Care bundles to reduce surgical site infections and promote positive outcomes

This article will explore care bundles as a tool for reducing surgical site infections (SSIs). To achieve this, the impact of SSIs on patient outcomes will be considered and guidance will be provided on how to reduce their occurrence, specifically through an exploration of how care bundles can assist in this. The article aims to provide practical direction for implementing change and improving standards of patient care in relation to reducing SSIs.

Surgical site infections

SSIs affect large numbers of veterinary patients each year and are infections that occur at, or near, to the surgical site up to 30 days post surgery, or up to 1 year after implants have been placed (Horan et al, 2008). In human medicine, SSIs are classified based on a set of criteria defined by the National Healthcare Safety Network (2023) (see Table 1). Generally, the same principles are applied to SSIs observed in veterinary medicine.

Understanding the aetiology and pathophysiology of SSIs is essential for practising veterinary nurses. SSIs can lead to increased morbidity, mortality and poor patient outcomes (Low, 2022). Patients may experience increased duration of hospitalisation, increased cost of treatment, the requirement for additional and perhaps more complex wound management and revision surgery (Nelson, 2011). The additional worry experienced by clients, not to mention the financial implications, are also serious concerns which in turn can result in poor patient outcomes (Low, 2022).

In veterinary medicine, the occurrence of SSIs has been linked to the level of contamination of the surgical site (see Table 2).

As demonstrated, even clean surgical procedures provide a significant risk of infection, therefore practices should be striving to reduce these risks and, in turn, improve patient outcomes.

Clinical signs

Although prevention of SSIs is desirable, recognition of clinical signs can facilitate early intervention, helping to reduce the impact of an infection. Key clinical signs associated with SSIs include (Yon, 2019):

• Local oedema of the surgical incision
• Erythema of the incision and skin around the incision
• Exudation from the wound
• Pain in the area surrounding the incision.

Other clinical signs can include dehiscence of the wound edges, pyrexia, seroma formation, ischaemia, loss of function (limbs) and necrosis (Jordan, 2022). See Figure 1 for common clinical signs associated with SSIs.

Reducing the risk of SSIs

While it is unrealistic and perhaps impossible to prevent all SSIs entirely, there are many preventative measures that can be implemented to reduce the risks associated with them. Interventions can be introduced in many areas of practice, but generally are focussed on care immediately before surgery, the intraoperative period and post surgery.

Summarising the evidence base, Stetter at al (2021) outlined that key risk factors for developing a SSI have been identified as age, American Society of Anaesthesiologist's (ASA) score, wound classification, anaesthesia time, surgical time, use of implants, antibiotic prophylaxis, timing of hair clipping, number of theatre personnel, hypotension, post-operative use of antimicrobials and presence of endocrine disease. It is important for veterinary nurses to be aware of these factors to identify at-risk patients, and to consider implementing strategies to reduce SSIs in these areas.

Preoperatively, widely accepted interventions associated with reducing SSIs include preparation of the patient, specifically the surgical site, and personnel. At this point, antibiotic prophylaxis may also be considered. Personnel should maintain good hygiene standards such as hand hygiene and nail length (Yon, 2019; Low, 2022). Surgical scrubbing should use medicated soap or alcohol-based hand rub to reduce the risk of contamination of the surgical site (Low, 2022). Surgical site preparation should be carefully considered. Clipper blades should be cleaned appropriately and well maintained to reduce the transmission of pathogens to the surgical site (Bowers, 2012; Low, 2022). With regard to surgical skin preparation, there are no standardised protocols accepted across the veterinary field and this is perhaps an area for profession-wide improvement. However, it is generally agreed that the final skin preparation should be carried out in aseptic conditions with the patient already positioned for surgery. Regarding solutions, a large meta-analysis of publications comparing the use of chlorhexidine and povidone–iodine found they demonstrated comparable effectiveness (Marchionatti et al, 2022). There is much discussion regarding scrub technique between the back-and-forth and concentric circles methods. In veterinary medicine, greater research is required to provide evidence in favour of one method over the other. At present, there is little evidence to suggest one method is more effective than the other at reducing the risk of SSIs (Kerrigan, 2018).

