FOCUS
Implementing enhanced patient
education for surgical site infection
prevention in cardiac surgery
Melissa Rochon, Rosalie Magboo, Carol Barlow, Sammra Ibrahim, Lena Carruthers,
Jane Pagett, Carlos Morais and Elizabeth Silva
ABSTRACT
Objectives: Photo at Discharge (PaD) is a nurse-led discharge strategy for
enhanced wound care information for patients and healthcare providers. The
purpose of this study is to describe implementation of PaD in three English
cardiac centres. Methods: A prospective, cross-sectional design was used
to evaluate implementation fidelity and sustainability of PaD on various
geographical settings. Results: Three out of four hospitals (75%) approached
agreed to complete surveys on implementation fidelity. Implementing the IT
component took an average of 16 months (range 11–21 months). Across
the three sites, 474 nursing staff have received training on PaD. Since
implementing, a combined total of 9007 patients have received PaD. A
1-month compliance snapshot indicated mean of 96% (range 92–100%).
Conclusions: PaD requires collaborative working, a change in behaviour and
a change to the service. Despite these challenges, fidelity and sustainability
scores across the sites were high. The findings from this study may help to
increase implementation quality and dissemination of PaD.
Key words: Infection prevention  ■ Surgical wound  ■ Cardiothoracic
nursing  ■ Service development ■ Patient-centred care
Melissa Rochon, Quality & Safety Lead for Surveillance, Harefield
Hospital, Royal Brompton and Harefield NHS Foundation Trust,
London, m.rochon@rbht.nhs.uk
Rosalie Magboo, Senior Sister Adult Critical Care Unit, Barts
Health NHS Trust, London
Carol Barlow, Matron Cardiothoracic Surgery, Sheffield Teaching
Hospitals NHS Foundation Trust
Sammra Ibrahim, Lead Surgical Care Practitioner, Barts Health
NHS Trust, London
Lena Carruthers, Staff nurse, Sheffield Teaching Hospitals NHS
Foundation Trust
Jane Pagett, Ward Manager, Sheffield Teaching Hospitals NHS
Foundation Trust
Carlos Morais, Clinical Nurse Specialist in Surveillance, Harefield
Hospital, Royal Brompton and Harefield NHS Foundation Trust,
London
Elizabeth Silva, SSI Audit Clerk, Barts Health NHS Trust, London
Accepted for publication: July 2020
994
W
orldwide, it is estimated that for every
16 surgical patients one will experience a
surgical site infection (SSI), a healthcare-
associated infection that carries an
increased risk of morbidity, mortality
and contributes to antimicrobial resistance (World Health
Organization, 2016). In the UK, the likely cost of managing
SSI exceeds £1 billion per annum (updated to 2020 costs)
(Frampton, 2010) and institutions are not paid for readmissions
of SSI above an agreed threshold of 30 days (NHS Improvement,
2019). Patients with SSI are six times more likely to be readmitted
to hospital impacting on all aspects of safety, quality, cost and
productivity in health care (Sanger et al, 2014; Shah et al, 2017;
Getting It Right First Time, 2019). That the majority of SSI
present after discharge (Woelber et al, 2016; Public Health
England, 2019), but patients and carers perceive information
for surgical wound care and SSI as of low value (Sanger et
al, 2014; Zellmer et al, 2015; Tartari et al, 2017) warrants
particular attention. Indeed, across surgical specialities including
cardiothoracic surgery there is a clear programme directed by the
National Wound Care Strategy Programme’s surgical stream to
improve the information provided at discharge to patients and
carers, as well as for referral pathways if wound concerns arise.
To address these challenges, the Photo at Discharge (PaD)
strategy was developed within the healthcare setting (Rochon
et al, 2016). On the day the patient leaves hospital, the nurse
takes a colour picture of the patient’s surgical wound, completes
an electronic assessment, and provides tailored advice on SSI
prevention and wound protection. The patient takes away the
PaD form with all this information as a bespoke discharge
resource. As a patient-centred strategy, PaD appears to meet
patient needs and preferences for information regarding surgical
wound care (Rochon and Morais, 2019) and may reduce the risk
of readmission for SSI (Rochon et al, 2018). Increasingly, cardiac
centres are adopting PaD as part of their standard discharge
process (Cardiothoracic Interdisciplinary Research Network
(CIRN) et al, in press).
© 2020 MA Healthcare Ltd
PaD is not a simple intervention and similar to any
intervention aiming to reduce 30-day readmissions, there are
many challenges to successful implementation (Hansen et al.
2011). PaD involves changes to the processes and practices
within the healthcare system (Thompson and Dobbs, 2018),
