Theory Guiding PracticePreventing Sternal Wound Infections

Marissa Balme RN, BSN

BackgroundNumber 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 morbidityHospital readmissionLengthened antibiotic therapyAdditional surgeries (wound debridement, flap closure)Death(Haycock et al., 2005; Hollenbeak et al., 2000)

Infection Prevention MethodsProphylactic antibioticsPreoperative skin

preparationPostoperative wound care Hand hygieneStrict glucose control (Haycock et al., 2005)

Risk Factors for InfectionRelated to surgery:

Use if internal mammary arteryReoperationIncreased stay in the intensive care unitProlonged mechanical ventilation

Preexisting Conditions/Factors:DiabetesSmoking/COPDObesityMale genderAdvanced ageSteroid use (Hollenbeak et al., 2000; Kohli et al., 2005)

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)

SignificanceEstimated 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)

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: $20,012Mortality: 22% (vs. 0.6%)

Specific AimsGoal is to decrease SWI by:

Identifying and strengthening self-efficacyEncourage 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).

Bandura’s Theory of Self-EfficacyTriadic 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 behaviorVicarious experience: watching similar people perform the

behaviorVerbal persuasionPhysiological feedback: experiencing fatigue or pain (Resnick, 2008)

Application of the TheoryHelps 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 educationGeneralized 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)

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.

Summary and ConclusionsSWI 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 outlookEnsure enhanced quality of life

Establish self-efficacy = increases motivation (Lau-Walker, 2007)Treatment plan for decreasing SWI:

Educate early in recovery processEnsure understanding of self-care behaviors AND complianceArrange 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).

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