Achieving a reduction in the readmission rate for post caesarean section infection.
Nationally 25.5% of births are delivered by caesarean section¹. Southend University hospital delivers around 3700 births per year, of these 29% are delivered by caesarean section (13% elective, 17% emergency)2. Surgical Site Infection (SSI) is second only to urinary tract infection as the most infectious complication following caesarean section3. A study in 2009 showed 9.6% of mothers post caesarean section developed an SSI, of these 0.6% were readmitted for treatment4. Currently maternity units are not obliged to report their surgical site infection rates to the surgical site infection surveillance service so it is difficult to compare SSI rates from one maternity unit to another. However there were concerns that the number of mothers being readmitted to a busy maternity unit with SSI (3.97%) requiring surgical intervention was high (1.98%). The maternity unit supports mothers from the local population where there is a large number of mothers with a high BMI, of high maternal age and young teenagers. These mothers are considered to be of higher risk of developing complications post caesarean section4. In 2013 to improve mothers’ experience and reduce post operative complications a “Mothers’ Care Pathway” was implemented onto the unit. The aim of the pathway was to standardise the care of mothers from pre-admission, through their operation and recovery.
To reduce the potential complication of infection following a planned caesarean section the “Mothers’ Pathway” was introduced (Figure 1). To demonstrate how effective the new pathway was the number of mothers being re-admitted to hospital following caesarean section with surgical site infection was audited following the implementation of the “Mothers’ Pathway” and compared to the previous year. The “Mothers’ Pathway” follows her journey from pre-admission to discharge. Within the past few months, Enhanced Recovery has been implemented into the maternity unit6 (Figure 2). This medical approach to Pre-op, during and post-op procedures compliment the “Mothers’ Pathway”.
Any SSI that is suspected or identified is seen by a midwife. This ensures accuracy of diagnosis and treatment and enables effective SSI surveillance. The graph compares the rates of infection and those requiring surgical intervention from 2012, before the Mothers’ Pathway was implemented and the same months in the following years. The graph demonstrates that there is a significant reduction in the number of SSIs from 3.97% to 1.06% and a reduction in those infections that required surgical intervention from 1.98% to 0.30%. To be able to recognise and document the mothers’ experience they are asked quality of life questions after their discharge home such as:
how comfortable the dressing feels.
does it remain in place?
The World Health Organisation (WHO) released a statement back in 1985 stating that there was “no justification for any region to have a caesarean section rate higher than 15%”5. However in the UK mothers’ are given the choice on where and how their baby is born, therefore many mothers may continue to opt for a caesarean section despite no medical justification for the procedure. It is therefore, important that mothers have the best possible experience pre, during and post their caesarean section. Continued surveillance of SSI will enable the maternity unit to demonstrate the efficacy of the Mothers’ Pathway alongside Enhanced Recovery and ensure that Quality care and standards are maintained resulting in the best possible experience and out comes for new Mothers and their babies.
References: 1. NHS Maternity Statistics – England 2012-2013. Publication date: December 05,2013. www.hscic.gov.uk/catalogue/PUB12744. 2. Caesarean Delivery Rates For The Essex Region (2013) www.birthchoiceuk.com/professionals/birthchoiceUKframe.htm. 3. Hillan E, (1995) Postoperative morbidity following Caesarean delivery J Adv Nursing 1995; 22:1035-1042. 4. Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E, (2012) Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study BJOG 2012 ; 119:1324-1333. 5. World Health Organisation WHO Statement on Caesarean Section Rates 2015 WHO_RHR_15.02 . 6. Enhanced recovery programme in obstetrics (2015) Southend University Hospital NHS Foundation Trust. *AQUACEL® Surgical dressings were provided to the author free of charge for the purpose of initial evaluation 2013 only.