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Table 1. Logic model for Photo at Discharge (PaD)
Core inputs Immediate impacts Short-term impacts
Nurse takes picture Enhanced discharge Healthcare providers have increased
and completes information information regarding surgical wound
e-assessment of and care
surgical wound
Patient/carer receives Increased confidence Surgical patients will have more
PaD for self-care knowledge of who to contact with
concerns
PaD accessible by Improved continuity of Increased engagement in SSI
multidisciplinary team care prevention
Table 2. Evaluation plan
Area to measure
Content Was each of the PaD components implemented as
planned?
Duration/dose Was each of PaD components implemented as often
and as long as planned?
Coverage What % of eligible patients received PaD?
as well as patient behaviour because of its explicit purpose
of engaging patient responsibility in the transition of care
(Coleman et al, 2004). A similar quality improvement (QI)
approach of using nursing staff to take a baseline image was
used in the USA to assist with SSI surveillance (Cannon et
al,2016). However, the remainder of the interventions seem to
focus on the use of (primarily patient-generated) photos after
the patient leaves hospital (Evans et al, 2019).
PaD has been identified as a positive area of practice during
the Royal College of Nursing (RCN) consultation on the
digital future of nursing (RCN, 2018). However, without a
top-down systematic planned approach, the spread of PaD has
been an unpredictable process, with the innovation spreading
in a non-centralised and informal framework (Greenhalgh et
al, 2004; Greszczuk et al, 2018).Thus little is understood about
the implementation at different sites. Here we refer to fidelity
as how closely the programme is implemented as intended
by the developer, based on Carroll et al’s (2007) conceptual
framework. Systematic evaluation of fidelity is the best way to
approximate implementation quality (Breitenstein et al, 2010).
Conversely, low fidelity during the spread of interventions can
reduce the intended benefits to care quality (Breitenstein et al,
2010). Fidelity may be determined by adherence (ie whether the
protocol has been fully implemented) and can be evaluated by
measuring content, coverage, frequency and duration (Carroll
et al, 2007; Breitenstein et al, 2010). This work will use these
elements, but departs from Carroll et al’s proposed moderators
of fidelity and instead refers to domains of sustainability within
the Long-Term Success Tool (LTST). LTST was developed
996
Impacts Health outcomes
Improved discharge Increased self-care of surgical
possibilities for better wounds and monitoring, increased
wound monitoring, satisfaction
earlier detection of
wound concerns
Reduced number of readmissions for
SSI, better communication between
health settings, reduced risk of
overtreatment
Standard to measure against
Colour image + e-assessment, provided to patient and
available to multidisciplinary team
Day of discharge
Discharged or transferred to other care facility after
cardiac surgery
by Lennox et al (2017) to examine 13 factors or domains
in order to identify potential barriers or opportunities to
sustain improvement. The inclusion of LTST was deemed to
be important as the majority of quality improvement projects
fail to be sustained (Szabla, 2007). Thus, in addition to fidelity,
we sought to study the methods that centres used to increase
uptake into routine practice (Curran et al, 2012).
In this study, the researchers sought to consult with other
centres using PaD in order to conduct an evaluation of outcomes
(fidelity and sustainability) to determine implementation of PaD
within different settings.This service evaluation was registered
(CIRIS ID0033795).
Methods
Study setting and sample
Four cardiothoracic centres in the UK that provide PaD were
contacted via email. Three centres (one teaching hospital and
two specialist tertiary referral hospitals) agreed to take part.
The fourth centre declined on the basis of workload/pressures.
Survey design
The service evaluation comprised two structured surveys for
self-completion designed by the team who created PaD (ie ‘the
developer’). Survey 1 was an Excel-based survey on site-specific
© 2020 MA Healthcare Ltd
information, based on a logic model (Table 1) and evaluation
plan (Table 2). Survey 2 consisted of the LTST. The LTST
was added to a dedicated secure online survey tool to collect
anonymous stakeholder feedback. Both surveys were reviewed
by team members before the surveys were piloted on the first
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Table 3: Survey 1 and results

