillance included challenges associated with data collection: data being located in numerous places, multiple SSI data reporting schemes, difficulty in finding denominator data, lack of interface between computerized systems, 'labour intensive' or 'antiquated' methods to collect data (e.g., using postal systems for patient questionnaires). Additional reported concerns included: relevance of definitions, perceived variability in data reporting, lack of surgeon engagement, unsupportive managers, low priority of SSIs among staff, and a 'blame culture' around high SSI rates. Facilitators were increased resources, better use of digital technologies (e.g., remote digital wound monitoring), integrating surveillance within routine clinical work, having champions, mandating surveillance, ensuring a closer relationship between surveillance and improved patient outcomes, increasing the focus on post-discharge surveillance, and integration with primary care data. CONCLUSION: Using novel interviews with 'front-line' staff, identified opportunities for improving participation in SSI surveillance. Translating these findings into action will increase surveillance activity and bring patient safety benefits to a larger pool of surgical patients.

Assessing the added value of group B Streptococcus maternal immunisation in preventing maternal infection and fetal harm: population surveillance study.

OBJECTIVE: To assess the incidence of maternal group B Streptococcus (GBS) infection in England. DESIGN: Population surveillance augmented through data linkage. SETTING: England. POPULATION: All pregnant women accessing the National Health Service (NHS) in England. METHODS: Invasive GBS (iGBS) infections during pregnancy or within 6 weeks of childbirth were identified by linking Public Health England (PHE) national microbiology surveillance data for 2014 to NHS hospital admission records. Capsular serotypes of GBS were determined by reference laboratory typing of clinical isolates from women aged 15-44 years. Post-caesarean section surgical site infection (SSI) caused by GBS was identified in 21 hospitals participating in PHE SSI surveillance (2009-2015). MAIN OUTCOME MEASURES: iGBS rate per 1000 maternities; risk of GBS SSI per 1000 caesarean sections. RESULTS: Of 1601 patients diagnosed with iGBS infections in England in 2014, 185 (12%) were identified as maternal infections, a rate of 0.29 (95% CI 0.25-0.33) per 1000 maternities and representing 83% of all iGBS cases in women aged 18-44 years. Seven (3.8%) were associated with miscarriage. Fetal outcome identified excess rates of stillbirth (3.4 versus 0.5%) and extreme prematurity (<28 weeks of gestation, 3.7 versus 0.5%) compared with national averages (P < 0.001). Caesarean section surveillance in 27 860 women (21 hospitals) identified 47 cases of GBS SSI, with an estimated 4.24 (3.51-5.07) per 1000 caesarean sections, a median time-to-onset of 10 days (IQR 7-13 days) and ten infections that required readmission. Capsular serotype analysis identified a diverse array of strains with serotype III as the most common (43%). CONCLUSIONS: Our assessment of maternal GBS infection in England indicates the potential additional benefit of GBS vaccination in preventing adverse maternal and fetal outcomes.

Future priorities of acute hospitals for surgical site infection surveillance in England.

BACKGROUND: Since the launch of the national Surgical Site Infection (SSI) Surveillance Service in 1997, successive expansions of the programme provided hospitals with increasing flexibility in procedures to target through surveillance. Ensuring that the programme continues to meet hospitals' needs remains essential. AIM: As a means to inform the future direction of the service, a survey of all acute National Health Service trusts was undertaken to assess and understand priorities for surveillance. METHODS: A web-based survey was circulated to acute NHS trust infection control teams in England, asking them to identify and rank (i) reasons for undertaking current SSI surveillance, (ii) priority surgical categories for future SSI surveillance, and (iii) reasons for prioritizing these categories. FINDINGS: Of the 161 trusts surveyed, 84 (52%) responded. Assessment of quality of care was identified as the most common driver for SSI surveillance activity. Considerable heterogeneity in priority areas was observed, with 24 different surgical categories selected as top priority. Of the procedures undertaken by 15 or more trusts, caesarean section (2.7), hip replacement (2.8) and coronary artery bypass graft (2.9) were highest ranked. All 17 categories in the current surveillance programme were selected as a top priority by one or more trusts. CONCLUSION: Whereas the majority of hospitals' priorities for SSI surveillance are included in the current programme, the top-ranked priority, caesarean section, is not included. Given the diversity of priority areas, maintaining a comprehensive spectrum of categories in the national programme is essential to assist hospitals in addressing local priorities.

