Post-discharge surgical site infection surveillance in a hospital in Brazil

Journal of Hospital Infection (2007) 66, 232e236 www.elsevierhealth.com/journals/jhin Post-discharge surgical site infection surveillance by automated telephony J. McNeish a,*, D. Lyle b, M. McCowan a, S. Emmerson a, S. McAuley a, J. Reilly c a Infection Control Department, Golden Jubilee National Hospital, Glasgow G81 4HX, UK Clinical Analyst, Golden Jubilee National Hospital, Glasgow, UK c Health Protection Scotland, Glasgow, UK b Received 5 April 2006; accepted 6 April 2007 Available online 4 June 2007 KEYWORDS Surgical site infection; Post-discharge surveillance; Automated telephony system Summary Surgical site infection (SSI) is an important outcome indicator after surgery and is part of a national programme of surveillance in Scotland. Post-discharge surveillance has important cost implications for both primary and acute areas of the NHS and it is therefore important to establish a robust method to obtain these data. This study used an automated telephony system to gain information on SSI developing post-discharge. The patients included were those who had inpatient surveillance carried out following hip and knee replacements, and cardiac surgery. A recorded message was used to ask the patient questions concerning the state of their wound. These questions were answered by pressing numbers on their phone. The study population was 104 and there were 18 patients who thought they had a wound infection but after clarification only nine patients suffered a post-discharge SSI. The number of patients who responded with at least one call to the system was 62. Although this pilot study was carried out with small numbers, it was felt that with certain refinements it should continue to be used for post-discharge surgical site surveillance of infection. ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. Introduction * Corresponding author. Address: Infection Control Department, Golden Jubilee National Hospital, Beardmore Street, Clydebank, Glasgow G81 4HX, UK. Tel.: þ44 0141 951 5441; fax: þ44 0141 951 5042. E-mail address: jane.mcneish@gjnh.scot.nhs.uk Surgical site infection (SSI) is an important outcome indicator after surgery. The costs for the patient, hospital and community care team are considerable.1 The cost of SSI to the NHS in England has 0195-6701/$ - see front matter ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2007.04.003 Post-discharge surgical site infection surveillance been estimated to be around £61 million per annum with the costs of treating a single infection estimated to be around £3200.1 The mandatory requirement from the Departments of Health’s National Surveillance systems in the UK has been established using a common definition for SSI2 and only rates of SSI identified in inpatients are published. This measure underestimates the true costs of SSI, as it is estimated that around 70% of post-operative infections present after discharge.3 Post-discharge surgical site infection surveillance presents a challenge to develop methods for data capture as the patient is no longer under direct medical supervision. A Department of Health expert working group in the UK concluded that post-discharge surveillance (PDS) was an important consideration in SSI surveillance and that priority procedures should be those with a short length of stay.4 It also concluded that methods should be sought where direct observation of the surgical site was possible by a healthcare worker in the normal patient pathway, to minimise additional cost associated with surveillance activities. National surveillance of SSI in Scotland is being facilitated and coordinated by Health Protection Scotland (HPS) within the Scottish Surveillance of Healthcare Associated Infection Programme. HDL(57)2001 required all acute NHS Health Boards to collect data on SSI following two categories of surgical procedure from a list of nine, one of which should be orthopaedic. The protocol for this programme encourages hospitals to develop programmes of post-discharge surveillance of SSI utilizing a method of direct observation of the patient’s wound as this is recognised to be the most reliable and valid way of detecting infection.3 Staff seeing the patient routinely in the course of normal clinical care could carry out direct observation of the wound after discharge. This is easily achieved with procedures such as Caesarean section and breast surgery following which community midwives and breast care nurse specialists respectively routinely see the patients for the 30 days following surgery. However, patients having other procedures, such as orthopaedic implant and cardiac procedures, are not seen post-operatively within 30 days and follow-up of all patients by healthcare workers for surveillance purposes is considered too costly.5 Alternative robust methods of data capture need to be explored. Recent literature on post-discharge surveillance has focused on patients’ ability to detect SSI. Postal questionnaires returned from the patient to the hospital have been utilised but in recognition of the number of people in the UK who now 233 have telephones, a few studies have explored this method as a possibility for collecting surveillance data.6e11 A further development of these studies is to test automated telephony for the purpose of post-discharge surveillance. Excelicare Direct is an interactive telephonebased, patient home-monitoring module linked directly to the electronic patient record. By integrating telephony technology with the Excelicare electronic patient record, the breadth and depth of the patient record is expanded to include home episodes as well as primary, secondary and tertiary encounters, making it suitable for home monitoring, e.g. PDS, chronic disease management and organization of a managed clinical network. The use of Excelicare Direct in the patients’ homes empowers them to become more actively involved in their own health and treatment, allowing closer and more accurate monitoring within their homes with minimal inconvenience, cost and time expenditure incurred for both the patient and the healthcare provider(s), whilst improving the overall outcomes of treatment. Patients access the system using their touch-tone phone. Once identified (by the use of a personal identification number, PIN) the system