Reducing Deep Joint Infection in Hip Hemiarthroplasty—A Quality Improvement Project

Quality Improvement Project

Pre-intervention Audit

A retrospective audit was carried out via interrogation of the Fracture Outcome Research Database (FORD) between January 2013 and July 2014. This is a prospectively collected database of demographic data and outcome measurements that is managed by a dedicated team employed by the institution. This ensures accurate documentation of hospital admissions for trauma, operations conducted, and outcomes, such as discharge destination and further procedures.

The search terms used were wound washout, irrigation and debridement, first stage revision, girdlestone, and excision arthroplasty. Exclusion criteria included washouts for septic arthritis of a native hip joint, open injuries, and repeated washouts on the same patient. Data were collected including demographics, comorbidities, surgeon level, ward, theatre and causative organism by reviewing the electronic and written records.

725 patients were identified who met the inclusion criteria and underwent a hip hemiarthroplasty. Of these, 20 had undergone a washout procedure for deep infection, a rate of 2.7%. There were 14 females, nine males, 12 were right hips, 8 left, with a mean age of 81 years (range, 66–92). The mean American Society of Anesthetists (ASA) score was 3.2 (range, 2–4). Fourteen infections were identified within 4 weeks postoperatively, 6 within 8 weeks. Nineteen out of 20 of the causative organisms isolated were sensitive to the standard prophylactic antibiotic regimen. There was no association identified with a particular theatre, presence of laminar flow, ward, or grade of operating surgeon.

Changes to Perioperative Practice

We met on 2 further occasions to discuss the findings of the literature review and strategy for improvement prior to institution of changes.

We reviewed the National Institute for Clinical Excellence (NICE) Clinical Guideline [9] and the “International Consensus on Periprosthetic Joint Infection” [10] to compare our perioperative practice to national and international recommendations. We identified that we were compliant with a large majority of recommended practices, for example using antibiotic prophylaxis, laminar flow theatres, and sterile disposable drapes. We defined an acceptable infection rate to be 1.6% following a comprehensive literature review [1–3].

Four potential changes to our perioperative practice were chosen based on our review of the clinical guidelines and consensus document. These were chosen due to the strong expert opinion that they commanded within the consensus document and their relative ease and speed of implementation.

• Standardized draping of the affected extremity using stockinette isolation and windowed drape towards patient’s upper body.

• Use of a chlorhexidine gluconate (2% [w/v] in 70% [v/v] isopropyl alcohol) preoperative skin solution in theatre as a preliminary antiseptic skin preparation prior to formal preparation with povidone-iodine. Darouiche et al [11] demonstrated that preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical site infection. Subsequent studies have suggested that concurrent application of the 2 antiseptic agents confer a further potential benefit by reducing the number of viable colony forming organisms and, subsequently, deep surgical site infection [12,13].
• Change from non-impregnated adhesive incision drapes to Ioban (3M, St Paul, MN) (other manufacturers available) iodophor-impregnated adhesive incision drapes. Experimental studies have demonstrated a lower rate of skin recolonization with bacteria following the use of impregnated drapes compared to non-impregnated drapes [14,15] although this has not been correlated to rates of deep infection.
• Change from simple absorbent dressings to interactive wound dressings (Aquacel and Duoderm; ConvaTec Ltd., Flintshire, UK) (alternative manufacturers available). There is evidence to show that Aquacel and Duoderm dressings were associated with reduced rates of skin blistering and infection in elective arthroplasty [16].

We also felt that staff education would be important for implementing change. We presented the results of the initial audit at departmental and regional quality improvement meetings, demonstrating the need for change in practice. Following the literature search and decision to implement 4 changes, medical staff were re-educated at the departmental audit meeting on the rationale behind the changes being made. Via liaison with the nurse lead of trauma theatres, nursing and auxiliary staff underwent education sessions. These were small group sessions, with visual aids, designed to fit in to staff breaks to reduce disruption of their work. Groups consisted of 4 to 6 people per session. They were led by the authors and focused on highlighting the reasoning behind the changes in practices and answering any questions that staff had. During these sessions, a revision of good theatre etiquette was conducted. This included reinforcing basic theatre principles, for example, reducing theatre traffic, ensuring correct theatre dress and head coverings are worn at all times, highlighting the need to regularly wash hands and wear gloves when required, and to respect the sterile areas and instruments appropriately.