Introduction!!Surgical Site Infections (SSIs)!• SSIs account for 16% of all hospital acquired infections1!• Highest rates of infection occur following large bowel surgery!• SSIs are associated with increased morbidity and ~15% increase in

mortality2!• Large bowel SSIs are classified as superficial, deep incisional and

organ space!!Negative Pressure Wound Therapy (NPWT) for closed incisions!• NPWT has become an established therapy for wound management

although its efficacy and cost effectiveness remains uncertain3 !• NPWT has a multifactorial mechanism of action (see Figure 1)!

!

!• PICO™ (Smith & Nephew, UK) is a novel self-contained NPWT

system that can be applied to open wounds, closed surgicalincisions and skin grafts (see Figure 2)!

Aims!!• To evaluate the use of PICO™ NPWT as prophylaxis to prevent SSI

following large bowel surgery!• Proposed benefit of a 50% reduction in superficial and deep

incisional SSIs with the use of PICO™!• Evaluate cost implications!!Methods!!• Adult patients undergoing laparotomy with a high risk for wound

complications based on established risk factors (see Figure 3)!• May-November 2014!• Prospective data collection!• Specifically designed proforma!

• Wounds closed in usual manner with PICO™ applied under sterileconditions in theatre!

• Data compared to same period in 2013!

Financial Impact Matrix!!• Tanner et al4 estimates the average cost of an SSI following large

bowel surgery to be ~£10,000!

Cost of 1 SSI ≈ 70 PICO™ NPWT systems !Based on a cost price including VAT (£144/unit)!

!

In other words, your Trust would remain cost neutral if the use of 70 PICO™ NPWT

systems prevented just one superficial or deep incisional SSI !

!References!

1. Public Health England. Surveillance of Surgical Site Infections in NHS Hospitals in England,2013/14. London: Public Health England, 2014!

2. Coello et al. Adverse impact of surgical site infections in English hospitals. J Hosp Infect.2005;60(2):93-103!

3. Webster et al. Negative pressure wound therapy for skin grafts and surgical wounds healing byprimary intention. Cochrane Database Syst Review. 2014;10:CD009261!

4. Tanner et al. Post-discharge surveillance to identify colorectal surgical site infection rates andrelated costs. J Hosp Infect. 2009;72(3):243-250!

!

Additional references for Figure 1 can be provided on request!

Figure 3: Study inclusion criteria!!• Age > 70 years!• BMI > 35!• Emergency operation!• Diabetes!• Immunosuppression or immunocompromise!• Consultant-based decision!

Figure 5: Analysis of PICO™ patients!

Number with PICO™! 27/102 (26.5%)!Number superficial/deep SSIs with PICO™! 1/27 (3.7%)!M:F! 13:14!Mean age! 67.4 years!ASA Grade! 1!

2!3!4!

2 (7.4%)!10 (37.0%)!4 (14.8%)!11 (40.7%)!

Mean BMI! 25 (range 19-31)!NCEPOD Classification of Intervention! All Urgent (Emergency)!

Control Group (2013)!!

Superficial and deep SSI infection!in 9/117 pts (7.69%)!

!

Cost = £90,000!

Study Group (2014)!!

Assuming no change in the SSI!rate implies 7.8/102 pts!

!

Cost = £78,000!

But, 2 confirmed SSIs cost £20,000!

Cost analysis of PICO™!!

1 PICO = £120 + VAT!!

• used (27 cases) = £3,240!• all high risk cases ~ £6,480!• all laparotomies (102) = £12,240!

Even if PICO™ is used for all laparotomies the cost is only slightly more than that of one SSI!

£58,000!

Assuming PICO™ used in all!laparotomies independent of!

risk factors!!

Potential saving!£45,760!

Results!!• In the PICO™ study period (May-November 2014), 102 laparotomies

were performed, of which 2 patients developed superficial or deepincisional SSIs (1.96%)!

• In the control period (May-November 2013), there were 9 superficialor deep incisional SSIs in 119 laparotomies (7.69%)!

• The reduction in SSIs is statistically significant, p=0.049 (Fisher’sexact test) (see Figure 4)!

• PICO™ NPWT was used for 27 patients (26.5%) (see Figure 5)!• 1 PICO™ patient developed a superficial wound infection!• All patients with SSIs from both the Control and Study Groups had

more than 1 risk factor and were suitable for PICO™!

Discussion!!• The aims of the study were met!• The rate of superficial and deep incisional SSIs was reduced by

almost 75% without any other significant change in practice apartfrom the use of the PICO™ NPWT system in high risk wounds!

• The financial impact of this reduction is significant (see FinancialImpact Matrix opposite)!

• PICO™ is a safe, comfortable and user-friendly system to applyNPWT to laparotomy wounds!

• In this small study, the use of PICO™ NPWT has been shown to bebeneficial in reducing the rate of superficial and deep incisional SSIsfollowing large bowel surgery!

!

Figure 2: PICO™ specifications!!• Cannister-free!• Negative pressure of 80mmHg!• 7 day therapy!• Comfortable silicone dressing!• 8 sizes (10x20cm to 25x25cm)!• 300ml total exudate capacity!

Figure 4: SSI rate between Control Group and Study Group!

7.69%! 1.96%!

Control Group (n = 117)! Study Group (n = 102)!

Holds closed incision edges!together and helps reduce

tensile forces across the!incision!

Leak. 2011!Wilkes et al. 2011 (in vitro)!

Helps improve perfusion!Canonico et al. 2012!

Helps reduce oedema!Canonico et al. 2012!

Reduces seroma and haematoma fluid collections!Pelino et al. 2013!

Protects the incision from external contamination!Hudson et al. 2013!

Figure 1: NPWT mechanisms of action!

Prophylactic use of PICO™ Negative Pressure Wound Therapy to reduce surgical site infections following large bowel surgery J.F. Caswell MBBS, S. Graham MBBS, P.A. Whitehouse MBBS MD FRCS Department of General, Endoscopic & Laparoscopic Colorectal Surgery!Worthing Hospital, Worthing, West Sussex, BN11 2DH, UK!

62328 June 2015