Intraoperatively, key areas for consideration include attire, draping, anaesthesia, demonstration of Halsted's surgical principles, wound closure and dressings (Low, 2022). A recent study investigating risk factors for SSIs found that surgical time was the greatest risk factor for SSI development (Stetter et al, 2021). Attention should be given to considering techniques and protocols for improving theatre management and efficiency to reduce this risk.

Postoperatively, effective patient and wound management should be adopted. Specifically, regular monitoring of vital parameters, wound site and dressings for signs of infection (Yon, 2019).

As with most areas of medicine, advancements with regard to improved patient care are being made constantly. The following implementations are relatively novel, or have not been adopted as widely as others, but have been found to have a positive impact on patient outcomes regarding SSIs.

ASA Scoring

Although ASA scoring is not necessarily novel, greater volumes of recent literature have investigated its relevance when discussing SSIs. In human medicine, ASA scores >3 are associated with increased risk of SSI development (Khan et al, 2010; Papadopoulos et al, 2021; Yin and Sun, 2023), although application of these results to veterinary medicine must be done with caution. The evidence base in veterinary medicine is comparatively weak. Eugster et al (2004) carried out a large-scale study and found that an increased ASA score was significantly associated with increased risk of SSI, however other studies also investigating the relationship between ASA status and SSI incidence have found no statistically significant links (Turk et al, 2015; Espinel-Rupérez et al, 2019; Billas et al, 2022). Yet although not statistically significant, this does not mean the results are not clinically useful. While the evidence base in veterinary medicine does not highlight strong links between ASA grading and SSI development, it is widely accepted that poor health status increases the risk of wound healing complications (O'Dwyer, 2012). Therefore, implementing ASA scoring for all surgical patients should help to identify those who are at greater risk of poor wound healing and infection generally, and thus additional measures can be considered to aid the prevention of SSIs.

Surgical safety checklists

Surgical safety checklists have been discussed in veterinary medicine for some time. Surgical safety checklists are comprised of a series of checks and assurances to ensure that patient identity and outlined procedure are correct and to facilitate structured safety checks on wound closure and exit from theatre (Cray et al, 2018). They were originally designed to reduce the risk of never-events (Yon, 2019); events that should not occur, such as administration of incorrect medications, failure to administer prophylactic antibiotics or leaving surgical equipment behind in the surgical site. Bergström et al (2016) found that implementation of surgical safety checklists significantly reduced SSIs and wound complications, and a study by Cray et al (2018) found concurrent results. Although Thieman Mankin et al (2021) did not find that implementation of a surgical safety checklist was associated with reduced SSI incidence, the researchers recommended surgical safety checklists to aid in compliance with safety measures and thus reduce the risk of morbidity and reduce never events. In human medicine, surgical safety checklists are an essential and required part of surgical protocols, with a wealth of evidence to support their use, yet the evidence in veterinary medicine is sparse. In future, it is hoped that greater research will be conducted in this area, not only with the view to reducing SSIs, but also to reduce morbidity and mortality of surgical patients.

