Surgical Site Infection surveillance & prevention – Are we there yet?

My role as a surgical site infection (SSI) surveillance team leader for an acute Trust in central London has humbled me, left me kinder and much improved in areas of my life that I originally thought I was perfect. I have come to appreciate the importance of having a right attitude irrespective of whether you’re right or not in any given scenario. In fact I now think that it doesn’t matter how smart or intelligent you’re, if your attitude is wrong then prioritising addressing any underlying causes that lead to unacceptable attitudes and behaviours is important. Acknowledging that certain behaviours and attitudes can be a result of underlying personal or other worries, emotionally intelligent managers should attempt to uncover these and provide support as necessary. It can be a bit blurred though in some situations – How does deliberate look like? How does genuine look like? I have come to the conclusion that for me it’s not going to be about how people treat me, good or bad I should still try and respond positively and be assertive also. Of course I’d hope that people don’t deliberately provoke me :-). I like this quote that my manager Neil has displayed in his office for years:

Each day I ask myself – how was I today? How many emails did I sent? Were they necessary? Is there anything I should have done better? Were there any reactions from others that I need to make a note of and be mindful of in future? Did I have enough time to self care today and refill my cup? Reflection enables you to constantly reflect on your attitudes and behaviours and promotes growth.

Why a focus on attitudes in an SSI prevention blog?

A role in surgical site infection surveillance involves working across specialties with various members of the multidisciplinary teams who undertake different specialist roles across patients’ surgical pathways. Depending on individual roles, there can be considerable amounts of stressful scenarios and even fatigue experienced on a daily basis that we must acknowledge and manage professionally. I think managing difficult situations professionally can be well executed by those displaying a good and positive attitude.

Preparation is always invaluable in any given situation; be it preparation for a meeting, an examination, travel, change management etc. Certainly when engaging in dialogue, various reactions and responses may be displayed and these can not always be anticipated. Having a right mindset is particularly important so you can manage any unpleasant reactions professionally and with compassion. For example if someone is coming from a 'heated meeting', presenting an important patient safety initiative or quality improvement project which may be perceived to increase workload is likely to be faced with resistance. It is important to reflect and re-evaluate after such meetings should challenges be encountered to find ways and perhaps a different time to pitch your ideas again. An emotionally intelligent approach is therefore desirable. I always tell myself that if SSI causes are multi-factorial, then perhaps there are multifaceted triggers for various behaviours and attitudes. I should therefore be emotionally prepared when engaging in any dialogue, with mindfulness, kindness and compassion. In summary, a good attitude always goes a long way.

One thing that Neil taught me is that you should always look for the good in people. Neil does it so well; always treats everyone with kindness and respect, always endeavours to help others and as a #HumanFactors expert, I'm not surprised. This Google image captures this concept of looking for the good in people so well and has been instrumental to my achievements.

SSI surveillance & prevention - a lonely journey?

When I started SSI surveillance in 2009, it seemed like a lonely journey with no light at the end of the tunnel. I was informed that this indeed was just a trial and that surgeons were a ‘difficult’ group to engage. They didn’t like being challenged. Well, I said to myself; if these surgeons are doing surgery to alleviate or cure patients’ symptoms/diseases, surely they must welcome a patient safety initiative. From my own experience on the front-line, I never came across a surgeon who didn’t want the best outcomes for their patients. In fact some used to call in the middle of the night from home asking how their patients were doing after cardiac surgery. So this concept of labeling surgeons as a 'difficult group' was not going to be an issue for me. I l respect all surgeons and am always in amazement at what they can manage to do with our bodies in such a calm way! Initially I planned 1:1 meetings with senior surgeons / consultants in my organisation and don’t recall ever feeling disrespected. In fact I remember one of my first meetings with Mr Blauth, a well-respected senior cardiac surgeon and Clinical Lead at the time. He motivated me to ‘do whatever it takes’ to get engagement from everyone and has supported me throughout including sending me encouraging emails regularly. In fact when we had our first journal publication his words were "Of course Lilian! No surprise at all. You are a shining star. Brilliant." He also told me to get back to him if anyone gave me trouble, so off I went super motivated to this day! So, no you'll never be alone.

