Caesarean section wound care management training

Transcription

1 Caesarean section wound care management training Welsh Healthcare Associated Infection Programme (WHAIP) - Public Health Wales, in conjunction with 1000 Lives Plus Contact: Lead for SSI surveillance, Public Health Wales: Dr Wendy Harrison wendy.harrison2@wales.nhs.uk Information Analyst: Alice Neden alice.neden@wales.nhs.uk The Temple of Peace & Health, Cathays Park, Cardiff, CF10 3NW Y Deml Heddwch ac Iechyd, Parc Cathays, Caerdydd, CF10 3NW

2 Acknowledgements We would like to thank Liz Waters (Consultant Nurse Infection Prevention in Aneurin Bevan) for her input into the training package. We would also like to thank the Caesarean Section Steering Group and the Health Boards in Wales for their contributions to this package.

3 C-Section wound care management training Summary of presentation for trainer The following information provides a summary of the information and what should be covered during the training session. It provides a summary by slide and overall objectives and outcomes that should be met following this training. The presentation will take minutes to deliver. There is an accompanying booklet to this presentation which can be found via the WHAIP intranet. Slide 2: Slide shows what will be covered in the training, briefly talk through this, and explain the purpose of the training. If you haven t got time to address surveillance, it is discussed in the booklet that is provided at the end of this training session. Talk about overall purpose of training in Wales, reducing surgical site infections in c-section wounds. Slide 3: Introduction to SSIs acquired after a c-section, focusing on cost to the NHS and patient. Use the slide citations as further reading for the topic. Slide 4: Introduce the Wound Care Pathway. This is a suggested pathway, available to all Wales, with the view to incorporating it into local caesarean pathways. The pathway is a set of interventions aiming to minimise infection in elective caesarean sections in Wales. Slides 5-7: These slides detail the Wound Care Pathway mentioned in slide 4. A copy of the pathway can be found in the training booklet and on the WHAIP website, along with further details of each intervention. For these slides, talk through the three stages of interventions, and what will be covered: Slide 5 Pre-operative Slide 6 Intra-operative Slide 7 Post-operative Wound care booklet MRSA screening Hair removal Daily showers/baths Hair removal Antibiotic administration Skin preparation Body temperature Glucose levels Wound dressing (application and removal) Advice to mother Assessing wound (aseptic) WHAIP surveillance Further reading: Tanner, J., Norrie, P., & Melen, K Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Review. Issue 11. Department of Health High Impact Intervention Care bundle to prevent surgical site infection. [Accessed 21/01/2015]. (And references in this document)

4 Slide 8: Provides important information to understanding how an infection may occur. It provides a summary of how infection may occur due to opening of the skin, instruments used and the environment during surgery. Ensure that the difference between wound colonisation and wound infection is highlighted. Slide 9: Provides information on how a wound infection can be recognised. Talk through these various infection characteristics. Slides 10-13: These slides provide examples (pictures) of a healthy wound, a superficial wound, a deep wound and an organ/space wound. Three types of SSIs superficial, deep and organ/space. WHAIP diagnostic tool can be found in the training booklet or online (via WHAIP intranet). Slide 10: Picture of a healthy wound would have some redness. Please ensure that trainees note that this is not an infected wound. Slide 11: Provides the definition of a superficial SSI. Point out why this is infected. Ask the question on why the audience think that this is an infected wound. Slide 12: Provides the definition of a deep SSI. Point out why this is infected. Ask the question on why the audience think that this is an infected wound. Slide 13: Provides the definition of an organ/space SSI. Point out why this is infected. Ask the question on why the audience think that this is an infected wound. Slide 14: Summary of how to take a swab, if an infection is suspected (as mentioned in the Wound Care Pathway). Important to mention key requirements, hand hygiene, swab prior to any cleaning and use sterile equipment. Slide 15: This slide details the procedure to follow when taking a sample from a suspected infected wound (follows the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 8 th ed. Procedure guideline 11.22, Swab sampling: wound). Talk through the process and highlight key aspects from the previous slide. 1. Hand hygiene 2. Take swab prior to dressing or cleaning procedures 3. Use sterile swab to collect exudate from the wound 4. Place specimen into sterile container 5. Rewash/decontaminate hands Slide 16: This slide provides detail on the required hand hygiene technique to be utilised and should be known to the audience. Hand hygiene is one of the key components in infection prevention (Humphreys, 2009). Talk through the WHO 5 moments for hand hygiene, explaining key 5 moments. Further reading: Humphreys, H Preventing surgical site infection. Where now? Journal of Hospital Infection, 73, (4) available from:

5 Slide 17: This slide provides a summary on the c-section SSI surveillance carried out by WHAIP. You will need to ensure that you cover the purpose of the surveillance, how it is undertaken, who s responsibility it is and how the data collected is used. If you are short of time, this section is covered in more detail in the training booklet. Slide 18: This slide provides key points from the training presentation re-iterate them these key points to the trainees. Slide 19: This slide has been left blank intentionally for local trainers to add any other information. Suggestions of other information include: Local health board or hospital contacts Messages for your specific health board or hospital. Slide 20: This slide provides full details of the references used through the presentation useful as further reading.

6 C-section wound care management training Welsh Health Associated Infection Programme (WHAIP) Public Health Wales, in conjunction with 1000 Lives Plus

7 What will be covered: - Surgical site infections - Wound care pathway (pre operative, intra operative and post operative) - Wound infection - Visual examples of SSI (healthy, superficial, deep and organ/space) - Aseptic swab procedure and hand hygiene - Surveillance - Points to take home - References

8 Surgical site infections (SSI) Infections that occur in a wound after an invasive surgical procedure (NICE, 2008) Mostly preventable (NICE, 2008) They cause excess morbidity and mortality (Plowman et al., 1999) Can double cost of treatment (Plowman et al., 1999) Additional cost of c-section SSI 3,716 (Jenks et al., 2014) Serious patient consequences (Coello et al., 2008) Second most common infection after a c-section (Sykes et al., 2005)

9 Wound care pathway Available to all Health Boards in Wales Should be adopted for mothers undergoing elective c-section, in line with NICE guidance NICE guidance outlined three phases Pre-operative Intra-operative Post-operative Focus on pre-operative and post-operative

10 Pre-operative Gestation weeks 1) Mother receives a local wound care leaflet? Signature Date Discussed / / 2) Optional: Mother is screened for MRSA using local guidelines? (Universal screening in Wales has not been adopted. However, if screened and mother is found positive, decolonise using local protocol prior to surgery) 7 days prior to planned section 3) NO further removal of pubic hair check on day of surgery. 4) Daily showers/baths using soap (paying attention to axillae, groins, perineum and skin folds) check on day of surgery. Day of surgery 5) Bath/Shower preoperatively using soap, paying attention to axillae, groins, perineum and skin folds. / / / / / /

11 Intra-operative 1) Remove hair if required using clippers with a disposable head (not by shaving). Time as close to the operating procedure as possible. Yes No n/a 2) Administer antibiotics within 60 minutes prior to incision. Only repeat if there is excessive blood loss or prolonged operation. 3) Patient skin is prepared with povidone iodine or 2% chlorhexidine gluconate and allowed to air dry. 4) Maintain body temperature above 36 C in the peri-operative period. 5) Maintain a glucose level of < 11mmol/l in diabetic patients.

12 Post-operative 1) Cover wound with an interactive dressing at the end of surgery. 2) Advise mother on post-operative wound care: a) Don t touch the wound unless necessary b) Ensure that hands are regularly washed, particularly before and after using the toilet c) If infection is suspected, contact local maternity unit (not GP) 3) Remove standard, interactive dressing after hours after the procedure. Alternatively if non-standardised dressing (eg. PICO, leukomed T+) consult manufacturer s guidance. 4) Assess wound for signs of infection. a) If the wound is clean and dry no further dressing is required and the patient may shower (or if using a transparent waterproof dressing, the patient may shower when they feel ready to). b) If the wound is displaying signs of infection (such as redness, in addition to swelling or pus) a wound swab must be taken aseptically and a fresh dressing applied daily. All assessments should be documented in the patient s record. 5) Aseptic, non-touch techniques must be used when the wound is being redressed. 6) Complete WHAIP SSI surveillance form a) on discharge from hospital b) Up to 30 days post operatively Yes No

13 How does a wound become infected? SSIs can result from contamination of the wound site. Skin is a natural physical barrier to micro-ogranisms, so once broken no natural protection (Patel, 2007) Wound colonisation: The presence of bacteria within the wound but with no patient immune response (Ayton, 1985). No signs or symptoms. Wound infection: The presence of multiplying bacteria that overwhelms the patients immune system (Kingsley, 2001). Active signs of disease present.

