Caesarean section woundcare management training

Welsh Healthcare Associated Infection Programme (WHAIP)

- Public Health Wales, in conjunction with 1000 Lives Plus

Contact:

Lead for SSI surveillance, Public Health Wales:

Dr Wendy Harrison wendy.harrison2@wales.nhs.uk

Information Analyst:

Alice Neden alice.neden@wales.nhs.uk

The Temple of Peace & Health, Cathays Park, Cardiff, CF10 3NW

Y Deml Heddwch ac Iechyd, Parc Cathays, Caerdydd, CF10 3NW

Acknowledgements

We would like to thank Liz Waters (Consultant Nurse – Infection Prevention in Aneurin

Bevan) for her input into the training package.

We would also like to thank the Caesarean Section Steering Group and the Health Boards

in Wales for their contributions to this package.

C-Section wound care management trainingSummary of presentation for trainer

The following information provides a summary of the information and what should be covered during the training

session. It provides a summary by slide and overall objectives and outcomes that should be met following this

training.

The presentation will take 30-40 minutes to deliver. There is an accompanying booklet to this presentation which

can be found via the WHAIP intranet.

Slide 2: Slide shows what will be covered in the training, briefly talk through this, and explain the purpose of the

training. If you haven’t got time to address surveillance, it is discussed in the booklet that is provided at the end of

this training session.

Talk about overall purpose of training in Wales, reducing surgical site infections in c-section wounds.

Slide 3: Introduction to SSIs acquired after a c-section, focusing on cost to the NHS and patient. Use the slide

citations as further reading for the topic.

Slide 4: Introduce the Wound Care Pathway. This is a suggested pathway, available to all Wales, with the view to

incorporating it into local caesarean pathways. The pathway is a set of interventions aiming to minimise infection in

elective caesarean sections in Wales.

Slides 5-7:

These slides detail the Wound Care Pathway mentioned in slide 4. A copy of the pathway can be found in the

training booklet and on the WHAIP website, along with further details of each intervention.

For these slides, talk through the three stages of interventions, and what will be covered:

Slide 5 Pre-operative Slide 6 Intra-operative Slide 7 Post-operative

Wound care booklet

MRSA screening

Hair removal

Daily showers/baths

Hair removal

Antibiotic administration

Skin preparation

Body temperature

Glucose levels

Wound dressing (application andremoval)

Advice to mother

Assessing wound (aseptic)

WHAIP surveillance

Further reading:

Tanner, J., Norrie, P., & Melen, K. 2011. Preoperative hair removal to reduce surgical site infection. Cochrane

Database Syst Review. Issue 11.

Department of Health. 2011. High Impact Intervention – Care bundle to prevent surgical site infection.

http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/2011-03-14-hii-prevent-

surgical-site-infection-final.pdf [Accessed 21/01/2015]. (And references in this document)

Slide 8: Provides important information to understanding how an infection may occur. It provides a summary of how

infection may occur due to opening of the skin, instruments used and the environment during surgery. Ensure that

the difference between wound colonisation and wound infection is highlighted.

Slide 9: Provides information on how a wound infection can be recognised. Talk through these various infection

characteristics.

Slides 10-13: These slides provide examples (pictures) of a healthy wound, a superficial wound, a deep wound and

an organ/space wound.

Three types of SSIs – superficial, deep and organ/space.

WHAIP diagnostic tool can be found in the training booklet or online (via WHAIP intranet).

Slide 10: Picture of a healthy wound – would have some redness. Please ensure that trainees note that this is not an

infected wound.

Slide 11: Provides the definition of a superficial SSI. Point out why this is infected. Ask the question on why the

audience think that this is an infected wound.

Slide 12: Provides the definition of a deep SSI. Point out why this is infected. Ask the question on why the audience

think that this is an infected wound.

Slide 13: Provides the definition of an organ/space SSI. Point out why this is infected. Ask the question on why the

audience think that this is an infected wound.

Slide 14: Summary of how to take a swab, if an infection is suspected (as mentioned in the Wound Care Pathway).