Language and perspective matter

I had to change my ‘language’ several times for different professional groups to ensure that key messages of our patient safety initiative were delivered. We moved away from using the term audit, because it was not a one off audit, this was continuous quality improvement and patient safety initiative. On wards, it was important to reiterate that a surveillance wound observation form was not just another additional document to complete. Staff needed to view it as a patient's surgical wound that needed special care and attention to prevent an avoidable infection. The other thing I was very mindful of is the importance of feeding back data to those who collect it so they can see outputs of their hard work. In general I always feel that if you’re asking people to do something e.g. collect data, think 'What's in it for them?'. This enables you devise strategies to keep staff engaged and motivated. This is particularly important in SSI surveillance therefore one of my initial tasks was to ask surgeons what they wanted in their reports and we worked together until we achieved a desired report formats.

Everyone was always so kind and compassionate, at least this is what I focused on the most. To be honest I was extremely nervous at times and yet I was always open to constructive criticism if I didn't get things right. I’ll never forget a day I presented to adult cardiac and orthopaedic surgeons with Professor Gary French. He was like a father to me after my first presentation. He sat me down: “Lilian, you’re a fantastic speaker but delivering a 20 minute presentation in 5 minutes is just not good enough. I know you’re nervous, now take some big breaths before we drive over to Guy’s for our next presentation”! I very much appreciated this feedback and of course the second presentation was so much better and I continue to improve on my presentation skills to this day.

I’m grateful to David Tucker who allowed me to attend conferences to boost my SSI prevention knowledge from the onset and also facilitated my studies for a Masters in Infection Prevention & Control qualification. Thank you to Jackie Miley who worked with me to improve my academic writing skills. An important free event that I attended back in 2009 inspired me such that I would never look back. I'm pleased to say that we have since achieved zero infections for 18 months in our paediatric spinal surgery patients.

I am also very delighted to have had the opportunity to share our SSI prevention work / progress at many conferences and events, locally, nationally and globally thereafter. It’s my absolute pleasure to now see the profile of surgical site infection surveillance rising. Certainly a recent state of the nation report by Professor Mike Reed, ongoing work by the Get It Right First Time, OneTogether® collaboration and CardiacSSINet in the UK are bringing SSI into more focus. I’m super excited to have been part of this global move aiming to reduce avoidable harm through SSI prevention.

COVID-19 disrupted our SSI surveillance programme

At a time when we felt we were doing so well in SSI prevention, came a deadly COVID-19 pandemic in 2020. This pandemic has altered my perspective on how I approach not only infection prevention and control (IPC) but patient and staff safety in general. COVID-19 has highlighted the importance of staff and patients’ wellbeing. IPC and SSI prevention activities must ideally embrace staff and patients’ wellbeing among other evidence based IPC or SSI prevention measures more now than ever. As I highlighted in a previous blog, about 20% of patients can develop post-traumatic stress disorder in the post-operative period which could possibly lead to poor overall outcomes. It’s likely to get worse after this COVID-19 pandemic. Similarly, we have had heard of numerous reports on the negative psychological consequences of this pandemic for front-line staff and others. Furthermore, there is clear evidence of a direct link between how happy and supported doctors and nurses feel at work, and the quality of patient care delivered… - according to Lesley Giles, Director of the Work Foundation. Psychological well-being of staff and patients alike need a refocus as neither can pour from an empty cup!

Image from Google.

I have highlighted in previous presentations and blogs that a heightened focus during and after COVID-19 is required. Inevitably, there is going to be increased surgical activity and pressure to catch up with surgical lists. Exhausted staff who were busy with the pandemic must be fully supported to maintain established gains in IPC and prevent avoidable surgical site infections; in a similar way we support our patients with compassion and kindness.

Surgical site infections cause a lot of discomfort and devastation for our patients and have negative consequences for healthcare settings. I extracted this from a talk I delivered recently:

Since SSI causes are multifactorial, every stage of the surgical pathway [pre-op, intra-op & post-op] must always be carefully addressed to minimise avoidable harm. We improved our SSI incidences across a wide range of surgical specialties in my organisation by incorporating the National Institute for Health & Care Excellence (NICE) SSI prevention evidence based interventions or care bundles within surgical pathways.

I therefore encourage healthcare settings to prioritise SSI prevention measures and aim to achieve good bundle compliance for optimum patient outcomes. Tanner and colleagues found that adopting a care bundle approach in colorectal surgery patients significantly reduced SSI risk.

It is acknowledged that some SSI prevention measures are expensive to implement. Having robust SSI surveillance programmes can help you demonstrate a return in investment; and therefore facilitate implementation of these best evidence based SSI prevention measures.

