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What is a sternal wound infection (SWI)?
According to Wendler and Baghai (2014), a sternal wound infection (SWI) is a type of surgical site infection (SSI); which proves to be one of the most challenging complications of surgery. Kotnis-Gaska et al. (2018) further explain that sternal wound infections are specifically related to cardiac surgical procedures, such as open-heart surgery, that use a sternotomy method. This healthcare problem is alarming considering the prevalence of cardiovascular disease in our society and the high demand for successful surgical treatment.

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Nurses play a vital role in reducing the occurrence and severity of sternal wound infections. They work towards this goal by being knowledgeable of the risk factors, implementing infection prevention protocol, and by providing thorough discharge teaching to post-op patients. This will ultimately allow patients to recognize indicators of infection so that they can be reported early. The nurse should not only educate patients of these risk factors, but to also include families and other interdisciplinary team members to aid in the prevention of sternal wound infections (Bell, Hinderer, Winter, & Alessandrini, 2017).

Examples of actions put into place in the hospital environment to prevent SWI's include:

Cleansing once daily with a Chloraprep swab

"Research has shown that the combination of 2% chlorhexidine gluconate and 70% isopropyl alcohol is superior to iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74% w/w) in terms of reducing bacteria from the skin, with decreasing positive culture rates from 65% to 30%" (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 63).

Sternal Precautions

As stated previously, sternal precautions are put into place as protective measures to reduce the incidence of dehiscence, which consequently causes infection. When done correctly, sternal precautions prevent the excessive pulling on the sternal incision (Sears, 2019).

Protective Precautions

Protective precautions are a type of isolation precaution that is set into place to protect immunocompromised patients who are susceptible to infection. Proper hand hygiene amongst staff and visitors is a vital element of this protocol. There should also be no ill visitors, as well as, dedicated patient specific equipment to help reduce the spread of bacteria (Annual Orientation to Sentara, 2014).

Is this improving or worsening the issue?
Nurses who adamantly follow these steps after a patient undergoes surgery help promote a path for better patient outcomes.

The nurses that neglect one or all of these duties impact the successfulness of the patient's healing process. Without providing proper care or education to individuals in need, the nurse's disregard ultimately affects the quality of care given.

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ANALYSIS: Importance of Nurse's Involvement in Care

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ANALYSIS: Importance of Nurse's Involvement in Care

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With sternal wound infections, and other illnesses, the main goal for each patient is health promotion. Nurses play a vital role in the promotion of quality care as they provide continuous and thorough one-on-one patient care. "Nurses assess individual health needs and provide patients with information needed to promote health and self-care" ("What is the Nurses Role," 2017, para. 4). For sternal wound infections, nurses assess, manage, and cleanse the wound to ensure a desired healing process. They are also tasked with various responsibilities that are related to advocating, enabling and mediating activities to reduce poor health outcomes ("What is the Nurses Role," 2017). Additionally, nurses communicate vital health information and updates not only with patients and their families, but other interdisciplinary team members as well. Ultimately, the use of critical thinking skills and knowledge of evidenced-based concepts guides them into making the best informed decisions on a daily basis for their patients.

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According to Morgante and Romeo (2017), the real incidence of a sternal wound infection occurring following a cardiac surgery is estimated to be between 0.25% and 10%.
Direct Adverse Outcomes Related to SWI

Increased hospital stay and cost

“The cost of OHS without complications averages around $78,318, although, in some cases, it exceeds $160,000. With SWI, cost increases by 2.8 times” (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61). Cotogni, Barbero, and Rinaldi (2015) explain that costs escalate due to the additional antibiotic treatments and correctional surgical procedures, as well as increased hospital stay time.

Increased morbidity and mortality

The mortality rate of individuals with sternal wound infections may be twice as high as those without. The development of a postoperative sternal infection is not only associated with increased morbidity, but death as well (Meszaros et al., 2016). "Mortality associated with superficial

SWIs ranges from 0.5% to

9%. Mortality associated with

DSWI ranges from 10% to 47%" (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61).

Other adverse effects

"One study of patients with postoperative SWIs after OHS found that 37% had problems carrying a grocery bag and 67% had problems putting on a coat 6 years or more after their surgery" (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61) .

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Two Curricular Concepts:
1. Infection prevention protocol
One notable lesson identified in the span of my student nurse career is the importance of infection prevention protocol. Infections are one of the most common complications of healthcare and are a considerable patient safety issue. Implementation of infection prevention procedures in everyday care is a foundational tool of nursing practice. "Isolation precautions are recommended to prevent the spread of pathogens associated with high morbidity and mortality, such as multidrug-resistant organisms" (Cohen et al., 2015, p. 2). Clients who have recently undergone surgery are susceptible to infections due to their compromised skin barrier. Putting these provisions in place aid in sustaining a safe healing environment for patients.

2. Patient advocacy
Another valuable concept learned throughout nursing school is that a nurse should always be an advocate for each patient in need. Nurses are advocates by being communicators, liaisons, educators, interpreters, and caregivers ("Critical Care," 2016). Patients who seek care are in a vulnerable state and trust the nurses and other healthcare providers to manage, protect, and nurture any ailments or conditions that they may have. The nurse needs to advocate and ensure that each patient is receiving proper care. For SWI's, the nurse should maintain a routine of adequately assessing, cleansing, documenting, and communicating pertinent information of the incision site.