Important to mention key requirements, hand hygiene, swab prior to any cleaning and use sterile equipment.

Slide 15: This slide details the procedure to follow when taking a sample from a suspected infected wound (follows

the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 8th ed. – Procedure guideline 11.22, Swab

sampling: wound).

Talk through the process and highlight key aspects from the previous slide.

1. Hand hygiene

2. Take swab prior to dressing or cleaning procedures

3. Use sterile swab to collect exudate from the wound

4. Place specimen into sterile container

5. Rewash/decontaminate hands

Slide 16: This slide provides detail on the required hand hygiene technique to be utilised and should be known to the

audience. Hand hygiene is one of the key components in infection prevention (Humphreys, 2009).

Talk through the WHO 5 moments for hand hygiene, explaining key 5 moments.

Further reading:

Humphreys, H. 2009. Preventing surgical site infection. Where now? Journal of Hospital Infection, 73, (4) 316-322

available from: http://www.sciencedirect.com/science/article/pii/S0195670109001807

Slide 17: This slide provides a summary on the c-section SSI surveillance carried out by WHAIP. You will need to

ensure that you cover the purpose of the surveillance, how it is undertaken, who’s responsibility it is and how the

data collected is used. If you are short of time, this section is covered in more detail in the training booklet.

Slide 18: This slide provides key points from the training presentation – re-iterate them these key points to the

trainees.

Slide 19: This slide has been left blank intentionally for local trainers to add any other information. Suggestions of

‘other information’ include:

Local health board or hospital contacts

Messages for your specific health board or hospital.

Slide 20: This slide provides full details of the references used through the presentation – useful as further reading.

C-section wound careC-section wound caremanagement training

Welsh Health Associated Infection Programme (WHAIP)

Public Health Wales, in conjunction with 1000 Lives Plus

C-section wound care management training

What will be covered:

- Surgical site infections

- Wound care pathway (pre operative, intraoperative and post operative)operative and post operative)

- Wound infection

- Visual examples of SSI (healthy, superficial,deep and organ/space)

- Aseptic swab procedure and hand hygiene

- Surveillance- Surveillance

- Points to take home

- References

C-section wound care management training

Surgical site infections (SSI)

• Infections that occur in a wound after an invasivesurgical procedure (NICE, 2008)

• Mostly preventable (NICE, 2008)• Mostly preventable (NICE, 2008)

• They cause excess morbidity and mortality (Plowman et

al., 1999)

• Can double cost of treatment (Plowman et al., 1999)

• Additional cost of c-section SSI £3,716 (Jenks et al., 2014)

• Serious patient consequences (Coello et al., 2008)• Serious patient consequences (Coello et al., 2008)

• Second most common infection after a c-section (Sykes

et al., 2005)

C-section wound care management training

Wound care pathway

• Available to all Health Boards in Wales

• Should be adopted for mothers undergoing electivec-section, in line with NICE guidancec-section, in line with NICE guidance

• NICE guidance outlined three phases

– Pre-operative

– Intra-operative

– Post-operative

• Focus on pre-operative and post-operative

C-section wound care management training

• Focus on pre-operative and post-operative

Pre-operative

Signature Date Discussed

Gestation 32-34 weeks

1) Mother receives a local wound care leaflet?/ /

2) Optional: Mother is screened for MRSA using local guidelines?2) Optional: Mother is screened for MRSA using local guidelines?(Universal screening in Wales has not been adopted. However, if screened andmother is found positive, decolonise using local protocol prior to surgery)

7 days prior to planned section

3) NO further removal of pubic hair – check on day ofsurgery.

/ /

4) Daily showers/baths using soap (paying attention toaxillae, groins, perineum and skin folds) – check on dayof surgery.

/ /

C-section wound care management training

of surgery.Day of surgery

5) Bath/Shower preoperatively using soap, payingattention to axillae, groins, perineum and skin folds.

/ /

Intra-operative

Yes No n/a

1) Remove hair if required – using clippers with a disposable head (not byshaving). Time as close to the operating procedure as possible.