delivers a customised script over the phone. Patients listen and respond to script questions by entering the corresponding keys on the touch phone. Each touch-tone response from the patient is interpreted by the system and the next appropriate reply or question is triggered and delivered to the patient dynamically. Excelicare Direct allows the recording of script questions and personalised voicemail messages by the healthcare provider. This study aimed to test the feasibility of automated telephony as an approach to post-discharge surgical site infection surveillance. It also had a number of further objectives, which were: e to assess the practicalities of this approach; e to evaluate whether sufficient information could be obtained using this method; e to analyse the cost implications of this approach. The Golden Jubilee National Hospital is the National Waiting Time Centre for Scotland. A large and increasing part of this work is for orthopaedic and cardiac surgery. The patient population is spread throughout all Scottish Health Board areas and therefore are discharged and followed-up by their own health board services. The hospital participates in the national mandatory surveillance of inpatient SSI surveillance for hip replacements, knee replacements and cardiac operations. The 234 patients included in this study of post-discharge SSI were those who had operations between 1 February 2005 and 4 March 2005, lived in Scotland, who had touch-tone telephones and were able to use the telephone. The definitions used for diagnosis of SSI were those of National Nosocomial Infection Surveillance system (NNIS, 1992) and are those used in the Scottish Surveillance of Healthcare Associated Infection Programme for inpatient surveillance. The criteria for classifying an infection for the telephone crib sheet were those proposed by the Centers for Disease Control and Prevention (CDC) and have been previously validated.2 Methods During the inpatient stay, the project leader interviewed all patients who met the study inclusion criteria, explained the aims of the pilot study and obtained consent. The process was explained and PINs were issued to allow access to the automated telephony system (ATS) on a freephone number. In addition, the system required use of the patient’s eight-digit date of birth. Patients were asked to phone on three occasions, at days 10, 20 and 30 following their operation date. A credit card-sized reminder with these dates was provided. To assist patients prepare for their calls, they were also issued with a printed copy of the recorded questions. Patients were assured that if a problem developed with their wound healing, this would be identified by their answers. A member of the postdischarge team would return their call to ensure that appropriate treatment had been given. On each occasion that the patients used the ATS, pre-recorded instructions were played, followed by the questions. Replies were a choice between ‘yes’, ‘no’ or ‘not sure’ and were answered by pressing ‘1’, ‘2’ or ‘3’ on their telephone. Defined alerts were set-up within the automated system if patients answered positively or were unsure whether they had developed a wound infection. All these patients were contacted by telephone, a detailed clinical history was taken and development of infection categorised in accordance with CDC criteria by an infection control surveillance nurse. The system has the facility to notify defined users of the arrival of patient alerts on screen, as well as by e-mail or pager. An electronic form was devised to allow the infection control nurse to document any communication with patients. Data analysis was carried out and reports were created by extracting information using the database. All data items entered either manually or via J. McNeish et al. the telephony system could be fully utilised for audit purposes. At the end of the surveillance period, patients were asked to evaluate the user friendliness and practicality of the system by completing a written questionnaire. This consisted of 13 Likert score questions with five graded possible answers from ‘strongly agree’ to ‘strongly disagree’ concerning use of the system, perception of care, clarity of the system, and patient’s preference. Results The pilot study of orthopaedic and cardiac patients included a total population of 109 patients. Five patients were excluded from the study as three were unable to respond appropriately to commands, one did not have access to a touch-tone telephone and one patient was blind. Of the remaining 104 patients, 53 (51%) were male and 51 (49%) female. Thirty-six percent of the patients had undergone total knee replacement surgery, 34% total hip replacement, and one bilateral hip replacement. There were also 27% with coronary artery bypass grafts, and 2% valve replacements. Sixty-two patients made at least one telephone call to the ATS, giving a response rate of 60%. Of these, 43 patients (69%) completed the three calls, 10 (16%) called twice and nine (14%) only called once. Among orthopaedic patients (N ¼ 74), 61% used the system, 44% calling three times. Fifty-seven percent of cardiac patients (N ¼ 30) used the system, with 33% calling three times. Eighteen patients (29%) self-reported ‘yes’ or ‘unsure’ to the question, ‘Do you think you have developed a wound infection?’ However, following clinical assessment by telephone, only nine (14.5%) fulfilled the CDC criteria for development of infection. Of these, seven (16%) were orthopaedic patients and two (12%) cardiac patients. All infections were superficial in nature with no deep tissue or organ space involved. Eleven patients answered positively when asked if they were taking antibiotics. Of these, one patient was referring to a prescribed cream and one had answered positively in error. The remaining nine patients were those who had infections confirmed by the study. During the same period, inpatient SSI surveillance identified one infection (N ¼ 154, 0.6%). Results of exit questionnaire The response rate was 56% (N ¼ 104). Overall, 81% responded positively to the system. Of those who Post-discharge surgical site infection surveillance responded (N ¼ 58), when asked if they would have preferred the hospital to call them 91% responded negatively; when asked if the telephone system was simple to use, 95% of patients answered