During the study period, we observed that in-hospital SSIs and other nosocomial infections following treatment and care for hip fractures can be significantly reduced by using the bundle approach based on the Safe Hands project. The initial early SSI rate in our cohort lies in the mid-range of previously reported rates (19) and the rate after the bundle interventions was in the lower range (20). Rates of pneumonia and unspecified infection increased slightly in the fifth study year and this is probably attributable to Covid-19. For every year, the odds of an early SSI decreased, despite that there were significantly more patients with cognitive impairment and nursing home residents in the last two study years, indicating greater frailty in the cohort (21). In line with the literature, male gender, prolonged procedure time and more than one urinary catheterisation increased the odds of early SSIs (2, 17, 19). In contrast, age, diabetes and an ASA score did not predict SSI in our cohort. The identification of discrete modifiable risk factors is clinically desirable to ensure optimal intervention. The strong association between sepsis and SSI was not surprising (22); it stresses the importance of handling all medical devices, such as venous and urinary catheters, with strict adherence to hand hygiene guidelines and aseptic techniques (23). S. aureus bacteremia, albeit to a lesser extent if hospital acquired, increases the risk of bacterial seeding to a previously inserted orthopaedic implant or another biomedical device, thereby compounding morbidity (24–26). There are studies from several centres including our hospital that report decreased mortality and hospital re-admission in key infections, including S. aureus bacteremia, following early Infectious disease consultations(27, 28). To this end, S. aureus alarms and the increased availability of bedside ID consultations were introduced in the second quarter of the first study year and in the first quarter of the third study year, respectively. Skin lesions on admission and severe pressure ulcers constituted a very high risk of SSI. The latter is a modifiable risk factor that shows the importance of a team effort preventing complications in surgery; by including RNs and emphasising the importance of optimal nursing care, pressure ulcers can be avoided. However there is a need for high-quality trials, establishing the optimal repositioning frequency in this patient group (29).
Strengths and limitations
As this is a single-centre observational study, there are caveats when it comes to the interpretation of these results. In addition, other changes in hospital standard practices, many of which were developed in relation to the growing organisational focus on this patient group, have probably impacted the results of the Safe Hands interventions. What we can see is a probable reciprocal effect where the different changes reinforce the results in terms of patient outcome. However, we have tried transparently to report all the changes that have occurred during the five years included here to minimise the risk of overstating the influence the Safe Hands project has had on clinical practice. The study also has its strengths, such as the large study cohort of 3,553 patients. To avoid imputation errors, the registered data have been validated against patient records. The local quality register started in 2015 and the number of patients included in it has fluctuated over the years. Fewer patients were included in the first years of the register. The estimated completeness in the first year was approximately 60%, based on a median value of included patients in years 2 to 5. No systematic errors that can explain the lack of imputation in the first year of the register have been found.
Using only routinely collected data to analyse outcome has its limitations. As a result, other important prognostic and confounding factors, such as blood transfusion, body weight and smoking, have not been controlled for in the statistical analysis.
Bundle approaches have inherent strengths and limitations. Previous bundle interventions have proven useful in improving the quality of care and reducing SSIs in HF patients (6, 20) and other serious HAIs, such as blood-stream infections (30) and ventilator-associated pneumonia (31). Others have criticised bundle approaches and challenged their usefulness, as it is difficult or even impossible to tease out the parts of the bundle that have contributed to the desired change and the extent. We argue that this criticism is less important than the potential benefits of bundles. Moreover, it might be useful to move away from linear thinking where every single part can be measured and understood, to acknowledge the complexity of change and view the transformation process from a holistic perspective where the whole is greater than the simple sum of parts.
Lessons learned
At the start of the Safe Hands project, we aimed to create sustained improvements in the treatment and care of older individuals with hip fracture, with special emphasis on infection prevention. The results of the present study indicate sustained improvements and, moreover, the incidence of early SSIs, UTIs and bloodstream infections continued to decrease even after the interventions were implemented in year three and the research team left the site. It is common for most interventions to show an effect in the short run, but the challenge has been to create sustained improvements after the intervention(32), a challenge we were aware of when deciding on the implementation strategy. We see some explanations of our promising results and sustained effect. Implementation theories and frameworks has highlighted how contextual factors can both promote and hinder the uptake of evidence-based care (33–36). For this reason, the results of our study cannot be understood without acknowledging contextual mechanisms such as leadership engagement, resources, an organisational safety culture and commitment to change. To add another layer of complexity, the Safe Hands implementation programme was aimed at surgeons, RNs, specialised RNs and nurse assistants, leaders (formal and informal) and managers. To handle this complexity, the programme was based on facilitating mechanisms for contextual negotiation and collective action; 1) Building a strong partnership between researchers, management and clinicians based on mutual respect, 2) External and internal facilitation as a role and a process that focused on enabling and supporting individual and organisational learning (37, 38). We found that the choice of facilitators was critical and needed to be adapted to match the context. To be perceived as trustworthy, these facilitators needed to have an in-depth understanding of the medical context and infection prevention. The internal facilitators were introduced step by step and represented all the professional categories. When the external facilitator left the site, the internal facilitators remained and were able to function as local championns (16). In this way, the improvements and learning in clinical practice could continue and may be one contributory factor in terms of the sustained and reduced infection rates. 3) Dialogue and co-creation, to facilitate organisational learning. Isaacs’ (39) and Schein’s (40–42) work has demonstrated the significance of creating space for dialogue. From their work, we used interprofessional dialogue to learn more about one’s own and co-workers’ ways of thinking about infection prevention and to inquire collectively about how available knowledge could best be transformed into co-creating and testing new ways of working together to reduce the risks of infection after surgery. As a result, the work aimed to create a cultural change instead of modifying behaviours. For this to occur, we found, in line with previous studies (41, 43) (p. 305), that the creation of psychological safety, mediated by respectful dialogue, was imperative to facilitate transformation.
Initially, very few people in the organisation appeared to acknowledge the magnitude of the problem with HAIs. Competing interests and other daily problems to resolve may have shadowed the infection issue. By using local quality data as a basis for dialogue with the management and clinicians lead to increasing awareness and a shared sense of urgency in relation to the problem. Most managers and clinicians developed the motivation to engage in the transformative work, even if not everyone was motivated to make changes. To sum up, the Safe Hands project changed the way risks, safety and infection prevention were perceived in relation to hip fracture patients (16) and significantly improved patient outcomes.