2) Administer antibiotics within 60 minutes prior to incision. Only repeatif there is excessive blood loss or prolonged operation.

3) Patient skin is prepared with povidone iodine or 2% chlorhexidinegluconate and allowed to air dry.

4) Maintain body temperature above 36°C in the peri-operative period.

C-section wound care management training

4) Maintain body temperature above 36°C in the peri-operative period.

5) Maintain a glucose level of < 11mmol/l in diabetic patients.

Post-operativeYes No

1) Cover wound with an interactive dressing at the end of surgery.

2) Advise mother on post-operative wound care:a) Don’t touch the wound unless necessaryb) Ensure that hands are regularly washed, particularly before and after using the toiletc) If infection is suspected, contact local maternity unit (not GP)

3) Remove standard, interactive dressing after 24 – 48 hours after the procedure.Alternatively if non-standardised dressing (eg. PICO, leukomed T+) consult manufacturer’sguidance.4) Assess wound for signs of infection.a) If the wound is clean and dry no further dressing is required and the patient may shower(or if using a transparent waterproof dressing, the patient may shower when they feel readyto).

b) If the wound is displaying signs of infection (such as redness, in addition to swelling orpus) a wound swab must be taken aseptically and a fresh dressing applied daily. Allassessments should be documented in the patient’s record.

C-section wound care management training

5) Aseptic, non-touch techniques must be used when the wound is being redressed.

6) Complete WHAIP SSI surveillance form a) on discharge from hospital

b) Up to 30 days post operatively

How does a wound become infected?

• SSIs can result from contamination of the woundsite.

• Skin is a natural physical barrier to micro-ogranisms,• Skin is a natural physical barrier to micro-ogranisms,so once broken no natural protection (Patel, 2007)

• Wound colonisation: The presence of bacteriawithin the wound but with no patient immuneresponse (Ayton, 1985). No signs or symptoms.

• Wound infection: The presence of multiplyingbacteria that overwhelms the patients immunebacteria that overwhelms the patients immunesystem (Kingsley, 2001). Active signs of disease present.

How can a wound infection berecognised?

Localised erythema

Discharge (viscous or purulent)

Unexpected painLocalised erythema

Localised pain

Localised heat

Abscess

Abnormal smell

Unexpected painat dressing change

Oedema CellulitusWound breakdown

Healthy wound

[Insert image]

C-section wound care management training

Superficial SSI

Infection involves only skin or subcutaneous tissueof the incision

[Insert image][Insert image]

C-section wound care management training

Deep SSI

Infection involves deep soft tissues (eg fascia and musclelayers) of the incision or another area, other thanopened/manipulated during the operation, where theinfection drains through the incisioninfection drains through the incision

[Insert image]

C-section wound care management training

Organ/Space SSI

Involves any part of the body, excluding the skin incision,fascia or muscle layers that is opened or manipulated duringthe operative procedure

[Insert image]

C-section wound care management training

Summary of aseptic swab procedure

Key aspects, detailed procedure on next slide

• Pre operative – hand hygiene

• Take swab prior to any dressing or cleaning procedure

• Sterile swab to collect exudate from the wound (collect

pus in a sterile syringe)

• Place specimen into sterile container

• Re-wash/decontaminate hands

C-section wound care management training

• Re-wash/decontaminate hands

Pre-procedure-Explain the procedure to thepatient-Wash hands with soap ordecontaminate with alcohol handrub, put on apron and gloves.-Remove current dressing if

Procedure-Roll swab in ‘zig-zag’ motion over theentire wound surface-Use enough pressure to obtain fluidfrom wound tissue but avoid exudatesand touching wound margin

Swab sampling: wound

-Remove current dressing ifapplicable-Re-wash/decontaminate hands

and touching wound margin-If wound dry, moisten the tip of theswab with 0.9% sodium chloride-If pus present, aspirate using sterilesyringe and decant into specimen pot

Post-procedure-Carefully place swab into transport tube, ensuringfully immersed in transport medium-Redress the wound, if applicable

C-section wound care management training

-Redress the wound, if applicable-Remove gloves and apron and discard the clinicalwaste. Re-wash and decontaminate hands-Complete microbiology request form-Arrange prompt delivery to microbiology labs

Hand Hygiene technique

C-section wound care management training

(WHO, 2006)

C-Section SSI surveillance

Data management

Responsibility?How issurveillance

Purpose of thesurveillance?

