Theory Guiding Practice Preventing Sternal Wound Infections

1. Theory Guiding PracticePreventing Sternal Wound Infections Marissa Balme RN, BSN

2. Background • Number of coronary artery bypass graft surgeries (CABG) performed in 2006: 448,000 (American Heart Association [AHA], 2010) • Percent of acquired nosocomial infections that were surgical site infections: 38%*Results from 1986-1996 study. (Mangram, Horan, Pearson, Silver, & Jarvis, 1999) • Consequences of a sternal wound infection (SWI): • Increased length of stay (LOS), cost, and morbidity • Hospital readmission • Lengthened antibiotic therapy • Additional surgeries (wound debridement, flap closure) • Death (Haycock et al., 2005; Hollenbeak et al., 2000)

3. Infection Prevention Methods • Prophylactic antibiotics • Preoperative skin preparation • Postoperative wound care • Hand hygiene • Strict glucose control (Haycock et al., 2005)

4. Risk Factors for Infection • Related to surgery: • Use if internal mammary artery • Reoperation • Increased stay in the intensive care unit • Prolonged mechanical ventilation • Preexisting Conditions/Factors: • Diabetes • Smoking/COPD • Obesity • Male gender • Advanced age • Steroid use (Hollenbeak et al., 2000; Kohli et al., 2005)

5. Statement of the Clinical Problem The presence of a sternal wound infection in the absence of proper infection prevention methods can have serious financial, physical, and emotional effects on the patient. (Popov et al., 2010)

6. Significance • Estimated cost of coronary artery disease in 2010: $177.1 billion (AHA, 2010) • Direct costs – hospital and nursing home services, cost of physicians and other professionals, home health services, medications, medical durables • Indirect costs – Loss of productivity due to morbidity and mortality • Average cost of CABG surgery in 2007: $112,377 (AHA, 2010) • Average SWI costs an additional: $41,559 (Herwaldt et al., 2006) • Percent of reimbursement for costs of infection that hospitals will receive: 1% to 5% (Chen, Chou, & Chou, 2005; Mangram et al., 1999) • Evidence of deep SWI: 0.5% to 5% (Haycock et al., 2005)

7. Study of Surgical Site Infections Following CABG Surgery (Hollenbeak et al., 2000) • Population: 1,519 procedures – CABG or CABG/valve • Patients that developed deep SWI: 41 • Of the infection group: • 42% were obese (vs. 9% of the non infected group) • 51.2% were diabetics (vs. 35%) • 22% had renal insufficiency (vs. 6.9%) • Average LOS: 27.5 days (vs. 7.4) • Average additional costs in the first postoperative year: $20,012 • Mortality: 22% (vs. 0.6%)

8. Specific Aims • Goal is to decrease SWI by: • Identifying and strengthening self-efficacy • Encourage compliance with self-care behaviors • Wound care, sternal wound precautions, hand hygiene, blood sugar monitoring and insulin administration (if indicated) • Enhance ability to cope with long-term changes as a result of surgery Establishing self-efficacy is essential because it motivates the patient towards the decision to perform the specified behavior (Lau-Walker, 2007).

9. Bandura’s Theory of Self-Efficacy • Triadic reciprocality: the interrelationships of person, behavior, and environment (Resnick, 2008) • Major concepts: • Self-efficacy expectations: personal belief in the ability to complete a given task (Resnick, 2008) • Outcome expectations: thoughts about what will result if the given task is successfully completed (Resnick, 2008) • Self-efficacy influenced by: • Enactive attainment: performing the behavior • Vicarious experience: watching similar people perform the behavior • Verbal persuasion • Physiological feedback: experiencing fatigue or pain (Resnick, 2008)

10. Application of the Theory • Helps modify and predict patient behaviors, while providing guidance in identifying patient-specific interventions (Jeng & Braun, 1994) • Establish patient’s level of self efficacy before initiating education • Generalized Self-Efficacy Scale (Developed by Sherer and Maddux) (Lau-Walker, 2007) • Educate on self-care behaviors by using: • Pamphlets, videos, in-patient informational sessions, enactive attainment (Fredericks & Sidani, 2008; Lau-Walker, 2007; Resnick, 2008) • Reinforce compliance after discharge based on patient’s needs through: • Out-patient cardiac rehabilitation programs, telephone monitoring (Gortner & Jenkins, 1990; Jeng & Braun, 1994)

11. Application of Self-Efficacy in the Literature • Lau-Walker (2007) evaluated self-efficacy and illness beliefs in cardiac patients 3 years after discharge, using 4 questionnaires. • Results: • Illness interpretation and a sense of control influences confidence in self-care behaviors. • Continuous, long-term support helps sustain exercise self-efficacy. • Gortner and Jenkins (1990) compared use of in-patient education in combination with telephone monitoring post-discharge to determine if cardiac efficacy and self-reported activity could be enhanced. • Results: • The experimental group experienced increased self-efficacy in walking and general activity. • Efficacy expectations and mood states (i.e. fatigue) were indicators of self-reported activity.