Inter-hospital comparison of rates of surgical site infection following caesarean section delivery: evaluation of a multicentre surveillance study.

BACKGROUND: Short postoperative stays following caesarean section delivery make it difficult to assess accurately the risk of surgical site infection (SSI). Methods of case-finding that minimize variation are required to support effective surveillance systems, especially where used for benchmarking. AIM: To evaluate the efficacy of case-finding methods for SSI following caesarean delivery and their utility in establishing benchmark rates of SSI. METHODS: Hospitals conducted surveillance over one or two 13-week periods. Patients were reviewed during their inpatient stay, post partum by community midwives and via patient questionnaire at 30 days post delivery. To estimate the reliability of case-finding methods, case-note reviews were undertaken in a random sample of four hospitals. FINDINGS: A total of 404 SSIs were detected in 4107 caesarean deliveries from 14 hospitals. The median time to SSI was 10 days, 66% were detected in-hospital or by community midwives, and an additional 34% were patient-reported. The rate of SSI was 9.8% but the proportion of patients followed up varied significantly between centres. The estimated sensitivity and specificity of case-finding was 91.4% [95% confidence interval (CI): 53.4-98.4] and 98.6% (95% CI: 98.4-98.8), the positive predictive value 91.0% (95% CI: 82.4-96.1) and negative predictive value 98.6% (95% CI: 93.9-99.5). CONCLUSIONS: Combined case ascertainment methods are a feasible way to achieve active post-discharge surveillance and had high negative and positive predictive values. Additional SSIs can be detected by patient questionnaires but rates of SSI were strongly influenced by variation in intensity of both healthcare worker- and patient-based case-finding. This factor must be taken into account when comparing or benchmarking rates of SSI.

Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study.

OBJECTIVE: To assess the frequency and risk factors for surgical site infection following caesarean section. DESIGN: Prospective multicentre cohort study. SETTING: Fourteen NHS hospitals in England, April to September 2009. POPULATION: Women who underwent caesarean section at participating hospitals during designated study periods. METHODS: Infections that met standard case definitions were identified through active follow up by healthcare staff during the hospital stay, on return to hospital, during midwife home visits and through self-completed patient questionnaires. MAIN OUTCOME MEASURE: Surgical site infection within 30 days of operation. RESULTS: Altogether, 9.6% (394/4107) of women in the study developed a postsurgical infection following caesarean section with 0.6% (23/4107) readmitted for treatment of the infection. Being overweight (body mass index [BMI] 25-30 kg/m(2) odds ratio [OR] 1.6, 95% confidence interval [95% CI] 1.2-2.2) or obese (BMI 30-35 kg/m(2) OR 2.4, 95% CI 1.7-3.4; BMI > 35 kg/m(2) OR 3.7, 95% CI 2.6-5.2) were major independent risk factors for infection (compared with BMI 18.5-25 kg/m(2)). There was a suggestion that younger women, and operations performed by associate specialist and staff grade surgeons had a greater odds of developing surgical site infection with OR 1.9, 95% CI 1.1-3.4 (<20 years versus 25-30 years), and OR 1.6, 95% CI 1.0-2.4 (versus consultants), respectively. CONCLUSIONS: This study identified high rates of postsurgical infection following caesarean section. Given the number of women delivering by caesarean section in the UK, substantial costs will be incurred as a result of these infections. Prevention of these infections should be a clinical and public health priority.