Being the 'I' in Infection Prevention
Infection control expert Cathryn Murphy* delayed knee replacement surgery for over a decade, concerned about the high risk of surgical site infection. Recently, she took her fears in hand and underwent the operation. Here she recounts her experience from the perspective of a patient with more knowledge than most of what can go wrong.
As someone whose career is dedicated to infection control, I’m inevitably aware of the risks associated with surgical site infection (SSI). For instance, did you know that Australian estimates suggest that three in every 100 surgical patients will develop an SSI?1
For patients having prosthetic joint replacement such as total hip or knee arthroplasty, SSI can be catastrophic, often requiring additional surgery, extensive antibiotic treatment and possibly staged removal and replacement of the infected prosthesis.
So in 2004, when I was advised that I would eventually require a left total knee replacement, I was not excited. Unwilling to risk surgical complication and encouraged by ongoing improvements in surgical techniques and prosthetic materials and longevity, I tolerated increased pain and loss of range of movement in my knee over the next decade.
Ironically, at the 2017 annual conference of the Australasian College for Infection Prevention and Control (ACIPC), several of my similarly aged peers were also lamenting their own loss of either hip or knee function and movement. Collectively, most of us agreed that the risk of SSI and the ever-increasing problem of antimicrobial resistance were major deterrents to undergoing future elective arthroplasty.
Around the same time, I had the privilege of presenting to a group of contemporary orthopaedic surgeons as they too attended their annual professional meeting. Convincing healthcare workers of the importance of infection control measures, many of which are inconvenient, uncomfortable and often unsightly, is difficult.
Surgeons and anaesthetists are notoriously difficult to access and particularly resistant to being challenged with information that may bring their own practice into question. Accordingly, I was overwhelmed by the genuine interest and curiosity the orthopods showed during my presentation. Their hunger for up-to-date information on infection control was palpable. It culminated in a multidisciplinary expert summit addressing prevention of orthopaedic SSI some six months later.
The way forward
In January 2018, buoyed by the commitment of the greater Australian orthopaedic community to reducing surgical infection risk and on the advice of my surgeon of choice, I consented to and began preparing for a primary knee replacement.
So began a four-month process where I sought information from the published research, my surgeon and my peers about the most effective ways I could reduce my risk of post-operative infection. Illogically, I also sought clarification from Google and from online user forums where previous knee replacement patients freely offered their opinions and remedies.
I undertook multiple readings of the printed material provided to me by the hospital and the nurses at the pre-admission clinic. Each time I failed to be consoled by sentences such as “this hospital is committed to providing all patients with the highest quality of care by preventing the spread of infection”.
My pre-operative work-up included collection of nose swabs for MRSA carriage, bloodwork, review by a haematologist and an iron infusion. Each event was marked by at least one breach of infection control. These included missed hand hygiene opportunities, incorrect glove use and breached aseptic non-touch technique.
Wanting to avoid confrontation I remained silent. For the first time I realised how difficult it truly is for patients to self-advocate.
Arriving for admission, I noted the reminders and portable hand hygiene stations at every entrance to the hospital. Observing that the majority of people passing them stopped and performed hand hygiene, my fears of acquiring an infection during this hospitalisation dissipated.
Immediately prior to my case my perioperative scrub nurse and surgeon, both of whom had coincidentally attended the national infection prevention summit, visited me in the anaesthetic bay. They both reassured me that everything was in order and with some trepidation I surrendered myself up into their care.
Like many other post-operative patients, I awoke to find a substantial dressing over my incision and invasive devices present. Unlike many other patients, I appreciated that my peripheral vascular access device and my urinary catheter could each easily become a source of invasive organisms. Accordingly, I counted down the hours to their successful removal.
During my stay I interacted with multiple clinical providers and ancillary staff. Although my observations were informal, I noted 100% compliance with hand hygiene and aseptic technique. Before injecting my IV antibiotics, staff scrubbed the hub of the needleless connector with a swab impregnated with 70% alcohol. Regardless, I asked the Nursing Unit Manager for a cap to cover the connector between use. She immediately provided one with no objections.
My canula and incision sites were inspected at least once a shift with the canula tissuing and being replaced in the pre-dawn period of Day 2. High touch areas and horizontal surfaces in my room were cleaned each day with a neutral detergent. My meals were served in bed and no impregnated hand towel was provided. I again celebrated having brought my own personal alcohol-based hand rub.
Many clinicians recount their own hospitalisations as a period of reflection and introspection. Being on the other side can help us to better understand the fears, challenges and stresses of our patients. After a lifetime of working in infection control, my own surgical experience offered a new dimension. It helped me appreciate the many ways in which systems and pressures make compliance with infection control difficult.
As well, I realised patients only really care about getting well and getting out. Patient instructions for infection control measures need to be clear, simple and unambiguous. Blanket statements about an organisation’s commitment to safety often seem hollow. In contrast, confident, compassionate carers committed to infection control provide patients with hope and reassurance.
As an at-risk patient who survived a major procedure without infection, I will be forever grateful to the surgical and ward-based teams for their diligent care and unwavering commitment to infection prevention. May it always outweigh unintended breaches and errors.
1. Australian Commission on Safety and Quality in Health Care. Approaches to Surgical Site Infection Surveillance: For acute care settings in Australia. Sydney: ACSQHC; 2017. Available from: https://www.safetyandquality.gov.au/wp-content/uploads/2017/07/Approaches-to-Surgical-Site-Infection-Surveillance.pdf Accessed 12/08/18
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