12. Summary and Conclusions • SWI have significant physical, psychological, and financial impact on patients and families. • Psychological needs (pre and postoperative) must be priority in recovery (Lau-Walker, 2007) • Leads to more positive outlook • Ensure enhanced quality of life • Establish self-efficacy = increases motivation (Lau-Walker, 2007) • Treatment plan for decreasing SWI: • Educate early in recovery process • Ensure understanding of self-care behaviors AND compliance • Arrange for out-patient plan (Cardiac rehab, home health care, telephone monitoring, family support)(Gortner & Jenkins, 1990) “People have to learn to monitor their health behavior and the circumstances under which it occurs, and how to use proximal goals to motivate themselves and guide their behavior” (Bandura, 2004, p. 151).

13. References • American Heart Association. (2010). Heart disease and stroke statistics: 2010 update. Dallas, Texas: American Heart Association. • Bandura, A. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31(2), 146-164. doi: 10.1177/1090198104263660 • Chen, Y., Chou, Y., & Chou, P. (2005). Impact of nosocomial infection on cost of illness and length of stay in the intensive care units. Infection Control and Hospital Epidemiology, 26(3), 281-287. doi: 10.1086/502540 • Fredericks, S. & Sidani, S. (2009). An exploration of the relationship between coronary artery bypass graft patient’s self-sought educational resources and outcomes. Journal of Cardiovascular Nursing, 23(5), 422-431. doi: 10.1097/01.JCN.0000317447.80026.4d • Gortner, S.R. & Jenkins, L.S. (1990). Self-efficacy and activity level following cardiac surgery. Journal of Advanced Nursing, 15(10), 1132-1138. Retrieved from CINAHL Plus with Full Text Database. • Haycock, C., Laser, C., Keuth, J., Montefour, K., Wilson, M., Austin, K., Coulen, C., & Boyle, D. (2005). Implementing evidence-based practice findings to decrease postoperative sternal wound infections following open heart surgery. Journal of Cardiovascular Nursing, 20(5), 299-305. Retrieved from www.cinahl.com/cgi-bin/refsvc?jid=455&accno=2009042919 • Herwaldt, L.A., Cullen, J.J., Scholz, D., French, P., Zimmerman, M.B., Pfaller, M.A., Wenzel, R.P., & Perl, T.M. (2006). A prospective study of outcomes, healthcare resource utilization, and costs associated with postoperative nosocomial infections. Infection Control and Hospital Epidemiology, 27(12), 1291-1298. doi: 10.1086/509827 • Hollenbeak, C.S., Murphy, D.M., Koenig, S., Woodward, R.S., Dunagan, W.C., & Fraser, V.J. (2000). The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest Journal, 118, 397-402. doi: 10.1378/chest.118.2.397 • Jeng, C. & Braun, L.T. (1994). Bandura’s self-efficacy theory: A guide for cardiac rehabilitation nursing practice. Journal of Holistic Nursing, 12(4), 425-436. doi: 10.1177/089801019401200411 • Kohli, M., Yuan, L., Escobar, M., David, T., Gillis, G., Garcia, M., & Conly, J. (2003). A risk index for surgical wound infection after cardiovascular surgery. Infection Control and Hospital Epidemiology, 24(1), 17-25. doi: 10.1086/502110 • Lau-Walker, M. (2007). The important of illness beliefs and self-efficacy for patients with coronary heart disease. Journal of Advanced Nursing, 60(2), 187-198. doi: 10.1111/j.1365-2648.2007.04398.x • Mangram, A.J., Horan, T.C., Pearson, M.L., Silver, L.C., & Jarvis, W.R. (1999). Guideline for prevention of surgical site infection, 1999. Infection Control and Hospital Epidemiology, 20(4), 247-278. doi: 10.1086/501620 • Popov, A.F., Schmitto, J.D. Tirilomis, T., Bireta, C., Coskun, K.O., Mokashi, S.A., Emmert, A., Friedrich, M., Wiese, C.H., & Schoendube, F.A. (2010). Daptomycin as a possible new treatment option for surgical management of methicillin-resistant staphylococcus aureussternal wound infection after cardiac surgery. Journal of Cardiothoracic Surgery, 5(57), 1-3. doi: 10.1186/1749-8090-5-57 • Resnick, B. (2008). Theory of self-efficacy. In M. Smith & P. Liehr (Eds.), Middle Range Theory for Nursing (2nd Ed.)(pp.183-204). New York: Springer Publishing Company.