positively; 96% answered positively when asked whether they appreciated that their concerns were being addressed; and 88% responded positively when asked if they liked this way of keeping in contact. Discussion This report describes a pilot study of the implementation of post-discharge SSI surveillance using an ATS. It was encouraging to find that 60% of patients used the system. Other studies using telephone surveillance found similar response rates.9 When studies used postal questionnaires the response was similar or at times higher.6,7 Reilly et al. found a higher response rate by the active telephoning of patients by a research nurse. The passive nature of the automated telephony may affect the response rate as the onus rests with the patient to initiate the call.8 Most patients found the system easy to use. However, two patients informed the project leader that they had been unable to access the system. It is unknown how many others may have had similar difficulties. Many patients were very positive at the interview stage and two apologies were received on the exit questionnaires concerning omitting one of the call dates. However, 40% of patients initially agreed to carry out the calls but failed to do so. Among these were two patients who, after agreeing to carry out the calls, refused to take the paperwork home. This limited the reliability of the deduced infection rates and it is not known whether the infection rate among responders was representative of the whole patient group. Although information concerning treatment with antibiotics was obtained, it may have been helpful to enquire whether a swab was examined. During the pilot study the team was able to obtain this information when responding by telephone to the alert generated by the computer system. This information was then typed into a note within the patient’s computer record. The advantage of being able to contact patients if any of their answers caused concern was especially valuable when they thought they had, or may have, developed a wound infection. Having spoken to all these patients, any false positives were eliminated. This supports the findings of 235 Whitby et al. that patients are able to recognise the absence of infection.11 We therefore concentrated our resources on those replies that suggested a potential post-discharge infection. A ‘G’ grade registered nurse led the pilot study. Wide clinical experience was considered essential to enable the nurse to assess the patients accurately and categorise them accordingly. It was also considered that one individual should take responsibility for the whole project, giving consistency to the initial interviews, and ensured that during follow-up telephone calls, patients spoke to a nurse that they had met. The total recurrent cost of the pilot study included the cost of freephone telephone calls from the patients (£31.80), the return calls when required (£32.00) and the cost of the nurse’s time (£828) giving a total cost of £891 for the 104 patients included in the surveillance, i.e. £8.56 per patient. The information technology infrastructure was in place and so no additional cost was incurred. However, considerable capital expenditure for the software was required which the Board provided. Due to the diffuse geographical location of the hospital’s patients, it is not possible for them to be monitored in person. This system enables the hospital to comply with the recommendations of HPS. This pilot study does, however, suffer from a number of limitations as it was carried out in one hospital and with small numbers of patients in a limited number of specialties. The use of the system on a larger scale would have cost implications, as additional user licences would have to be purchased. Furthermore, the number of infections identified is a minimum estimate as non-responding patients were not included in the infection rate calculations. Conclusions This pilot study indicates that automated telephony is a feasible approach for post-discharge SSI surveillance. However, the system requires formal validation by further research. Once validated, the system would have the potential to be extended and could provide a means of standardizing postdischarge surgical site infection surveillance. References 1. Plowman R, Graves N, Griffin MA, et al. The rate and cost of hospital-acquired infections occurring in patients admitted 236 2. 3. 4. 5. to selected specialties of a district general hospital in England and the national burden imposed. J Hosp Infect 2001;47:198e209. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, the Hospital Infection Control Practice Advisory Committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol 1999;20:247e278. Bruce J, Russell EM, Mollison J, Krukowski ZH. The quality of measurement of surgical wound infection as the basis for monitoring: a systematic review. J Hosp Infect 2001;49: 99e108. Reilly J, Ward V, Crawshaw S, et al. A UK approach to post discharge surveillance: exploring the decision making process. In: Poster presented at 5th international conference of the Hospital Infection Society, September 2002, London. Glenister HM, Taylor LJ, Bartlett CL, et al. An evaluation of surveillance methods for detecting infections in hospital inpatients. J Hosp Infect 1993;23:229e242. J. McNeish et al. 6. Manian FA, Meyer L. Comparison of patient telephone survey with traditional surveillance and monthly physician questionnaires in monitoring surgical wound infections. Infect Control Hosp Epidemiol 1993;14:216e218. 7. Noel I, Hollyoak V, Galloway A. A survey of the incidence and care of postoperative wound infections in the community. J Hosp Infect 1997;36:267e273. 8. Reilly J, Noone A, Clift L, et al. A study of telephone screening and direct observation of surgical wound infections after discharge from hospital. J Bone Joint Surg 2005;7:997e999. 9. Taylor EW, Duffy K, Lee K, et al. Telephone call contact for post-discharge surveillance of surgical site infections. A pilot, methodological study. J Hosp Infect 2003;55:8e13. 10. Fanning C, Johnston BL, MacDonald S, LeFort-Jost S, Dockerty E. Postdischarge surgical site infection surveillance. Can J Infect Control 1995;10:75e79. 11. Whitby M, McLaws M-L, Collopy B, et al. Post-discharge surveillance: can patients reliably diagnose surgical wound infections? J Hosp Infect 2002;52:155e160.