Getting It Right First Time: Tackling surgical site infections

Dear Editor

We read with great interest your editorial published in the last issue of the Journal of Infection Prevention and welcome your insight to the challenges of surgical site infection (SSI) surveillance as currently performed and the suggestions for us to ‘get it right first time’ (Wilson, 2017).

Getting It Right First Time (GIRFT), a partnership between the Royal National Orthopaedic Hospital NHS Trust (RNOH) and the Operational Productivity Directorate of NHS Improvement (NHSI), is a national programme led by senior, frontline clinicians. It seeks to improve the quality of care provided by the NHS and drive efficiency gains by identifying and reducing unwarranted variations in clinical practice and service delivery. The GIRFT methodology, as successfully employed in the pilot in Orthopaedic surgery (Briggs, 2015) has been/will be adopted in the 35 medical and surgical work streams encompassed in the national programme. The impact of the programme thus far has been reported by Timmins (2017) and an evaluation of the orthopaedic pilot is currently underway, led by Barratt et al. (2017). This clinically directed approach has led to savings in orthopaedic surgery estimated to be up to £60–90 million over the first two years of the pilot, through smarter procurement, improving evidence-based practice, reducing length of stay, among others. Litigation rates in orthopaedics have also reduced by 5% in 2014–2015 and 8% in 2015–2016, creating a further saving of about £40 million.

Fundamental to our approach has been the extraction and sharing of data with clinicians; yet, our reviews in surgical specialties have identified a paucity of accessible data on SSI rates, an arguably crucial metric in the assessment of the performances of surgical units. Public Health England’s (PHE) national SSI surveillance programme has been the mainstay for SSI reporting in England for decades and, indeed, establishes the gold standard whereby patients are painstakingly monitored actively following surgical procedures for the accurate identification of SSI cases (PHE, 2016). However, such an approach requires workforce resources not readily affordable to trusts in the current climate and may have played a key factor in determining the scope of the programme, currently limited to 17 surgical categories (or broadly, eight surgical specialties).

The GIRFT SSI audit was launched in April 2017 and encompasses 13 surgical specialties: breast surgery; cardiothoracic surgery; cranial neurosurgery; ear, nose and throat surgery; general surgery; obstetrics and gynaecology; ophthalmology; oral and maxillofacial surgery; orthopaedic surgery; paediatric general surgery; spinal surgery; urology; and vascular surgery. The aims are to: (1) identify the rates of SSIs following specific procedures in each specialty; and (2) assess local practice in the prevention of surgical site infection for the specified procedures.

In the first iteration of this audit, healthcare professionals conduct a six-month prospective audit to identify SSI and collect supporting data. Where units already have an established system in place to identify SSIs pre-launch, they are asked to retrospectively collect additional information in relation to the identified cases. The retrospective identification of SSI cases, for all the reasons you have highlighted in your last editorial, is not a requirement in our programme.

Audit questions were those put forward by the respective GIRFT clinical leads for each specialty, sometimes following consultation with their own specialty associations. To limit the burden of data collection, only a specific number of procedures are reviewed in each specialty, selected on the basis of the perceived rates of SSI, consequences of SSI and the national volume of procedures carried out and potential burden of SSIs on the service. In addition, only more serious SSIs (i.e. deep incisional or organ/space SSIs) diagnosed during primary admissions or following re-admissions are to be included. Such cases are deemed to be of more relevance to secondary care trusts (the current scope of GIRFT) as they are inherently associated with more adverse patient outcomes, prolonged hospitalisation, lengthy antibiotic courses and costly revision surgeries; urgent actions by trusts to prevent such cases from arising are of paramount importance. The review of superficial SSIs being treated in the community falls beyond the scope of the current audit and we feel would be better explored in the PHE surveillance programme as is currently designed.

The significant impact of trainee-led audit and research initiatives and their successes are well-known to us and we seek to harness the same potential in this audit. The majority of participants leading on the GIRFT audit locally, i.e. ‘audit leads’, are doctors in training, in part also to introduce them to the GIRFT methodology as future consultants and to train a cohort of future surgeons who have instilled into them the practice of scrutinising and tackling SSI rates. Medical Directors, who are frequently nominated as ‘GIRFT champions’ within their trusts, act as executive sponsors of the programme and, together with their clinical directors, lend support to the audit leads who are encouraged to embark on quality improvement projects. Collaborations with local infection control teams are expected and, indeed, we have several specialist nurses among our list of audit leads. This clinically fronted, clinically owned approach, empowered by the support of senior leadership at trust and national levels, is in line with the GIRFT methodology which has so far demonstrated successes in driving improvement in clinical practice. The vision would be that this increased scrutiny of SSIs by frontline clinicians will facilitate GIRFT reviews in clinical practices to combat SSIs.

To date, we have more than 600 audit leads registered to take part, covering over 400 surgical units in England. We will learn as we embark on this programme, the results of which will culminate into a national report. It is envisaged that our methodology and data quality will improve with further iterations of the audit, which is hoped will become compulsory for all trusts as part of the solutions being developed from the GIRFT programme. Any suggestions to improve our methodology will be carefully considered; methods to improve SSI identification, such as those proposed by Macefield et al. (2017) are very much welcomed.