Reports From the Field

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

Journal of Clinical Outcomes Management. 2018 March;25(3)

References

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Results

A re-audit of hip hemiarthroplasties was conducted after a 12-month interval to allow proposed changes to become routine practice. Re-audit was undertaken retrospectively from April 2015 to March 2016 using the same methods and search strategy as before. 457 (male 43.3%, female 56.7%) hip hemiarthroplasty procedures were carried out in this time period with 5 deep infections occurring, a rate of 1.1%, demonstrating a statistically significant reduction in periprosthetic joint infection rate (P = 0.03, chi square test). There were 3 males and 4 females, with a mean age of 79 years (range 57–91), and mean ASA of 3.1 (range, 2–4). Two were right hips, 3 were left hips. Four infections occurred within 4 weeks and one at day 50. The overall mortality rate for those patients who developed deep periprosthetic infection within our study time frame was 28%.

Findings were presented at the regional audit meeting. This highlighted the positive impact of the changes to practice and stimulated discussion on further improvements to practice that could be instituted. Prior to implementation of any further changes to practice a re-audit was conducted over a further 12-month period. This demonstrated maintenance of an infection rate below the literature standard of 1.6% and a continued reduction in the initial audit rate of 2.7%

Lessons and Limitations

This quality improvement project demonstrates how simple changes can deliver large benefits to both patients and the health system. There is considerable variability in worldwide orthopedic practice, due in part to the limited evidence base for some perioperative infection precautions. This was the first attempt in Northern Ireland to quantify the effect of some of these precautions and to contribute to the evidence in support of their implementation. We acknowledge that the numbers involved in our project are small, and the effect size is likely to be overestimated. Factors contributing to this include the Hawthorne effect, improved staff awareness of postoperative infection, and that patients who either died or were treated conservatively did not undergo a washout procedure and therefore would not have been identified.

Institutional change is challenging. We selected the changes to practice that we felt would likely provide the largest benefit, with minimal cultural resistance. All materials (eg, Ioban drapes and Chloraprep skin solution) were already stocked in theatre suite and therefore did not have to undergo procurement procedures. Junior medical staff were instructed on strict standardised draping technique, as agreed by revision arthroplasty surgeons working within the unit.

We would advocate that theatre staff at every level are involved in this process from the outset in order to maximise the overall benefit. It is important that medical, nursing, and auxiliary staff are involved in decision making and implementation to facilitate uptake of new practices. All staff were re-educated on the impact of deep infections in these patients and the importance of perioperative practice in minimising these. Whenever resistance was met we addressed with open discussion and answering all questions to ensure staff understanding and acceptance.

Conclusion

Deep joint infection represents a significant cause of morbidity and mortality in the elderly population and a financial burden on the health service. The implementation of these simple perioperative interventions has achieved a significantly reduced rate of infection in a regional trauma center. Our interventions have been straightforward to implement, cost-effective and, most importantly, have demonstrated a significant, tangible benefit to our patients.

Corresponding author: Mr. Brendan Gallagher, Department of Trauma and Orthopedics, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, N. Ireland, BT12 6BA, brendan.gallagher@belfasttrust.hscni.net .

Financial disclosures: None.