Wound Infection post total knee replacement surgery

Nursing practice is the actual provision of nursing care. In providing care, nurses are implementing the nursing care plan which is based on the client’s initial assessment. This is based around a specific nursing theory which will be selected as appropriate for the care setting. In providing nursing care the nurses uses both nursing theory and best practice derived from nursing research. Nursing is practice profession which is depends on a variety of skills which are strongly related to ethical and social aspect in healthcare. There are lists of contemporary issue exist, in an effort to fulfill modern health care system in Malaysia. These contemporary issues provide a challenge in this practice discipline and other health care teams.

Contemporary issues defined as present or current issues which is happening, existing, living or coming into being during the same period of time. Contemporary issue in professional practice is closely related to ethical component of practice also competing ideologies and practice realities.

This assignment will explore contemporary issue on infection control. I’m interested to present about increasing rate of wound infection post total knee replacement (TKR) surgery. TKR or knee arthroplasty is surgical procedures in which the worn, damage surfaces of the knee joint are replaced with metal and high-density plastic. TKR may result in general pain relief, deformity correction and resumption of normal activity. As I’m working in orthopedic ward for the 10 years, wound infection especially post TKR complications commonly affect patients. Wound infection can give a big impact in patient recovery and indirectly public can question the quality of care delivered. Therefore I have decided to discuss about the infection control surveillance and ongoing for patient health care programmed also organization action and strategies undertaken.

In this paper I will critically discuss, how it occur and about how to decrease wound infection of post TKR. This paper also will provide critical knowledge and understanding patient’s needs during hospitalization via reflection upon nurse’s responsibility in health care.

BODY

Total knee replacement is a common surgical procedure done routinely around the world on patients with severe arthritis. The surgery has a high rate of success and complications are rare. Most post operative complications are anticipated and prophylactic medications or therapies are administered on a preventative basis. It is a major procedure and recovery will not occur overnight. Post operative care following knee replacement begins immediately and involves basic wound care, a step- wise activity regimen and prevention of complications. TKR is the most devastating and challenging complication for both the surgeon and the patient to face. According to Bengston and Fitzgerald (1991) although surgical techniques and treatment operation have improved the overall risk for deep infection after TKR still remains 1-2 %. In case of infection, it is of great importance to quickly identify the problem and treat it adequately to minimize the risk of complications. A straight forward management algorithm is the only way of dealing with infected implants properly.

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Post TKR infection which is a result of treatment in a hospital or a healthcare service unit, but secondary to the patient’s original condition. According to Fehring et al (2000), the diagnosis of infection depends on the clinical appearance of the patient is generally based on joint aspirates and cultures, laboratory results. [Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], radiography and clinical examination. The knee joint can present inflamed, red, swollen, tender on palpation, feeling warm and the patient can show clinical signs of systematic infection like fever, shivering, night sweating, etc. Sometimes the only complaint patients have is continuous pain. This should be considered as an infection until proven otherwise. Zimmerli W (2004) present most commonly cultured microorganisms are coagulase- negative staphylococci (30-43% of cases) and Staphylococcus aureus (12-23%), and followed by mixed flora (10-11%), streptococci (9-10%), Gram- negative bacilli (3-6%), enterococci (3-7%) and anaerobes (2-4%). No microorganism is detected in about 11% of apparent infection. Polymicrobial infections are reported in 12-19% of cases.

Many medical procedures bypass the body’s natural protective barriers. Routine use of anti-microbial agents in hospitals creates selection pressure for the emergence of resistant strains. According to Rutala et al (1983), investigating on Methicilin Resistant Staphylococcus Aureus (MRSA) outbreak, found that MRSA comparised 16% of all bacterial isolates sampled from the air and 31% of the isolates from elevated surfaces.

After knee surgery, infection is a major concern. A standard treatment protocol must be followed. All patients post TKR must treated with intravenous flucloxacillin and benzyl penicilin (erythromycin for penicillin allergic patients) for a minimum of 6 weeks. According to Lewis G (2006) antibiotic -loaded cement were also found to be efficient in reduced the risk of infection in the early post operative period. However, Joseph TN (2003) states high doses of antimicrobial agents may result in the bone cement has lower mechanical properties and there are also concerns regarding the allergic reaction to impregnated antibiotics and the potential for the emergence of antibiotic-resistant bacteria.

Knowledge is one factors contribute of infection. “Barriers to good hand hygiene include poor knowledge of infection control, time pressure, poor technique, inadequate facilities and inappropriate clothing and hand adornments. (NOA 2004: Department of Health (DH) 2005). Professional healthcare staff must have a good knowledge hand washing follow by standard precaution to prevent infection. It can decrease infection via hand among them. Gould et al (2008) thinks that infections in healthcare setting are spread by direct contact (cross infection) of health workers.

