Title: A Surgical Site Infection Risk Prediction Tool to Enable Targeted Infection Prevention Strategies in Adult Cardiac Surgery
Funder: Department of Health and Social Care

Abstract: Development Work Question Will using a novel surgical site infection (SSI) risk prediction tool to administer personalised SSI prevention interventions to people undergoing cardiac surgery be superior to the existing standard of care with respect to SSI rates, the development of antimicrobial resistance, and cost effectiveness? Background Reducing healthcare associated infections and preventing the emergence of antimicrobial resistance are national research priorities. SSI are the most common healthcare-associated infections in people undergoing cardiac surgery. They increase mortality, long-term morbidity, and cost the National Health Service millions of pounds per year. Most SSI are preventable, however the certainty of the evidence to support existing prevention interventions is low. This is associated with variation in the implementation of prevention strategies, and SSI rates that range from 1%-9% across UK centres. Personalised SSI prevention, stratified to individual risk, is preferable, as this reduces drivers of antimicrobial resistance. However, existing SSI risk prediction tools have important limitations and are not widely used. In response, we have outlined a programme of work that includes the development and validation of a novel SSI risk prediction tool in a prospective observational cohort study, followed by evaluation of targeted SSI prevention interventions based on this tool in people undergoing cardiac surgery, in a randomised trial. The development work plan addresses a series of unknowns that are required for the design and success of this programme. Aims and Objectives 1. To identify candidate predictors to be considered in the design of the new SSI risk prediction tool. 2. To develop strategies and tools to overcome the barriers to implementation of the targeted SSI prevention during the research programme and afterwards as the new standard of care. 3. To develop systems and processes for the precision measurement of SSI in the research programme using the Public Health England SSI surveillance system. 4. To prepare a high quality programme grant application. Work Plan We will ensure that our research takes into consideration the needs of the diverse UK population. Work Package 1: A systematic review of studies that have evaluated risk factors for SSI in clean surgery. Work Package 2: A study to identify barriers/facilitators to implementation of SSI prevention strategies and to characterise what is usual practice through process maps and structured interviews using patients as researchers. This will increase compliance in our future clinical trial and will help to develop a standardised care pathway for SSI prevention. Work Package 3: A study to identify barriers/facilitators to engagement with the SSI surveillance system using surveys, structured interviews with key stakeholders, and process maps. A surveillance implementation strategy will be developed to increase participation in surveillance and the number of centres who participate in the programme. Timeline The development work will be completed in 14 months allowing 4 months for the development of a Programme Grant for Applied Research. Impact and Dissemination This programme of work will lead to development of tools and processes to implement a new national SSI prevention pathway for people undergoing cardiac surgery.

Lay abstract: Aims To develop new care pathways for the personalised prevention of wound infection following heart surgery based on measurement of individual risk. We believe that this will reduce numbers of infections, the development of bacterial resistance to antibiotics, and costs to the NHS and society. Background Prevention of wound infections after heart surgery is a national research priority. Wound infections have a significant impact on the physical and mental health of patients, as well as on the lives of their relatives or carers. Treatment of wound infection costs the NHS millions of pounds per year. Evidence obtained by our group show that the rates of these infections vary from hospital to hospital within the United Kingdom. Treatments and practices between hospitals to prevent wound infections also vary, for reasons that are not clear. This may be due to the lack of high quality research guiding healthcare professionals as to what is the best treatment(s) to reduce an individual s chance of getting a wound infection. Some people are at increased risk of developing infections and targeting prevention to this group makes sense. This reduces the unnecessary use of antibiotics, and the development of bacterial resistance to antibiotics (anti-microbial resistance). However, existing tools to identify high-risk groups (risk prediction tools) are poor. To address these challenges we have outlined a programme of research that will develop a new wound infection risk prediction tool. We will then test whether using this tool to target infection preventions based on individual risk, will reduce infection rates, antimicrobial resistance, and save the NHS money, in a clinical trial. Our development work will generate essential new information required for the design and successful implementation of this programme. Work Plan Work Package 1: We will review all the previous studies that identified patient factors that increase the risk of wound infection. We will use these factors in the development of the new risk prediction tool for cardiac surgery patients. Work Package 2: We will study why different hospitals use different treatments to reduce wound infection, and make recommendations as to how these might be modified. Work Package 3: Wound infection rates after surgery are monitored by Public Health England, however not all hospitals use this service. We will work with hospitals to develop strategies to improve monitoring, and increase the numbers of hospitals participating in our research. Patient and Public Involvement A trained patient researcher will participate in Work Packages 2 and 3. National PPI groups will support consultation, governance, and dissemination. Impact and Dissemination This program of work will develop and implement a new national wound infection prevention pathway to reduce the variations in care and rates of wound infection following cardiac surgery in UK centres.

Research activity codes: 6.4 SURGERY;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: INFECTION