I took this extract from a talk I delivered in 2020:

People may be hesitant to support SSI surveillance programmes but you should always prioritise patient and staff safety before declining a submitted business case. When a patient develops a surgical wound infection, consequences for the patient are dire, so are consequences for staff who need to work perhaps twice as hard to care for someone with an infected wound compared to someone without an infection. For example, patients may end up requiring several dressing changes in hospitals or community settings. They may need intravenous or oral antibiotic therapy which alone increases risk of antimicrobial resistance, admission to critical care units may become necessary which all adds to the overall costs and may present bed capacity challenges in healthcare.

Be that as it may, we have evidence to show that robust SSI surveillance works. We reduced our adult cardiac surgery SSI incidence from 5.4% in 2009 to 1.2% in 2016. We also presented a poster at the Society for Cardiac Surgery (SCTS) in Belfast with our fantastic MDT led work. Let’s use this evidence to promote wider uptake of SSI prevention work or activities. We must use SSI data to inform and improve clinical practice! It is hard work but it can be done – see examples below.

Journal of Hospital Infection publication: Reducing adult cardiac surgical site infections and the economic impact of using multidisciplinary collaboration. Lilian Chiwera, Neil Wigglesworth, Carol McCoskery, Gianluca Luchese, William Newsholme

Adult cardiac surgery SSI progress

We also reduced our caesarean section SSI incidence from 13.3% in 2013 to 5.1% by 2019 as shown below:

Caesarean section SSI prevention work has been ongoing for several years now as below. Once we started, we never looked back.

Check out our published paper highlighting the most recent SSI prevention intervention on Implementation of vaginal preparation prior to caesarean section here: https://bmjopenquality.bmj.com/content/9/3/e000976. Adam D Jakes, Annie Bell, Lilian Chiwera, Jilly Lloyd

I was privileged to present our caesarean section SSI work at one of the conferences in the Midlands which led to the publication of an article in the British Journal of Midwifery (BJM) in 2017. It was also an opportunity to network with some of the finest surgeons in the UK. As I always say, I can never boast about my achievements. On this occasion, an opportunity was presented to me by Philippa Clark, a very good friend and colleague from Cardiac SSI Network who is a Tissue Viability expert in Cambridge after a cancellation – what an honour! Here’s me & Mr George Smith discussing SSI prevention strategies and how we can improve uptake of this patient safety initiative.

Mr George Smith & Lilian Chiwera in an article in the British Journal of Midwifery in 2017 by Camila Fronzo on reducing postpartum infection: How to beat the challenges and take action. https://www.magonlinelibrary.com/doi/full/10.12968/bjom.2017.25.11.689.

Another example is from our fantastic MDT led SSI reduction work in paediatric scoliosis (spinal) surgery. Credit to one of the greatest and fierce supporters of our SSI surveillance programme at Guy’s & St Thomas’ NHS Foundation Trust, Mr Jonathan Lucas & Rachel Hunt.

Poster presented at Kings Health Partners Conference in 2017

Publication: Reducing Surgical Site Infection in Pediatric Scoliosis Surgery: A Multidisciplinary Improvement Program and Prospective 4-Year Audit - Geoffrey A. Tipper, Lillian Chiwera, Jonathan Lucas.

We were shortlisted for a Nursing Times Award four times & also at other events but we never won because there were always better projects than ours. To be a finalist from so many applicants was always such a huge honour and big achievement for which I will always be proud. To be honest for me it was always a good thing if I didn’t win because I never wanted these achievements to start getting in my head and cause me to be proud. I needed to remain grounded, with a main purpose of passionately making a difference for our patients. The main reason I submitted Award applications at so many events & conferences was to raise the profile of SSI and encourage uptake of an important patient safety initiative. Once I felt that we had exhausted this mode, I stopped initiating submissions or entries for Awards unless someone else volunteered.

I was privileged to participate in a round table SSI discussion at the Patient Safety conference in 2016 alongside the wonderful Mel Burden (Associate Director of IPC at Royal Devon & Exeter) and others from various Trusts and NHS England. An article was later published in the Nursing Times and the Health Services Journal. Check out my passion for SSI prevention oozing here: ”Once we say: ‘We want to improve, here are the reasons why’, people will want to do it”. I just wanted everyone to join forces in a patient safety initiative that was very dear to my heart. Sometimes I don’t know where I got the courage from as I’m someone who can get very shy (but can you see the serious face here lol!).