Normally in crowded with full patient’s orthopedic ward with 3-4 staff nurses per shift, this can cause the workload. It a high was too heavy and they have not enough time to carry out their job properly. It’s difficult to practice good hand washing hygiene before and after touch every patient. Infection can cause by the nurses while practicing nursing interventions via poor hygiene control and failure to maintain sterility in procedure especially do dressing to post TKR patient. When hand washing facilities are poor, it contributes to infection. Clinical hand wash sink are required in all areas where clinical activities are performed. Provision of adequate and appropriate facilities could be improved hand washing compliance. According to Harris et al (2000) stated that hindering factors and good and hand washing are lack of time, poor facilities and materials. From one study of compliance with hand washing (Girou and Oppein, 2001) state that 50% of healthcare workers’ did not wash their hands after procedure.

A nation review of nursing workforce predicts the demand for nurses will increases in hospital admissions. With many nurses hearing retirement, a national shortage of up to 40,000 nurses is predicted by 2010. Therefore recommend that the Department of Health require all hospitals to use the general workload calculation tool to assess the number of nurses needed in appropriate wards.

A compounding factor and one that is the cause of many post TKR infection in hospital, staff especially nurses they not able to practice proper hand washing technique as they have too many procedures to be settle before end of the shift staff nurses are always running out the time to manage all about patients including orders from doctor, they must manage pre and post operative patients too. Among crowded hospital populations and where poor infections control practices exits it may facilitate bacteria transmission. A commonly in ward, nurses have to follow ward round and carry out order from doctors such as taking blood, do dressing and sent patient for x-ray or physiotherapy. During ward round, staffs unable to wear proper mask, glove and apron before enter isolation room patient post TKR as an action from doctor which wants it to be fast. In this situation, nurses must be the best way to perform nursing role in whatever situation no matter it is a busy day, emergency situations or lack of staff. It is important the nurse to analyze and utilize the situation in work management. The Infection Control Nurses Association (1998) mention that commitments by managers to improved resources are important to prevent poor hand hygiene among healthcare and patients.

During ward round, staffs unable to wear proper mask, glove and apron before enter isolation room’s post TKR patient as an action from doctor which it to be fast. In this situation nurses must be the best way to perform nursing role in whatever situation no matter it is a busy day, emergency situation or lack of staff. It is important for the nurse to analyze and utilize the situation in work management. According to Hanssen AD et al (1999) the incidence of infection as cause of prosthetic failure varies depending on the joint involved with the rate of arthroplastis becoming infected being 1.7% of primary and 3.2% of non primary hip arthroplasties, 2.5% of primary and 5.6% of non primary knee arthoplasties and 1.3% of shoulder arthoplasties.

A nation review of nursing workforce predicts the demand for nurses will increase by over two percent a year due to expected increases in hospital admissions. With many nurses hearing retirement, a national shortage of up to 40,000 nurses is predicted by 2010. Therefore recommend that the Department of Health require all hospitals to use the general workload circulation tool to assess the number of nurses in appropriate ward.

Learning through reflection is more potent if there is an understanding of frameworks that encourage a structural process to guide the act of reflection. In this paper I would like to reflect about one cases happened in my work place. One old male patient about 80 years old develops deep infection after a two – stage revision of an infection post TKR. The ideal definitions of post operative wound infection remain problematic. A substantially higher audited rate of wound infection is produced by applying the clinical definition proposed by the Surgical Infection Study Group (SISG). After apparent early post operative wound infection in to patients, only three (4%) had definite ongoing wound problem or deep sepsis at 1 year.

As an experienced nurse, I feel upset if the infection is cause by the lacking of staff’s knowledge in wound management. Patient might be depressed as the result from infection and complication and need longer hospitalization period. They also must waiting and have maintain period of healing process.

Regarding this situation, I applying Gibbs Reflective Cycle, Nurses play a crucial role in the management of wounds. So they need to have good current knowledge and be more aware of their own wound care practice so to bring about more effective wound management. Professional Development in Nursing Time, (1994,p1), describes the nurses to be more observant of their patients’ wounds, increased their knowledge and skills on wound care and assisted them in acquiring more experience and skills in nursing research and get up on going frame work for improvements in wound management.

I’m as a staff nurses, I give moral support to built patient confidence level and avoid depression. Health education also might be useful for the patient facing with their condition. Nurses should foster better work among the many disciplines, improved the nurses reflection on their clinical and ultimately procedure better nurse practitioners.