C-section wound care management training

surveillanceundertaken?

Points to take away

• Know the Wound Care Pathway and follow it

• Ensure good communication with the mother• Ensure good communication with the mother

• Follow hand hygiene and asepsis techniques

• Complete Public Health Wales surveillance(inpatient and post-discharge forms)

C-section wound care management training

C-section wound care management training

References• Ayton in Patel, S. 2007. Understanding wound infection and colonisation. Wound Essentials, 2, 132-142• Coello, R., Charlett, A., Wilson, J., Ward, V., Pearson, A., & Borriello, P. 2005. Adverse impact of surgical site infections in English

hospitals. Journal of Hospital Infection, 60, (2) 93-103• Centres for Disease Control and Prevention (CDC). 1988. Guidelines for Evaluating Surveillance Systems. Available:

http://www.cdc.gov/mmwr/preview/mmwrhtml/00001769.htm [Accessed 24/02/2015]• Dougherty, L., & Lister, S. (Eds.). 2011. Royal Marsden Hospital Manual of Clinical Nursing Procedures (8th edition).• Gardner, S.E., Frantz, R.A., & Doebbeling, B.N. 2001. The validity of the clinical signs and symptoms used to identify localized

chronic wound infection. Wound Repair and Regeneration, 9, (3) 178-186• Humphreys, H. 2009. Preventing surgical site infection. Where now? Journal of Hospital Infection, 73, (4) 316-322 available from:

http://www.sciencedirect.com/science/article/pii/S0195670109001807• Jenks, P.J., Laurent, M., McQuarry, S., & Watkins, R. 2014. Clinical and economic burden of surgical site infection (SSI) and• Jenks, P.J., Laurent, M., McQuarry, S., & Watkins, R. 2014. Clinical and economic burden of surgical site infection (SSI) and

predicted financial consequences of elimination of SSI from an English hospital. Journal of Hospital Infection, 86, (1) 24-33• Kingsley, A. 2001. A proactive approach to wound infection. In: Patel, S. 2007. Understanding wound infection and colonisation.

Wound Essentials, 2, 132-142 available from: http://www.wounds-uk.com/pdf/content_9407.pdf• National Institute for Health and Clinical Excellence (NICE). 2008. Surgical site infection prevention and treatment of surgical site

infection. CG74• National Institute for Health and Clinical Excellence (NICE). 2011. Caesarean section.

https://www.nice.org.uk/guidance/cg132/chapter/1-guidance#/procedural-aspects-of-cs [Accessed 06/01/2015]• Patel, S. 2007. Understanding wound infection and colonisation. Wound Essentials, 2, 132-142 available from:

http://www.wounds-uk.com/pdf/content_9407.pdf• Plowman, R. 2000. The socioeconomic burden of hospital acquired infection. Euro surveillance: bulletin Europeen sur les maladies

transmissibles= European communicable disease bulletin, 5, (4) 49-50• Sykes, P.K., Brodribb, R.K., McLaws, M.L., & McGregor, A. 2005. When continuous surgical site infection surveillance is

interrupted: The Royal Hobart Hospital experience. American Journal of Infection Control, 33, (7) 422-427 available from:interrupted: The Royal Hobart Hospital experience. American Journal of Infection Control, 33, (7) 422-427 available from:http://www.sciencedirect.com/science/article/pii/S0196655305004293

• Tanner, J., Norrie, P., & Melen, K. 2011. Preoperative hair removal to reduce surgical site infection. Cochrane Database SystReview. Issue 11

• World Health Organisation. (2006). Five moments for hand hygiene. http://www.who.int/gpsc/tools/Five_moments/en/ [Accessed15/12/2014].

C-section wound care management training