14 How can a wound infection be recognised? Discharge (viscous or purulent) Localised erythema Localised pain Abscess Unexpected pain at dressing change Abnormal smell Oedema Localised heat Cellulitus Wound breakdown

15 Healthy wound [Insert image]

16 Superficial SSI Infection involves only skin or subcutaneous tissue of the incision [Insert image]

17 Deep SSI Infection involves deep soft tissues (eg fascia and muscle layers) of the incision or another area, other than opened/manipulated during the operation, where the infection drains through the incision [Insert image]

18 Organ/Space SSI Involves any part of the body, excluding the skin incision, fascia or muscle layers that is opened or manipulated during the operative procedure [Insert image]

19 Summary of aseptic swab procedure Key aspects, detailed procedure on next slide Pre operative hand hygiene Take swab prior to any dressing or cleaning procedure Sterile swab to collect exudate from the wound (collect pus in a sterile syringe) Place specimen into sterile container Re-wash/decontaminate hands

20 Pre-procedure -Explain the procedure to the patient -Wash hands with soap or decontaminate with alcohol hand rub, put on apron and gloves. -Remove current dressing if applicable -Re-wash/decontaminate hands Swab sampling: wound Procedure -Roll swab in zig-zag motion over the entire wound surface -Use enough pressure to obtain fluid from wound tissue but avoid exudates and touching wound margin -If wound dry, moisten the tip of the swab with 0.9% sodium chloride -If pus present, aspirate using sterile syringe and decant into specimen pot Post-procedure -Carefully place swab into transport tube, ensuring fully immersed in transport medium -Redress the wound, if applicable -Remove gloves and apron and discard the clinical waste. Re-wash and decontaminate hands -Complete microbiology request form -Arrange prompt delivery to microbiology labs

21 Hand Hygiene technique (WHO, 2006)

22 C-Section SSI surveillance Purpose of the surveillance? How is surveillance undertaken? Data management Responsibility?

23 Points to take away Know the Wound Care Pathway and follow it Ensure good communication with the mother Follow hand hygiene and asepsis techniques Complete Public Health Wales surveillance (inpatient and post-discharge forms)

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25 References Ayton in Patel, S Understanding wound infection and colonisation. Wound Essentials, 2, Coello, R., Charlett, A., Wilson, J., Ward, V., Pearson, A., & Borriello, P Adverse impact of surgical site infections in English hospitals. Journal of Hospital Infection, 60, (2) Centres for Disease Control and Prevention (CDC) Guidelines for Evaluating Surveillance Systems. Available: [Accessed 24/02/2015] Dougherty, L., & Lister, S. (Eds.) Royal Marsden Hospital Manual of Clinical Nursing Procedures (8 th edition). Gardner, S.E., Frantz, R.A., & Doebbeling, B.N The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair and Regeneration, 9, (3) Humphreys, H Preventing surgical site infection. Where now? Journal of Hospital Infection, 73, (4) available from: Jenks, P.J., Laurent, M., McQuarry, S., & Watkins, R Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. Journal of Hospital Infection, 86, (1) Kingsley, A A proactive approach to wound infection. In: Patel, S Understanding wound infection and colonisation. Wound Essentials, 2, available from: National Institute for Health and Clinical Excellence (NICE) Surgical site infection prevention and treatment of surgical site infection. CG74 National Institute for Health and Clinical Excellence (NICE) Caesarean section. [Accessed 06/01/2015] Patel, S Understanding wound infection and colonisation. Wound Essentials, 2, available from: Plowman, R The socioeconomic burden of hospital acquired infection. Euro surveillance: bulletin Europeen sur les maladies transmissibles= European communicable disease bulletin, 5, (4) Sykes, P.K., Brodribb, R.K., McLaws, M.L., & McGregor, A When continuous surgical site infection surveillance is interrupted: The Royal Hobart Hospital experience. American Journal of Infection Control, 33, (7) available from: Tanner, J., Norrie, P., & Melen, K Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Review. Issue 11 World Health Organisation. (2006). Five moments for hand hygiene. [Accessed 15/12/2014].