Active surveillance

Practices with a surgical caseload of primarily day procedures may benefit from implementing protocols of active surveillance to identify incidence of SSI. Some 92–100% of SSIs are diagnosed after discharge (Garcia Stickney and Thieman Mankin, 2018; Glenn et al, 2024) and studies have found that significant percentages of SSIs are identified only through active surveillance (Garcia Stickney and Thieman Mankin, 2018). Active surveillance of patients relies on appointments or directly contacting clients, for example via telephone, email or client questionnaires, to query patient status. Although this can be time consuming and could be burdensome on staff in practice (Garcia Stickney and Thieman Mankin, 2018), it has been found to be more effective at identifying SSIs (Ruple-Czernaik et al, 2013; Turk et al, 2015) than passive surveillance which typically involves the retrospective analysis of data (Burgess, 2019). Garcia Stickney and Thieman Mankin (2018) found an SSI rate of 2.83%, and 27.8% of these SSIs were detected via active surveillance. A recent study investigating development of SSIs using passive and active surveillance methods reported similar findings, with a higher SSI incidence of 8.2% of 309 procedures, and with 19.4% of these detected exclusively by active surveillance (Glenn et al, 2024). These findings may highlight a key area for quality improvement in practice, and identification of otherwise undiagnosed SSIs could improve patient health and outcomes associated with surgical procedures.

The above three interventions have been specifically discussed as they are key areas for veterinary nursing involvement. Although veterinary nurses are not allowed to diagnose conditions, they are able to ASA score based on known diagnoses. These areas may provide autonomy for veterinary nurses and also provide interesting areas for veterinary nursing research.

Care bundles: a novel approach to SSI reduction

Care bundles are a group of evidence-based interventions, usually three to five in number, which when performed together, as opposed to individually, improve patient outcomes (Lavallée et al, 2017). Care bundles themselves can be implemented on a small scale within a ward of a practice, or as global health initiatives.

Care bundles are well-established in human medicine with their implementation helping to improve healthcare and prevent health complications. Examples include the Sepsis Six, a six-step initiative to treat critical sepsis within 1 hour of patient presentation. This has been shown to reduce relative deaths from 44% to 20% and is estimated to save approximately 15 000 lives per year across the NHS (Daniels et al, 2011). Not only are lives saved, but it is also suggested that millions of pounds for the NHS have been, and will continue to be, saved following implementation of the Sepsis Six (UK Sepsis Trust, 2022). This is just one example of how care bundles can benefit patient outcomes in addition to clinical effectiveness. An example from veterinary medicine includes the RECOVER initiative, which provides techniques for basic and advanced life support for veterinary patients. Implementation of the RECOVER guidelines in cases of cardiopulmonary arrest have been shown to improve outcomes of cardiopulmonary resuscitation in dogs (Kawase et al, 2018; Nas et al, 2020), although greater research is needed to provide a wider evidence base applicable to UK pet populations.

What are the benefits?

As discussed, the main benefit of the creation and use of care bundles is the promotion of good patient outcomes. These can be achieved by (Waxman, 2022):

• Helping to promote and maintain consistency in the approach to patient care, ie encouraging standardisation by use of evidence-based guidelines
• Setting patient care standards
• Helping to establish best clinical practices, guided by best practice guidelines and clinical benchmarks
• Improvement of clinical effectiveness
• Reducing patient morbidity and mortality.

Creating a care bundle to reduce SSIs: what is the evidence?

In human medicine, it is widely accepted that care bundles are an effective way to reduce SSIs (Wolfhagen et al, 2022). However, in veterinary medicine, there is, to the authors' knowledge, no literature exploring care bundles as a technique to reduce SSIs. Although successful measures for human medical practices cannot be assumed to be applicable or relevant to veterinary medicine, a care bundle itself can be tailored to individual veterinary settings using evidence-based procedures and techniques that are identified as relevant. This may be an ideal opportunity to learn from colleagues from human medicine and to take the leap with implementing care bundles. To do this, individual practices must identify which evidence-based procedures and techniques are most applicable to their practice type and surgical caseload.

How to choose?

A care bundle implemented to reduce SSIs that works well in one practice may not be suitable for another practice. For instance, when comparing the needs of a general, first opinion practice with a multidisciplinary specialist referral centre, it is easy to differentiate needs. For example, it could be suggested that in general practice, day procedures are common with few surgical patients needing overnight/multiple day hospitalisation, whereas larger referral hospitals could expect more complex procedures, requiring greater surgical times and greater length of stay. Both offer different risk factors for SSIs and thus any care bundle would need to be designed to fit practice requirements.

