INTRODUCTION

As part of a hospital quality improvement programme,a project was undertaken to reduce the incidence ofinfection following elective joint replacement surgeryat Maitland District Hospital. The aim of the projectwas to reduce wound infections following joint replace-ment surgery to international best practice rates within3 months and to zero infection rate within 12 months.The project was conducted at Maitland Hospital aspart of a Clinical Practice Improvement Programmeof the New South Wales (NSW) Department ofHealth using previously described methodology.1,2

Maitland Hospital is a district general hospitallocated in the Hunter Valley in NSW. From the col-lection of surgical audit data, it was noted that between1997 and 1999 the incidence of superficial and deepwound infections in total hip and knee replacementsurgery was 5–28%, with an average of 18%. The inter-national best practice rate is reported as being0.69–1.77%.3,4

Surgical site infections had a major impact onpatients and health-care resources.5 Additionally, eachdeep wound infection led to extensive hospital stays of2–3 months, including revision of joint replacementsin some cases. Prolongation of stay also impacted onbed availability for other patients.

METHOD

A quality improvement team was established. Thisteam comprised of the Director of Clinical Services(Maitland Hospital), the three orthopaedic surgeonswho performed the procedures, an infection controlpractitioner, the operating suite manager, the nurseunit manager of the surgical ward, a general surgeonand the Professor of Surgical Science, University ofNewcastle, who was also the Area Health ServiceDirector of Clinical Governance.

Regular meetings of the team were held to identifystakeholders’ expectations, outcomes and outcomemeasures (Table 1):• to map the process (Appendix I);• brainstorm cause and effect (Appendix II); and• review the process.

A detailed audit tool was developed based on bestpractice guidelines for the prevention of surgical siteinfection.4,6,7 Internal processes were audited againstthis tool which included a method of ranking strate-gies according to risk. An external review was con-ducted to verify the data, review the risk minimisationliterature, identify process issues and make recom-mendations for change. The issues reviewed involvedboth management and process issues. Managementissues included:• feasibility of a separate orthopaedic ward;• development of a protocol for patient selection

criteria;• increase day of surgery admissions;• a review of clinical pathways;

J. Qual. Clin. Practice (2001) 21, 149–153

Prevention of orthopaedic wound infections: A quality improvement project

PAUL DOUGLAS,1 MB BS, DRACOG, MHA, FRACMA, MARGO ASIMUS,1 RN, JUDITH SWAN,2

RN, BSC, GRADDIPPH, ALLAN SPIGELMAN,2,3* MB BS, MD, FRCS, FRACS1Maitland District Hospital, Maitland, 2Clinical Governance Unit, Hunter Area Health Service, and3Discipline of Surgical Science, Faculty of Medicine and Health Sciences, University of Newcastle,Newcastle, New South Wales, Australia

Abstract Using clinical practice improvement methodology, a project was undertaken to reduce the incidenceof surgical wound infections following elective hip and knee replacement surgery. A team was established, keymeasures for improvement were identified, strategies for change were developed and an action plan was imple-mented. Outcomes for this project included a reduction in the rate of clean surgical wound infection for jointreplacement surgery from 28% to zero. Average length of stay for total hip replacement surgery was reduced from13.9 to 9.3 days and from 14.6 to 10.4 days for total knee replacement surgery. Guidelines for patient selectionwere developed along with a protocol for the management of preparation to prevent urinary tract infections. Post-discharge surveillance and a preoperative rehabilitation and exercise programme have been implemented. Thereis potential for wider uptake and implementation of the quality principles described herein.

Key words: prostheses; quality management; total hip replacement; total knee replacement; wound infection.

*Correspondence address: Professor Allan Spigelman,Discipline of Surgical Science, John Hunter Hospital, LockedBag 1, Hunter Region Mail Centre, Newcastle, NSW 2310,Australia (Email: Allan.Spigelman@newcastle.edu.au).

• medical record documentation review;• a report to the Area Orthopaedic Management

Group;• training of specific orthopaedic ward staff;• monthly meetings of the quality improvement team;• education sessions to staff and visiting medical

officers;• improved supervision of junior medical officers.

Process issues included:• surgical gowning/face mask;• preoperative preparation of patient;• pulse irrigation;• gloving techniques;• preoperative wash process;• operating theatre traffic and sterilisation procedure;• antibiotic prophylaxis;• protocol for wound dressings;

• surgical techniques, for example duration of oper-ation, use of wound drainage and blood loss;

• disposable linen and gowns;• post-discharge wound surveillance letter.

Strategies for change

Based on recommendations from the reviews, a planof action was drawn up incorporating time-lines andthe person or persons responsible for the action.Actions were implemented sequentially including:1. Best practice guidelines for antibiotic prophylaxisand monitoring were developed and antibiotic usagewas audited (Appendix III).2. The admission process was altered so that allpatients were admitted on the day of surgery directlyto the operating theatre overcoming the need forovernight admission to the ward.3. Selection criteria were developed for patients eli-gible for surgery (Table 2). For patients with greaterthan two risk factors, surgery was postponed until thesefactors could be rectified. This was of little inconve-

150 P DOUGLAS ET AL .

Fig. 1. Rate of clean surgical wound infections from March1997 to September 2000. (––) rate; (– –) benchmark.

