Mrs. Susan Elizabeth Ryan1, Professor Rhonda L Stuart1,2,3
1Infection Prevention, Monash Health, Clayton, Australia, 2Public Health and Infection Prevention. Monash Health, Melbourne, Australia, 3Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia
Biography:
Susan Ryan has 36 years of nursing experience, with lead roles in Critical Care and Infection Prevention at Monash Health. Last year she took on the role of Infection Prevention Site Lead at the new Victorian Heart Hospital. She has a keen interest in Infection Prevention research and quality improvement.
Abstract:
Background
We describe an outbreak of 16 surgical site infections in a newly opened cardiac hospital lasting from March to September 2023. These infections met the Victorian Nosocomial Infection Surveillance System surgical site infection definitions. Three deep, four organ space and nine superficial surgical site infections were identified. The outbreak was polymicrobial, with 8 different organisms identified: 3 cases grew Staphyloccocus epidermidis, 2 cases grew Serratia marcescens, 2 cases grew Pseudamonas aeruginosa and 2 cases grew Enterobacter cloacae. No other organism was identified in more than one case.
Actions
An in depth investigation of all infection prevention processes from pre-admission to discharge was undertaken to identify potential factors contributing to the acquisition of surgical site infections. This included decolonisation, preparation for operating theatre, operating theatre processes, surgical antibiotic prophylaxis, blood glucose control, surgeons, graft sites used, surgical tray crossover, instrument reprocessing, return to operating theatre, cleaning of the environment and clinical equipment, hand hygiene, aseptic technique and wound care.
Results
Multiple potential contributing factors were identified. Interventions to address these were instituted. No new deep/organ space surgical site infections have been identified since August 2023 and only one superficial surgical site infection after September 2023.
Conclusion
Our investigation led to the identification of multiple potential contributing factors in this outbreak. By improving infection prevention practices throughout the patient’s surgical journey we demonstrated that surgical site infections can be prevented.