Centre 1 Centre 2 Centre 3

IT system

IT system used PATS/Dendrite Lorenzo PATS/Dendrite (Iweb)

Date proposal/request for PaD went to IT August 2014 February 2018 August 2016

Date database available July 2015 November 2019 January 2018

Approximate time from IT proposal to implementation (months) 11 21 17

Implementation Totals (n)

Number of ward(s) providing PaD 4 1 6

Number of beds 76 28 96

Number of nursing colleagues who can deliver PaD (system users) 265 15 194

Since implementing. how many PaD records in total (n) are there? 5121 98 3788

In January 2020, how many patients were eligible for PaD (ie discharged in 77 65 144
January alive)?

In January 2020, how many patients received PaD? 77 65 133

Monthly compliance (%) snapshot, January 2020 100% 100% 92.4%

Resources Totals (n)

Please complete this data for ONE ward only for equipment used for PaD

Camera 1x Sony 20.1 1x Sony Cybershot 0

megapixels (new) (new)

Tablet 1 1 1

Other (eg dedicated ward mobile phone) 0 1 0

Colour printer* 1 1 1

Practice

Is PaD taken routinely on the day of discharge (not other day eg D5)? Y Y Y

Do you provide a colour copy to the patient/carer? Y Y Y

Are you able to email the copy to the patient? planned possible but not N
routine

Is PaD on a patient portal to allow the patient to view the form remotely? planned N N

Do you routinely provide a copy of PaD to the GP/other healthcare provider? Y GP has access to N
system

Is the PaD form saved on EPR (electronic patient record, so that all staff can view)? Y Y Y

Does PaD include assessment/advice? Y Y Y

Is the PaD just a standalone image (no printed assessment or advice on the same N N N
form as image)?
* Centres indicated they needed to reverse strategic decisions to remove or limit access to staff colour printing in order to undertake PaD

site. Following minor grammatical changes to the pilot study, centre. Leads were asked to share Survey 2 (link to electronic
the surveys were finalised. online survey: https://123formbuilder.com/form-5289305/
PaD-2020) with key stakeholders for anonymous completion.
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Survey distribution and data collection

Data were collected in the period 1-29 February 2020. Surveys Data storage and governance
were distributed electronically (via email) to named lead recipients Data were collected and stored on a secure cloud-based server
at the hospitals identified through collaboration with Cardiac during the survey period. No patient identifiable information
SSI Network members. Survey 1 was completed once for each was collected.This study is not considered research as defined by

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Very good Good Fair Poor Very poor No opinion/Don’t know

Commitment to the improvement

Alignment with external political and 70 Involvement—Own
financial environment
60

50
Support for improvement Involvement—Stakeholders inc patients
40 47
32
32
30
42
47
20
Alignment with organisational
10 Skills and capabilities of those involved
culture and priorities 35 37
47

32
11
37 16

Robust and adaptable processes Leadership

47
42
63

Evidence of benefits Team functioning

Progress monitored for feedback

Resources in place
and learning

Figure 2. Results of Survey 2

the UK Policy Framework for Health and Social Care Research
as outlined by the NHS Research Authority and so ethical
approval was not required.
Analysis of data
Findings from the surveys are displayed using descriptive analysis.
Nonparametric data are presented with median and range.
Frequency distribution of aggregate scores are provided for
ordinal data subgroups (Likert scale) for Survey 2 in graphical
form (Sullivan and Artino, 2013). A gradient six-point scale
was used to reflect the ordered opinions (very good, good, fair,
poor, very poor) and middle values (‘no opinion’ and ‘don’t
know’) were included (Bowling, 2014). Cronbach’s alpha
was used to test the intercorrelation of grouped items and
measure the underlying variable, sustainability (Sullivan and
Artino, 2013). Intraclass Correlation Coefficient (ICC) was
used to measure an average reliability, modelled with the same
accessors (respondents) rating the same domains, wherein the
systematic differences between the raters were not relevant (ie
validity rather than absolute agreement model) and no opinion
Outcomes
Three centres agreed to take part (75% response rate) on this
study. Participants completed Survey 1 in full, with no missing
data (Table 3). Overall, the centres reported a combined total
of 9007 patients received PaD since implementation began.
The number of wards involved with PaD varied across the
sites (ranging from one to six wards), with an overall bed-
to-staff ratio of 100:237. Centres reported high concordance
with fidelity measures.This included content (100% reported
combining the colour image with bespoke wound assessment
and advice), coverage (all centres reported high compliance
rates, ranging between 92% and 100%), duration and dose
(once, ie baseline picture, not a series of pictures, provided
at discharge/transfer by the discharging healthcare provider).
The centres were all currently undertaking PaD (none had
discontinued the scheme) and sustained over the long term
(>4 years), mid term (>2 years) and shorter term (<6 months).
From time of proposal, the IT system took an average of 16
months to implement (range 11-21 months) with centres
modifying existing in-house databases and colour printers.
© 2020 MA Healthcare Ltd

