Trust implements interventions to reduce surgical morbidity stemming out of post-operative infections in joint replacement, reducing readmission rates and patient length of stay

Outline:

In Northumbria we implemented two novel interventions with evidence gathered from international randomised trials or best practice guidance – our aim is to now see wider spread and adoption across the NHS. Total joint replacement (TJR) is increasing year on year, with 170,000 being performed in the UK. Infection is often followed by poor outcome, and patients face a heavy long-term burden. Infections have a higher mortality rate than prostate, breast and colorectal cancer at 5 years.

Each infection costs up to £75K to treat, scaled up, the cost of TJR surgical site infection (SSI) is approximately £45 million pa. Our project successfully reduced surgical site infections caused by a common and aggressive bug. Screening and decolonisation is now a recommended intervention by the World Health Organization for orthopaedic surgery, but uptake rates in the UK remain low.

Pre-operative anaemia in patients undergoing elective hip and knee replacement is associated with increased post-operative morbidity and mortality as well as increased transfusion rates, hospital readmission and length of stay. Joint replacement uses around 10% of blood stocks. There is a need to increase the management of preoperative anaemia in the UK. Improvements in practice would benefit patients and reduce costs.

Challenges:

Although the clinical case for both MSSA reduction and treating anaemia pre –operatively is strongly evidenced based, most NHS trusts perform neither intervention. Our plan was to evidence the benefits of implementation in practice and to modify the intervention for clinical practice in the NHS.

Our ambition is to support spread and adoption at scale across more than 30 NHS sites. In phase 1 implementation, each intervention required pathway changes across multiple specialties in many hospital sites including engaging patients and their GPs, testing patients for anaemia or bactreila carriage early in their pathway, and optimising the patients prior to surgery.

Although good for patients this involved convincing teams to redesign the clinical pathway and front load work to avoid complications later. We face challenges from both acute hospital consultants (taking the test) and primary care (prescribing iron). Our goals at the start included the following :- Infection: To reduce surgical site infection with Staphylococcus aureus, which could be measured objectively with Public Health England surgical site infection criteria

• MSSA hip and knee replacement infection rates

• Anaemia: To increase anaemia screening and correction pre-operatively to reduce

• Transfusion rates

• Critical Care admission

• Length of Stay

• Readmission

Outcomes:

Reducing MSSA Infection: The Northumbria programme for screening for MSSA, and decolonising patients with joint replacement was trialed with almost 13000 individuals. MSSA infection rates fell from 0.75 to 0.25% (p<0.0001), and the cost of avoiding such an infection was conservatively estimated at £1893 per infection.

Northumbria saved £1,230,450 throughout the course of the study. There is strong evidence to support the intervention: in a New England Journal of Medicine double blind placebo controlled trial of surgical patients decolonised of MSSA, infection was significantly lower in the treatment group (3.4% v 7.7%, relative risk of infection 0.42).

Our work was innovative because no randomised study has been performed in orthopaedics, or in the UK. In Dec 2016 The WHO recommended testing for, and decolonising MSSA for orthopaedic patients, although it still rarely occurs within the NHS. Anaemia : Tested in three hospitals within Northumbria. In a trial involving 3000 patients they demonstrated reduced transfusion rate (5.9 to 3.9%), readmission rate (4.47 to 2.9%), and length of stay (3.9 to 3.64 days), as well as reduced critical care admission (1.3 to 0.55%). The Trust reports annual savings of £412,000, just within orthopaedics but the intervention may be scalable to all surgery.

Spread:

We published the results of both interventions in peer reviewed journals, and presented the data at both national and international meetings - our hope was to use this evidence to make the case for wider adoption across the NHS. Moreover we have committed to hosting a large scale QIST Breakthrough Series Safety Collaborative. To achieve this we have needed to :-

• secure senior NHS executive support, successfully recruiting 40 NHS partner organisations by April 2018.

• partner with the British Orthopaedic Association

• Raise £1.5M of funding for wider NHS adoption from NHSI, NHS Vanguards and industry to fund some of the treatment costs, ensure effective coaching and learning support over 2 years and provide an independent evaluation of outcome.In order to assess the implementation robustly we have worked with the University of York Clinical Trials Unit to build a randomised prospective trial involving 30000 patients to test the benefits of the implementation.

We are brininging teams together over 4 learning events to review the evidence, governance arrangements, business cases, communication strategies, pathways, data collection and reporting. These sessions will be supported by programme leads, experts, improvement fellows and patient leaders. Monthly coaching calls will support local teams.

Value:

Public Health England identified that both MSSA and MRSA are common causes of infection in joint replacement surgery. Whilst MRSA infections have received wide attention and action has been taken to reduce their impact, MSSA continues to be a dominant cause of infection.

The Northumbria team have now adapted their care bundle specifically to meet the needs of joint replacement patients and have implemented it on over 9000 patients. The before and after data is very encouraging, showing a statistically significant reduction in overall infection rates and this is dominated by the reduction in MSSA - annual savings for Northumbria of £1,230,450.

The cost of screening is £8 per patient and the treatment costs an average of £9 per patient, for the 20% of the population carrying the bug. It costs less than £2000 to avoid an infected joint replacement, which would cost many tens of thousands to treat. QIST Anaemia saves on RBC transfusion, Re-admissions, Critical care admission rates and length of stay. The cost of treatment is under £30 per patient and in the Northumbria study delivered an average total saving of £160 per patient. For an average sized Trust this equates to an annual saving of £120,000.

Involvement:

On the back of proven interventions in Northumbria, our hope is to spread across more than a quarter of eligible NHS hospital acute sites. Experience from Safety Campaigns is that QI communities should combine grass roots momentum with vertical integrating structures that co-ordinate and manage potentially competing interests and motives. We have invested heavily in a number of important relationships and secured support at the highest level to ensure funding of £1.3m for our ambitious 2 year programme.

We have successfully articulated the case for improvement to the wider NHS, with 40 Trusts signing up to join the collaborative by April 2018. The involvement of the BOA as spread partner and the University of York Trials Unit to lead on outcome evaluation, adds further weight and credibility to the work we want to do. Well trained patient leaders have been recruited to join Northumbria’s faculty, to ensure diverse perspectives influence our improvement work.

Finally it is our intention to do all we can to support highly engaged and committed collaborative site teams to enable front line staff who are closest to the issue play a leading role in developing changes and testing whether these change result in the improvements predicted.