Discussion
This study evaluated patients’ adherence to recommendation from a clinical guideline recommending preoperative oral hygiene before planned open-heart surgery. The recommendation was implemented to reduce the number of patients developing NI during the hospital stay and needing antibiotics postoperatively.
Evidence-based initiatives to reduce the use of antibiotics and prevent antibacterial resistance have been an issue for healthcare for many years. Governments around the world have been experimenting with different policy interventions, such as regulating where antibiotics can be sold, restricting the use of last-resort antimicrobials and launching public awareness programmes.6 Despite control efforts, the burden of healthcare-associated infections in Europe is high and leads to around 37 000 deaths each year.11 In a systematic review, 10 crucial elements for the organisation of effective infection prevention programmes in hospitals were identified: organisation of infection control at the hospital level; bed occupancy, staffing, workload and employment of pool or agency nurses; availability of and ease of access to materials and equipment and optimum ergonomics; appropriate use of guidelines; education and training; auditing, surveillance and feedback; multimodal and multidisciplinary prevention programmes that include behavioural change; engagement of champions; and positive organisational culture.11 These components comprise manageable and widely applicable ways to reduce healthcare-associated infections and improve patient safety.11 None of these elements focus on actively involving patients in the prevention of postoperative infections.
In this study the clinical guideline was considered to have been fully implemented as all patients referred for elective open-heart surgery were informed about the importance of systematic oral hygiene before admission to hospital. The challenge was to make patients adhere to the recommendation. Patients awaiting open-heart surgery have expressed the view that waiting for surgery is stressful.19 They are troubled by anxiety, uncertainty and symptoms of distress and they need support from caregivers to manage their self-care successfully.19 20 Open-heart surgery is an important intervention for patients as the procedure relieves angina and improves patients’ quality of life,21 but the adherence to advice can be variable, depending on patients’ awareness of the severity of their disease.22 Inability to adapt to the situation may result in increased anxiety.23 24 Uncertainty and anxiety are associated with deterioration of functional status and it is anticipated that each patient will have a unique presentation of symptoms of distress and a correspondingly unique psychological response.25 Anxiety level is influenced by family members as well as stories heard from friends or acquaintances who had also experienced CABG.26
The patient’s physical and psychological status was considered when planning the information strategy in this implementation study. We focused on translating evidence into relevant and instructive information based on the material that could be understood by patients and their relatives and was available to patients when they needed it. Written information in the form of a leaflet improves patients’ knowledge and reduces confusion especially if provided before admission.25 Procedures demonstrated in videos are found to be more effective in increasing patients’ knowledge that just verbal description of the procedure and demonstrating the procedure increases the reported outcome.25 Furthermore, patients had the possibility to receive a text message when they were supposed to start on the oral procedure and every time they had to carry out oral hygiene. Text messaging is effective and improves outcomes when it is tailored to the target group.26 Findings reveal that significant proportions of older adults already use mobile technology, are willing to engage in the existing mobile interventions for health reasons and have positive attitudes towards mobile technology.27
In a trial the patients were supposed to start oral hygiene 2 days before planned surgery.12 They performed oral hygiene for 1.9 (1.2) days indicating a degree of adherence of less than 50% of the intended time.12 In our study, 86.9% of the patients reported that they had completely adhered to the oral hygiene recommendation. This indicates that it is feasible and not a mental strain for patients to perform oral hygiene as recommended and that the information strategy was effective. This is in line with findings reported in a meta-analysis.28 Several simple interventions appeared to improve adherence to short-term regimes.28 It was not possible in our study to identify subgroups of patients who did not adhere to the oral care recommendation and identify whether we could improve our way of informing patients.
In a meta-analyses of the effect of oral hygiene in critically ill surgical patients, nosocomial pneumonia was reduced by 34% (OR 0.66, 95% CI 0.51 to 0.85)29 and in patients before open-heart surgery it was estimated that oral hygiene would reduce the number of NI by 35% (RR 0.65, 95% CI 0.55 to 78), lower respiratory tract infections by 52% (RR 0.48, 95% CI 0.36 to 0.92) and deep surgical site infections by 60% (RR 0.40, 95% CI 0.27 to 0.84).14 In this study, the number of patients needing antibiotics on the fifth postoperative day was reduced by 34% in the intervention group, and by 50% in the group of patients who reported they had adhered to the recommendation. A reduction was registered in all types of infections, even though the changes, due to the low number of infection in total, were too low to be significant, as power calculation had been based on a higher incidence of NI.
Strengths and limitations
The strength of this implementation study is that the procedure that was implemented was based on evidence presented in a clinical guideline. The number of patients was calculated based on previous research. Patients in the control group were included based on the list drawn from the hospital; as these lists document the department’s activities it is unlikely that patients were missed. Patients in the intervention group were allocated to the study when they were referred for surgery and all names were later checked with the hospital’s electronic record in order to check if any patients had been overlooked.
Data on the prescription of antibiotics were drawn from the individual patient medical record. As all antibiotics had to be prescribed and the reason for the prescription has to be documented in the medical record before antibiotics are administered and signed for by the nurses, it is very unlikely that patients in need of antibiotics have been overlooked. The reason for prescribing antibiotics was based on the physicians’ clinical judgement. The decision could be based on X-ray, blood test and clinical symptoms, we have not compared the prescription with recommended criteria for the respective infections. The purpose of this implementation study was not to test physicians’ accuracy in identifying infection but to test whether fewer patients were prescribed antibiotics when they had adhered to the oral hygiene recommendation. Some infections might have been misclassified by the physicians, but this misclassification must be the same in both the control group and intervention group. Furthermore, it has been reported that physicians could judge the occurrence of pneumonia more accurately in comparison to making the diagnosis based on established criteria after open-heart surgery.30
Information on patients’ adherence to the recommendation was collected from the patients at admission. Patients were asked to fill out a questionnaire. If this was missed patients were contacted by phone shortly after discharge. If patients could not be reached they were classified as not having performed the procedure. The results show a reduction in frequency of prescribing antibiotics for the intervention group which included patients who adhered and did not adhere to the recommendation, and a further reduction in the group that reported to adhere to the recommendation. As intention-to-treat analysis has been applied to the data both patients adhering and not adhering are included in this analysis and the further reduction of infections in patients who reported that they adhered must be considered as valid. Patient adherence was monitored throughout the study. Adherence was above 85% and quite stable for 2 years which indicates the recommendation has been implemented in clinical practice.
No other intervention to reduce the prescription of antibiotics was introduced during the study period. The changes in the need for antibiotics on the fifth postoperative day were reduced immediately after introducing the oral hygiene recommendation and remained constant during the study period. If changes in the prescription of antibiotics were due to other intervention one might have expected a gradual reduction in the prescription pattern.
Implications for practice
In Denmark approximately 3000 patients are undergoing elective open-heart surgery each year. Based on the estimates from meta-analysis14 and the degree of adherence reported in this study a reduction in postoperative use of antibiotic from 12.5% to 7.7% might be expected. This could contribute to reducing the number of patients needing antibiotics on the fifth postoperative day from 375 to 231 patients.