Table 1. Identification of stakeholders’ expectations, outcomes and outcome measures

Stakeholder Expectation Outcome Measurement

Administration Improved efficiency Happy, healthy patients ReadmissionsNo complaints Lower costs Length of stayEffective teamwork Satisfied staff Infection ratesSatisfied patients Complaints

Patient and relatives 100% successful Pain-free Length of stayPain-free Pre-morbid state Satisfaction surveyNo complications Home quickly Morbidity scaleHome quickly (Rankin Park Scale)

Surgeon Stable joint Ambulating Day 1 Clinical pathway varianceFunctional range of movement Able to sit, toilet and get in car Complication ratesOrthopaedic unit and nurses Home on time

Junior Medical Officer Support from Visiting Medical Well-educated, available Nurse satisfactionOfficers access, supervision Junior Medical Officers Term appraisaland education

Nurse No unnecessary delays Prompt surgery Surgery delaysAppropriate patients Uneventful recovery Clinical pathway varianceSupportive Junior Medical Officers Supportive Junior Medical Officers Complication ratesPatient rehabilitation Active patients

Table 2. Risk factors for joint replacement surgery

Immune system impairmentSystemic lupus erythematosusSystemic steroid useDiabetes mellitusRheumatoid arthritisAdvanced age (> 80 years)Obesity (> 20% over ideal weight)Malnutrition (<15% BMI)SmokerMalignant diseaseRe-intervention (revision surgery)Previous joint infectionPeripheral vascular diseaseIncontinenceUrinary tract infectionRemote site infectionPotential for rehabilitation

nience to the patient as they were detected at the timeof the initial booking. In addition, it was consideredwhether the risk of complications outweighed the benefits of surgery; if not, the risk factors were clearlyidentified on the admission form and the patientdeclared eligible for surgery. 4. The traffic flow in the operating theatre was minimised.5. Preoperative wash techniques were improved.6. Staff were educated on cross-infection issues.7. Nurses received further training in caring fororthopaedic patients.8. A urinary tract infection management protocol wasdeveloped.9. Post-discharge surveillance and a follow-up pro-gramme were implemented allowing early interventionin any future problem.

Patients were informed of the issues and given thechoice of whether to proceed, to delay the surgery orto be referred elsewhere.

RESULTS

Data for the period March 1997 to September 2000revealed a reduction in the rate of surgical wound infec-tions for joint replacement surgery from 30% to 0%(Fig. 1). The average length of stay reduced from 13.9to 9.3 days and from 14.6 to 10.4 days for patientsundergoing total hip replacement and total kneereplacement, respectively.

During 2000 a total of 15 patients had their surgeryeither postponed or cancelled to allow for treatment ofconditions diagnosed at the pre-admission clinic (Table

3). One patient opted to delay surgery after beinginformed of the issue involving risk of wound infection.

DISCUSSION

In order to maintain an acceptable wound infectionrate, the indicators outlined in Appendix II continueto be monitored. All orthopaedic surgeons are givenregular feedback on their individual and unit perfor-mance. A preoperative rehabilitation and exercise pro-gramme is being implemented to further enhance theservice. More importantly the acceptance by theorthopaedic surgeons of the process used in this project has seen them keen to be involved in other quality improvement projects.

This project confirms that quality improvementmethodologies can be applied in a clinical setting withexcellent results.

Others should consider adopting the approach out-lined herein when dealing with similar issues.

ACKNOWLEDGEMENTS

We thank Dr C Cole, Dr A Isaacs, Dr J Hammond,Dr L Fenton, Ms M Mantle, Ms C Tranter, Ms SBerenger and Ms B Bint for their contributions to theproject.

This project was conducted as part of the ClinicalPractice Improvement Programme, NSW Health. Wethank NSW Quality Branch for conducting this pro-gramme, and Hunter Health for funding attendance(PD).

REFERENCES

1 Institute for Healthcare Improvement. A Model for Acceler-ating Improvement. Institute for Healthcare Improvement,Boston, 2001. Website accessed November, 2001. Availablefrom: http://www.ihi.org/resources/qi/index.asp.

2 Berwick D. Developing and testing changes in delivery ofcare. Ann. Int. Med. 1998; 128: 651–6.

3 National Nosocomial Infections Surveillance (NNIS) report,data summary from October 1986–April 1998, issued June1998. Am. J. Infect. Control 1998; 26: 522–33.

4 Lew DP & Waldvogel FA. Infections of skeletal prostheses.In: Bennett JV, Brachman PS (eds). Hospital Infections, 4thedn. Lippincott-Raven, Philadelphia, 1998; 613–20.

5 Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE &Saxton DJ. The impact of surgical site infections in the1990s. Attributable mortality, excess length of hospitalisa-tion, and extra costs. Infect. Control Hosp. Epidemiol. 1999;20: 725–30.

6 Mangram AJ, Horan TC, Pearson ML, Silver LC & JarvisWR. Guideline for prevention of surgical site infection, 1999.Infect. Control Hosp. Epidemiol. 1999; 20: 250–76.

7 Sanderson PJ. Orthopaedic implant infections: Can they bereduced still further? Curr. Opin. Infectious Dis. 1994; 7:469–70.

PREVENTING WOUND INFECTIONS 151

Table 3. Conditions diagnosed at the pre-admission clinic

Condition Action taken

Anaemia Surgery postponedCough/pneumonia Surgery postponedDeep venous thrombosis Surgery cancelled

(not required)Hypothyroidism/urine, Surgery cancelled

mixed growth (not required)Lesions Surgery postponedMobility problem Surgery postponedOverweight Surgery cancelled

(not required)Peripheral vascular disease Surgery cancelledPeripheral vascular disease Surgery postponedPrevious methicillin-resistant Surgery cancelled

Staphylococcus aureusRash Treated at another

institutionRash Surgery postponedSkin lesions Surgery postponedUnfit Treated at another

institutionUnfit Surgery cancelled

152 P DOUGLAS ET AL .

APPENDIX I

Flow chart for joint replacement surgery

APPENDIX II

Brainstorm cause and effect diagram

PREVENTING WOUND INFECTIONS 153

APPENDIX III

Antibiotic prophylaxis audit form