Surgical wound infection : addressing the risk factors within a change theory framework

Surgical wound infection is a common post-operative complication despite the advances in patient care during the last century. This thesis consists of 4 research studies examining risk factors for surgical wound infection and what can be done interms of audit to prevent them. Prevention of surgical wound infection is hindered by a lack of agreement over risk factors and audit methods. A prospective cohort study of 2202 surgical patients from7 surgical wards, across two hospitals, using "gold standard" methods and definitions led to the development of a mathematical model for risk of clean, elective surgical wound infection. Risk of surgical wound infection was increased by smoking, increasing body mass index (BMI), presence of malignancy, haernatorna formation, increasing numbers of people in theatre, adherent dressing usage and increasing time to suture removal. Some of these risk factors had not been previously identified within the literature review as significant.To further investigate these findings, an evaluation research design was adopted using both quantitative and qualitative methods. A longitudinal study of nurses' and surgeons', (n=107), patient care practice attitudes and beliefs served to measure the impact of audit and feedback on practice. A change intervention, in the form of anormative re-educative strategy for the introduction of recommendations for best practice, served to illustrate the impact this strategy can have on subsequent attitudes of staff and patient care practices. The use of a qualitative study, interviewing a subset of the nurses involved in the research study revealed that practice was affected by a number of issues and adaptation to change was dependent on internal and external issues, namely pressure, hierarchy, personal adaptation and awareness. An economic analysis of the project revealed that, contrary to the belief in the literature that gold standard methodology is impossibly expensive, this type of study is an effective way of attaining reliable data and can be justified in terms of cost savings resulting from a significant reduction in the surgical wound infection rate.The use of a multi-method approach within this study enable an evaluation of the subject matter at a level which led to new knowledge and the findings have wide implications for audit and prevention, of surgical wound infection.