Once patient can be discharge, some of them though they are fully recovered, therefore they neglected the proper hygiene in daily living activities in other habit for patients are not coming for the appointment and did not taken antibiotics as ordered. Before patients discharge from hospital, decisions will be made about their continuing health needs. Information will be provided on the need further medical care including any necessary medicine, or services such as home nursing and delivered meals can be obtained.

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Educational strategies need to be specifically targeted to meet the needs of different professional groups and levels of expertise to maximize effectiveness. An example of this would be the appropriate preparation of clinical leaders such as specialist nurses so that they are equipped with the skills, knowledge and implement evidence-based wound care locally. According to Lucker and Kenrick, (1995), is also helps to create effective role models as health professionals are more likely to implement the good practice demonstrated by a colleague than good practice read about in a journal. In recent years it has become common for education to work in collaboration with clinicians, industry and wound organizations to provided more effective educational initiatives that provided an opportunity to network, while keeping abreast of current opinions and developing critical thinking skills.

Although hand washing may see a simple process, it is often performed incorrectly. Healthcare settings must continually remind a practitioner especially nurses and visitors and the proper procedure in washing the hand to comply with responsible hand washing. Elliott (1996) believes that education and training adequate about hand washing is important safe practice for professional healthcare workers. Therefore all visitors must follow the same procedures as hospital staff to adequately control to spread of infection especially before entered and after leaving an isolation room’s post TKR patient. In this situation, patient and family members also must learn how to do proper hand washing whether at home to promote safety life. “Many patients treated in hospital develop infections after discharge, for example 50-70% of surgical wounds infections become apparent after discharge but these are not monitored” NAO (2004).

Knowledgeable are important among healthcare professional of preventing infection. Gould’s (1995) mention that nurses’ theoretical and knowledge of universal precautions is useful to prevent infection and ability assimilate theoretical knowledge into practice. Knowledge followed by standard precaution can give a best treatment to the patients, therefore it can decrease infection problem. “The nurse with limited background knowledge will lack the tools needed from experience and the scope of practice will be limited by background the nurse to the clinical situation” (Banner 1984).

Guidelines and policies should clear to describe wound care dressing. Gould (2002) says that a general rules was recommended for healthcare workers to breaking the chain of infection. New protocol and guidelines may lead to clearer definitions of terms being developed. Educating healthcare works on protocol and guidelines may be equally and beneficial in encouraging to them. “Infection control nurses or their link nurses could undertake this teaching at ward level as this is viewed as best place to teach good clinical practice” (Gould 1996). However, this could be lacking and vague in evidence based guidelines and a clear documented standard principle are needed. Pratt et al (2000) mentions that The Epic Projects was designed to develop guidelines and standard principles for preventing Healthcare associated infection (HAIs). Therefore, failure technique of dressing among the healthcare workers especially staff nurse cause of failure of guidelines.

From the literature it is clear that poor wound dressing care by healthcare workers increase the risk of infection. “Most infections in hospitals and other settings where health and social care are delivered are transmitted to patients directly via the hand of health workers” (Gould et al 2008). Evidence indicates that many factors to contribute infection among healthcare staff. Confidential Enquire into Stillbirth and Deaths in Infancy CESDI (1999) study that around 5% of the death analyses cause of infection. Factors influence to infection such as lack of knowledge, lack of attitude, lack of facilities, lack of technique and lack of times. An intervention to promote wound dressing care plays an important role in the prevention of infection in hospitals.

CONCLUSION

As a conclusion, this assignment show that wound infections are preventable via integrated and collaborative effort among patient as a client, nurses as professional health care services. Therefore all medical staff must follow prevention of wound infection and improved their knowledge and training to know what it is, thus allowing workers to create a safe environment. However the setting of the work place needs to be conducive to allow workers to be empowered to do this.

In nursing practices reflection are important thing to nurses and management. Nurses must take accountability in practice setting and work efficiently through integrated self awareness, descriptive and critical reflection also evaluation reflection toward excellent patient’s care.

Modification of work practice such an appropriate handling of wound infection, the adoption of the concept of universal precaution and compliance with use of personal protective barriers should be emphasized. The primary goal of Infection Control is to educate all staff and family members to practice good infection prevention technique to protect patients from spreading infection. Guidelines and protocols should therefore be clear to encourage universal compliance to best practice. This topic becomes important in view of its ramifications to the accountability and accreditation of hospitals and staff. Therefore self awareness about the important of standard nursing skill is priority in whatever condition appears.

Using a few strategies discussed in this paper it helpful to reduced wound infection. Therefore patients are safe and receive quality care and can save cost of treatment because they do not stay in hospital for long period of time. Hospital and staff also get good image from public and this can improving productivity among medical workers.