/don’t know were excluded from this agreement /responsiveness
testing. For consistency and reliability testing, a value of 0.7
or above was set for significance. Data were analysed using
MedCalc Statistical Software version 19.2 (MedCalc Software
Ltd, Ostend, Belgium).
All three indicated a camera or tablet was purchased to assist
with image capture.
Survey 2 was completed by 19 anonymous respondents
from the three centres (ten from Centre 1, four from Centre 2
and five from Centre 3). Overall, responses were consistent in

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LTST (Cronbach’s alpha with standardised variables was 0.92
(95% lower confidence limit 0.8511)); although reliability as
determined by average measures in ICC only just reached
significance (0.6971; 95% confidence interval 0.3926 to 0.8902).
Favourable responses in the domains, such as ‘very good’ or
‘good’, were observed most frequently (n=114 (46.0%) and
n=88 (35.5%), respectively). ‘Fair’ (n=4 (11.7%)), ‘poor’ (n=2
(2.0%)) or ‘very poor’ (n=1 (0.4%)) less commonly, with 4.4%
of responses as ‘no opinion’/’don’t know’. Figure 1 provides
an overview of the 13 domains believed to influence the
sustainability of quality improvement projects. The more
outward the solid colour line, the higher the proportion (%)
of respondents. Conversely, lines closer to the centre of the
radar graph received a lower proportion (%) of responses. Using
this model, respondents selected very good most frequently for
‘commitment to the improvement’ and ‘evidence of benefits’
(63% and 63%, respectively). Only one respondent selected
very poor for any of the domains, in this case ‘alignment with
external political and financial environment’.
Discussion
Approximately 1 in 75 coronary artery bypass graft (CABG)
patients are readmitted with SSI (Lamagni et al, 2020). In many
cases, early detection and sufficient therapy will reduce the burden
of direct and indirect costs associated with SSI (World Health
Organization, 2016) and it is notable that acute care and GPs
find PaD helpful in wound review and management (Rochon et
al, 2018). Furthermore, as patients are becoming more involved
and better informed in their health and care (Tartari et al,
2017), the value of interventions to reduce readmissions within
30 days and patients’ capacity for self-care in their transition
from hospital to home should not be underestimated (Leppin et
al, 2014). However, as Balasubramanian et al (2015) suggested,
‘demonstration’ projects such as PaD may have their impact
evaluated (listed in Table 1 under health outcomes), but the
iterative process of system change, including an evaluation of
core outputs, is often not measured. As a result, when quality
improvements fail to achieve their projected outcomes, the
mechanism(s) for the failure may not be well understood
(Balasubramanian et al, 2015).
In this study, the authors consulted with three centres in
different organisations to evaluate implementation fidelity
and possible factors influencing sustainability for PaD. This
has been guided by the work of Hasson (2010) and the fidelity
adherence theoretical framework proposed by Carroll et al
(2007) and included factors for sustainability proposed by
Lennox et al (2017). The purpose is to contribute to a greater
understanding of fidelity and its processes, which may inform
a broader knowledge base to create sustainable interventions
(Breitenstein et al, 2010). The results of this study may be
of particular interest to centres planning to implement PaD
(McCabe et al, 2018; Tyrer, 2019).
Fidelity is understood to moderate the relationship between
the intervention and its outcome (Carroll et al, 2007). For PaD,
the ‘essential elements’ or content (Carroll et al, 2007) refer
to enhanced surgical wound advice; frequency, duration and
dose provided objective measures for effectiveness, with high
1000
levels of concordance (integrity) reported with the intended
intervention. The majority of surgical wounds heal well, and
the intention is to balance the practical application of the
digital image without increasing patient workload unnecessarily
(Zellmer et al, 2015) or that of the healthcare service (Sanger
et al, 2016). PaD does not prevent infection (nor does any
digital image), but can improve patient confidence in caring
for the wound, provides important reassurance and acts as a
tool to monitor the wound for changes (Rochon and Morais
2019). Poor or incomplete implementation can impact on an
intervention’s efficacy (‘type III error’ where a potentially useful
intervention appears ineffective due to failed or diminished
fidelity) (Dobson and Cook, 1980) thus findings from these
surveys are reassuring in terms of successful spread of PaD.
Interestingly, there is a very high compliance within
the centres involved despite slow progress of technological
advancement within the NHS (Royal College of Nursing,
2018). Information technology in healthcare may be limited by
internal barriers that may prevent uptake, including unsupportive
organisation structure, irreconcilable differences of stakeholders
and poor understanding of the process (Walley and Davies,
2002). In contrast, the experience of centres implementing
PaD demonstrated strong nurse leadership, commitment to
the improvement, involvement of stakeholders and evidence
of benefits. Further, common adherence barriers to guidelines
implementation such as education and training (Fischer et al,