In practices where routine or fewer complex surgeries are carried out, it may be sensible to suggest that care bundle procedures should be focussed on pre- and intraoperative care, in addition to emphasis on educating clients on how to manage surgical wounds at home and carrying out active surveillance.

In larger practices carrying out complex procedures with surgical patients remaining in hospital, there may be a greater emphasis on postoperative care received in the clinical setting. Depending on whether there are multiple departments, care bundles may be developed by departments, such as an anaesthesia team creating a pre- and intraoperative care bundle focussing on ASA scoring, and surgical safety checklist completion; the theatre team focussing on skin preparation technique and operating theatre management; and the wards teams considering postoperative wound management and nutrition.

How to implement a care bundle in practice

As with the introduction of any new initiatives, care must be taken to do so carefully to ensure compliance from staff. Those required to use the care bundle must understand the individual procedures and the benefits of the bundle must be explained.

Implementing change in practice can be difficult. It is widely accepted that veterinary practices, and veterinary nursing teams, are often stretched regarding staff numbers and time, however implementing strategies such as care bundles can improve clinical effectiveness. As discussed, reducing the incidence of SSIs can improve patient outcomes, relieving some of the burden for those involved in clinical care. Specifically, reducing the occurrence of SSIs can improve morale, reduce staff workload and improve reputation, profitability and income of the practice (Low, 2022).

Clinical auditing is a process by which new techniques can be implemented and their outcomes monitored in clinical practice with a view to improving patient outcomes. See Figure 2 for an overview of the audit cycle. Clinical auditing should be used when introducing any new techniques, such as individual protocols to reduce incidence of SSIs, or for protocols such as care bundle introduction. Auditing involves the whole clinical team (Yon et al, 2022). Although change may be resisted, the audit process itself can be beneficial to reducing clinical error, promoting higher standards of care and strengthening the bond of the team (Rose et al, 2016). It must also be emphasised that it is the responsibility of veterinary nurses to promote patient health and welfare through clinical governance; clinical auditing is a vital governance activity (Yon et al, 2022).

Clinical governance offers a pivotal backbone to the assurance of the delivery of best practice techniques, procedures and protocols through processes of reflection, analysis and improvement (Yon et al, 2022). It ensures evidence-based practice by relying on benchmarking, clinical auditing and research findings to provide guidance for best practice initiatives. Many of these initiatives focus on one technique, procedure or protocol, such as flushing a peripheral intravenous catheter with heparin/saline solution or using a back-and-forth skin preparation technique before surgical incision. Care bundles arguably offer an even more stringent approach to evidence-based veterinary and veterinary nursing care. Carrying out a clinical audit would be imperative to monitor outcomes following implementation of a care bundle aiming at reducing SSIs. There are many excellent and helpful resources available to assist with carrying out an audit from the RCVS Knowledge site (https://knowledge.rcvs.org.uk/quality-improvement/tools-and-resources/clinical-audit/).

Conclusions

Reducing the risk of SSI in practice is a key area for any practice carrying out surgery. There are many, widely accepted techniques and protocols that are implemented commonly within a variety of practices. Those involved in surgical procedures should be aware of emerging initiatives, such as routine ASA scoring, creation and use of surgical safety checklists and completing active surveillance of post-discharge patients. Enveloping all of this, care bundles can provide a structured and whole-team approach to improving patient care, which, if implemented, could lead to reduced SSIs and improving patient outcomes. The authors encourage readers to consider implementing care bundles with the view to reducing SSIs and to investigate the outcomes via clinical audit or clinical research.

KEY POINTS

• Surgical site infections are a potential complication of all surgical wounds.
• Surgical site infections are relatively common and can significantly affect patient outcomes.
• Care bundles are grouped evidence-based interventions that can improve patient outcomes.
• Care bundles may be created and implemented to reduce the risk of surgical site infections.