7 Optimising surgical skin prep: lessons from post-discharge surveillance

Aim Tallaght University Hospital (TUH) conducts surgical site infection surveillance (SSIS) in both elective and trauma orthopaedics. The process monitors and identifies potential surgical site infections (SSI) for 90 days post-surgery. Orthopaedic procedures, particularly implant surgeries, carry a higher risk of morbidity and mortality if infections occur, leading to significant consequences and costs for both patients and healthcare systems. TUH follows specific guidelines for pre-operative skin preparation in orthopaedics to reduce the risk of SSI. Chlorhexidine soap is used for pre-operative skin preparation. It is also employed in the decolonisation protocol for patients identified with methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-susceptible Staphylococcus aureus (MSSA). SSIS results from 2022–2023 identified that 50% of orthopaedic SSI were caused by MSSA. Our data also showed an increase in patient age and weight which may adversely impact the patient’s capacity to shower effectively pre-operatively. A quality improvement project was commenced to improve efficacy of pre-operative skin preparation, reduce MSSA SSI, and enhance patient safety. A trial commenced of 2% Chlorhexidine Gluconate (CHG) saturated cloths which were selected as being easy to use, patient friendly and as the 2% CHG solution required no rinsing it would remain on the skin for maximum antimicrobial persistence. The CHG wipes were piloted in orthopaedics from May 2024 onwards. Methods As the TUH SSIS continues for 90 days post-surgery, the identification of infections is inherently retrospective. While this retrospective surveillance ensures a thorough evaluation of post-operative outcomes, improving the timeliness of infection identification can further enhance patient safety and care quality. Post-discharge surveillance plays a vital role in tracking post-operative outcomes, particularly as hospital length of stay (LOS) has decreased due to advancements in surgical care and enhanced recovery protocols. For patients undergoing surgery at TUH, the SSIS program ensures that outcomes are monitored beyond the hospital setting. Key components include:Patient questionnaires to assess wound healing, detect signs of potential infection (for example redness, discharge), and identify delays in recovery.Early detection of SSI, which may otherwise go unreported due to shorter hospital stays.Enhanced quality improvement by evaluating the effectiveness of protocols such as pre-operative skin preparation and decolonisation procedures for MRSA/MSSA. Post-discharge surveillance bridges the gap between hospital care and recovery at home, ensuring comprehensive monitoring and improved patient safety. Results We have seen a gradual but sustained 36% reduction in SSI from 2023 to 2024. This decrease was first identified through post-discharge surveillance data returns, allowing early appreciation of the benefits associated with the change in the product and skin preparation process. A significant decrease occurred in SSI identified as deep or organ-space infections, which decreases the risk of additional interventions required for the patient. This reversal reduced the costs incurred by TUH as a result of SSI with a 77% decrease in the day bed costs year-on-year, equating to approximately €318 262. Conclusion Early results are promising in the reduction of SSI since the introduction of CHG wipes. We will continue to analyse trends in SSI rates, compliance, and outcomes to identify areas needing further improvement.