2016) have been addressed by the majority of stakeholders (84%)
felt skills and capabilities were ‘very good’ or ‘good’ for the use
of images and digital assessment in wound care.
To the authors’ knowledge, this is the largest collaborative
implementation evaluation of PaD, and undertaken in three
separate, ‘real world’ settings in order to better understand the
care and quality benefits of the scheme.A strength of this study
is that in conjunction with implementation fidelity evaluation,
the authors have opted to use the LTST to examine 13 factors.
The LTST, which can be used in combination with other
tools and theories (Lennox et al, 2017), was developed for ‘real
world settings’.The findings of LTST may prompt local action
planning and may be combined with advice for developing
policies and standard operating procedures for the use of digital
images in wound care (Rochon et al, 2017). From a practical
perspective, centres looking to implement PaD may wish to
review findings particularly in relation to the resources in place
(involving IT early in the implementation process and increasing
cameras or consoles to more than one in each ward), skills and
capabilities of those involved (new online learning course,‘The
use of digital images in wound care’ endorsed by the RCN
is now available), and alignment with external and financial
environment (Rochon and Morais, 2019).
This study has a number of limitations. First, the cross-sectional
design means that results are reflective of a certain point in time.
The authors attempted to control for this by using tools within
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the surveys that could be repeated/comparable (Adamson, 2005).
Drawbacks of using a Likert-type scales include its ordinal nature,
and that different combinations of the multiple items can result in
the same aggregated scale or score (Adamson, 2005).Therefore,
although factor analysis was to check internal consistency, it
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remains the case that some information may have been lost from
components of the score (Bowling, 2014). Another important
limitation of this work is the small sample size and incomplete
coverage of centres performing PaD, and this potential source
of bias may threaten the generalisability of the data (Bowling,
2014; Moore et al, 2015). A UK 2019 variation in practice audit
conducted in cardiothoracic centres found approximately one-
third (n=7) of the 19 anonymised centres that participated in
the survey indicated they were undertaking PaD (CIRN et al,
2020). In this study, the authors have attempted to use validated
implementation tools to improve the validity and reliability of
findings; however, the tools have not collected qualitative data,
which could provide deeper insight into the variables of interest,
nor did the study use direct observation of those delivering the
intervention to evaluate fidelity to improve the validity of self-
reported fidelity (Carroll et al, 2007; Bowling 2014). Finally, this
study examines the experience of PaD in cardiothoracic centres,
which may not be readily transferrable to other specialist or
acute services.
Conclusion
Traditional models of surgical wound care and assessment are
not always aligned with the needs of patients or onward care
providers. Within the cardiac specialism, PaD is an emerging
strategy to share a baseline visual record and enhance discharge
information. In the absence of external support for change
on a large scale, PaD implementation has been nurse-led and
accompanied by ‘on-the-ground’ learning. For this reason, the
work here has focused on implementation, using a systematic
approach to determine whether there are differing levels of
fidelity, compliance and/or sustainability factors between three
hospital sites.Although arising from a relatively small number of
centres, this design enables comparison of core inputs (identified
within the PaD logic model) reliably and consistently to produce
actionable information, which in turn can be used to enhance,
scale and accelerate PaD in other contexts. BJN
Declaration of interest: none
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KEY POINTS
■ Photo at Discharge (PaD) is a nurse-led initiative to enhance patient-
centred wound care advice, including a healthcare-provided colour image,
assessment and care plan for the patient/carers
■ Previous studies of PaD focused on patient public feedback as part of a
surgical site infection prevention strategy however did not examine the
implementation of PaD technology in the healthcare setting
■ PaD was spread through informal networks, thus little was known about
the fidelity (whether the intervention was delivered as intended) or
sustainability of the scheme
■ This study sought to investigate implementation outcome measures in
three different English hospitals using valid and reliable tools
■ Findings from this work suggest that across the different settings, fidelity
was high. Centres differed in periods of implementation (short, mid and
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CPD reflective questions
■ Many evidence-based interventions are not implemented successfully. Why might this be?
■ Before implementing an intervention, what factors or domains might you consider with key stakeholders?
■ Could PaD be adopted in your area? What are some of the barriers and facilitators?
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