Https://www.nursingtimes.net/home/a-safe-and-financially-sound-nhs-07-10-2016/.

After this event, I was in the Kings Health Partners bulletin. I remember being asked by our communications teams to send them a picture for this article, and struggled to find a suitable one so I sent a couple. I’m sure they probably laughed – I never expected to be featured anywhere, this was all very new to me and perhaps a but much. To be honest sometimes I don’t think I paid much attention to it at the time, I just wanted to get back to my work and continue making a difference. But hey, the picture below from a recent conference won!

https://www.kingshealthpartners.org/latest/580-shortlisting-for-nursing-times-awards.

This is what I said at the time (helped by our fantastic communications teams of course!):

“There is always a risk of infection after any major operation such as a heart bypass. But our team has worked closely with surgical and ward staff to improve the way we gather and report information about infections, so that we can provide the best possible care during and after surgery for our patients.

We are striving to be the best at preventing avoidable surgical infections at our hospitals.”

Then came one of my most memorable opportunity in 2018. I was having lots of personal challenges and thought a holiday would help me figure some things out. So when I saw my colleagues submitting work to the Surgical Infection Society Europe (SIS-E) conference, I said to myself, ‘why don’t you just submit an abstract on your published adult cardiac SSI prevention work and see what happens? This may be an opportunity for that holiday in Greece you’ve always dreamt of…’. As it turned out my abstract was accepted and had an opportunity to present our achievements to respected surgeons in Athens. I’m now honoured to interact and be part of a group of surgeons globally with a keen interest to make a difference on surgical infections. I then had to pay for a short break in beautiful Greece after the conference which helped me to clear my head also. (I only told Neil why I submitted this particular abstract recently :-)!)

Lilian presenting published adult cardiac SSI prevention work at SIS-Europe conference in Athens.

This conference was a big boost for me and I remember a very senior surgeon and former president of the society come to me after my talk and said "that was an exceptional presentation, well done!" Wow, I must have done well and of course I submitted another abstract the following year (2019) and had an opportunity to share our SSI prevention work / progress in Dublin. You can see me below networking with conference attendees.

Lilian networking with conference attendees in Dublin

An abstract had been accepted for the surgical infections conference in Madrid in 2020 but the conference had to be cancelled due to the COVID-19 pandemic.

What a journey! I enjoyed our SSI surveillance work and built a good reputation with fantastic members of the multidisciplinary teams across my organisation, locally and nationally too. SSI committee meetings were always fun. Towards the end of 2019, I realised that my leadership skills needed a boost. On the recommendation of Karen Bonner (Chief Nurse at Buckinghamshire Healthcare NHS Trust, whom I identified as an external mentor; I applied for the Florence Nightingale Windrush Leadership development programme. I’m very grateful to Neil and our former Chief Nurse Dame Eileen Sills who promptly approved my application for this course which commenced in 2020 – the year of the pandemic! That same year I was scheduled to spend some time with our Chief Nurse but had to cancel due to lockdown. I was devastated because this was an opportunity to talk about what we achieved together over the years. Dame Eileen Sills always used to sent me emails encouraging me to keep going and also just telling me how fantastic I was! Yes I am fantastic, ask Neil :-).

The leadership development programme was a game changer for me. I had always thought I had a voice but I realised that I could improve. I needed to now think broader than just SSI surveillance and look at other aspects of quality improvement and leadership within large organisations. That’s the beauty of having a growth mindset, you constantly want to learn and improve on your performance, behaviours and attitudes. I had the opportunity to meet the wonderful Dr Elaine Cloutman-Green who gave me lots of tips on how to make a blog stand out. What an honour it was to meet this wonderful lady! I’m absolutely delighted to now be reading her super inspiring blogs. Colleagues whom I was with on the leadership development course encouraged me to post my very first blog which I had been postponing for a while. I have never looked back since I started blogging and one of my most read blog was the one on my reflection of the Leadership course. Even though COVID-19 appears to have disrupted everything and has presented several challenges, it has given me an opportunity to reflect. For the first time in years, I have given myself a pat on the back for all the hard work over the years.

So how did I do all these things? Was it favouritism? Was it easy?The simple answer to that is NO!

There were challenges along the way but I never focus on them because they will consume me otherwise. We submitted our caesarean SSI work to 2 journals and were rejected. I was disappointed but then when I saw on Twitter that even top experts also get their papers rejected, I felt better and was eager to learn from feedback provided. I now review submitted papers to two infection control journals in the UK and continue to learn. I only get one conference sponsorship per year from my Trust. I have always given more hours into my work than were required and my managers noticed that and allowed me to work flexibly. It gave me an opportunity to attend free events in my own time. When Neil was the president of the Infection Prevention Society (IPS), I paid attention to everything he did (not stalking him of course!) I just wanted to learn from this great and unique leader! How lucky I was to have him as my manager over the last 6 years. I was part of the IPS education committee, conference planning committee, research & development committee where I picked up various skills and IPC knowledge. I'm now very humbled to be the current Deputy Treasurer of this wonderful society. I attended the majority of the free events over the years in my own time and at times using my own resources i.e. on a voluntary basis. For IPS members, we know that there are various free events that come as part of member benefits so I definitely capitalised on them whenever I had free time and continue to do so for my development. I also presented at many IPS events which increased my confidence over the years.You always get so much more than you give. So, what are you waiting for? Come and join our fabulous Infection Prevention Society (IPS) membership, we will treat you well.

I don’t expect my organisation to pay for everything I wish to pursue so I used my time to develop myself and look out for free events I feel will benefit me. I’m grateful for having flexibility which enabled me to grow and I cannot be thankful enough to all those who facilitated my growth, in particular Neil. As you can probably tell, there is a lot to write about but will leave the rest for now.

I have been very busy, to give you an idea, check some of our key achievements which were shared at conferences or other events are below (not exhaustive):

2012 – SSIS Newsletters locally via our Chief Nurse

2012 – SSIS Committee meetings chaired by Dr Bill Newsholme

2012 – Infection Prevention Society (IPS) SSIS generic poster

2012 – IPS Caesarean section poster

2013 – IPS Gynaecology Poster (Award Winner)

2013 – Caesarean section validation Clinical Audit celebration event poster (October)

2013 - IPS Caesarean section presentation

2013 - Paediatric IPC awareness week poster – paediatric cardiac SSI progress

2013 - HIS-IPS -Abdominal-hysterectomy SSIS poster

2014 – Trust SSIS intranet pages

2014 - SSI detailed investigation protocol (after publication of NICE SSI quality standard where I participated as a Topic expert)

2014 - SSIS conference 2014 London- Implementing the new NICE SSI quality standard

2015 – Quality Improvement in Surgical Teams (QIST) conference in Newcastle

2015 – IPS posters – MDT working and demonstrating a sustained improvement

2016 – IPS Posters

2017 – IPS -EPDC committee member

2018 – HIS posters https://www.his.org.uk/media/1706/98.pdf.

2019 - IPS SPC member

2019 – Nightingale Nurse Award

2020 – Presentation at the Future Surgery Show conference: https://www.futuresurgeryshow.com/speakers?azletter=C. (support by BD, thank you!)

2020 - Participation in webinars hosted by Cardinal Health & Molnlycke (thank you!)

2021 – Humbled, humbled, humbled!

I will always be grateful to the wonderful Melissa Rochon, another SSI prevention guru for the help, support and fun over the years. I have supported Melissa fiercely with developments at the cardiac SSI network and its an absolute delight to see what this network has achieved to date and with various projects and initiatives in the pipeline, the future is bright! I can't forget Lisa Butcher who is now the Vice President of IPS, she has been super inspirational to me over the years. I'm super excited that we're now working together to promote IPS and provide support to members.

We're not there yet with SSI surveillance and prevention, but we're making significant progress. For those aspiring to have a go at SSI surveillance, know that fantastic surgeons and other members of the multidisciplinary teams will be there to support you, so you will never be alone. 

Don't underestimate the power of compassionate and kind leaders, they bring the best in people!

Acknowledgements to Guy's & St Thomas' managers / colleagues/MDT teams

1. Dr Neil Wigglesworth (blog dedicated to Neil)

2. Dr Bill Newsholme (Infection Control Doctor & SSIS Trust Medical lead)

3. David Tucker – Former Deputy Director IPC

4. Dame Eileen Sills – Former Chief Nurse

5. Dr Nicholas Price – Clinical Director / Director of Infection

6. Dr Susan Bewley – Consultant Obstetrician & first Caesarean Section SSI champion

7. Miss Rachel Bell

8. SSI Team (special mention super hard working Marlene McKenna!)

9. All members of the Surgical Site Infection Surveillance Committee & Infection Control Teams