Leadership Role
These curricular concepts learned during my time at Sentara College of Health Sciences have encouraged me to take on a leadership role once I progress into professional practice. This will be accomplished by following specific hospital guidelines and protocols as well as continuously advocating for each patient's safety. These significant factors have aided in my leader development by showing me that patient well-being should always be top priority. Being a leader means listening, inspiring and encouraging, being attentive, and maintaining a productive culture (Seitovirta, 2017). Actions that may be necessary to stay true to these ideas would be: speaking up when patient care is not ideal, and advocating for proper patient care among all staff members. With these elements in mind, I will strive to provide exemplary care throughout my future nursing journey.

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What is the problem?

The issue at hand is the infection of the sternal incision site after a cardiovascular surgery has been performed. There are two different types of sternal wound infections: a superficial sternal wound infection (SSWI) and a deep sternal wound infection (DSWI) (Lazar, Salm, Engelman, Orgill, & Gordon, 2016). “The Centers for Disease Control and Prevention (CDC) has specific criteria that must be met to use these specific classifications, including wound depth and signs of infection” (Bell, Hinderer, Winter, & Alessandrini, 2017, p. 61).

Who is affected?
SWI’s can occur in any individual that undergoes a corrective surgical procedure that aids in stabilizing, or bettering their cardiovascular system. There are also those that are at higher risk of developing this type of infection. Some of the higher risk individuals include those who have: chronic infections, older age, diabetes, a body mass index (BMI) >40, chronic lung disease, and use tobacco (Bell, Hinderer, Winter, & Alessandrini, 2017). Berríos-Torres (2017) explains the CDC guidelines and states, “Surgical patients initially seen with more complex comorbidities and the emergence of antimicrobial-resistant pathogens increase the cost and challenge of treating SSI’s” (para. 1).

How?
A patient can develop a SWI from a variety of different contributing factors. One component is by not following strict hygienic precautions, such as hand hygiene, amongst the staff and the patient themselves. Poor hand hygiene is a risk factor that is present in the preoperative, intraoperative, and postoperative phases of surgery (Bell, Hinderer, Winter, & Alessandrini, 2017). This action alone increases the likelihood of microorganisms being introduced to the surgical site of the sternum. Another contributing element would be the non-application of sternal precautions. Sears (2019) states, “Sternal precautions are used after open heart surgery to avoid pulling apart the breast bone as it is healing. They are meant to protect the patient and prevent possible infection of the healing sternal incision” (para. 1). Other ways the incision site may become infected is through tobacco use and poor glycemic control in diabetic patients; as both behaviors cause delayed surgical wound healing (Bell, Hinderer, Winter, & Alessandrini, 2017).

Where?
A sternal wound infection can develop in both hospital, and home setting. This infectious complication tends to emerge and show signs and symptoms within 30-days of cardiac surgery (Yusuf, Chan, Renz, & Trampuz, 2018). Within these 30-days, the patient is usually discharged early, unless experiencing other postop complications in which continuous hospital monitoring is necessary. Once the patient suspects infection at home, readmission to the hospital is vital.

When?
A sternal wound infection can develop any time during the recovery period after surgery. The healing process of the sternal incision site takes around 4-8 weeks following open heart surgery, or other surgeries involving a sternotomy (Sears, 2019). Typically, either type of sternal wound infection can occur within a 30-day time frame postoperatively (Rickard et al., 2015).

Why?
As stated previously, sternal wound infections can arise in patients following surgery due to varying contributing factors. The most common risk factors include: poor glycemic control in diabetic patients, insufficient hygienic care, and by not following strict sternal precautions after surgery (Bell, Hinderer, Winter, & Alessandrini, 2017).

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1. Staff Education
The first recommendation to improve outcomes of the healthcare issue at hand is to have consistent staff education. Staff should be educated on ways to provide adequate, evidence-based care to patients who have undergone a recent surgery. Some of the main educational topics would be recognizing signs of infection at the incision site, and proper sternal precaution techniques. If the nurses on the unit are not knowledgeable on these subjects, they cannot teach the patients. This ultimately sets the patient up for failure once they are discharged, as they are not properly educated on the care that they need. Some ways that staff can be informed are by the use of webinars and routine in-person staff meetings. The World Health Organization (WHO) (2018) states that webinars provide an inexpensive way to share information to several people all at once. They can be interactive, as well as convenient, which allows staff to learn information at their own pace. Routine in-person meetings promote consistent updates and information on quality measures that are expected to be performed. "Participants benefit greatly from in-person meetings
so that they can share their experiences and learn
from peers" (WHO, 2018, p. 20).

2. Patient Education
To continue the healing process in a home environment, patients should be taught accurate ways to care for themselves after being discharged. Nurses should take the time to supply detailed discharge teaching, and allow time for any questions the patient may have. The nurse should physically perform and provide a visual example of correct sternal precautions. Giving a diagram with pictures of correct form would facilitate better learning, and would also give the patient something to reference in the future. Nurses tend to fly through the section of discharge teaching that involves the signs of infection a patient should lookout for. Taking the time to list possible signs, and explain them in a way the patient can understand will likely assist with the prevention of infection.

3. More Specific Screening Tool
There are numerous high-risk factors noted that contribute to the development of a SWI. Implementing a specific screening tool that would identify these risk factors in individuals would allow the healthcare team to be more cautious and alert of this possible complication. In doing this, critical thinking skills could be utilized between the healthcare team to come up with the best individualized plan of care. Once this occurs, further steps can be taken to ensure prevention of a SWI. This new screening tool should be readily available for nurses to use, whether in an online database or a document positioned at a nurse's station. Depending on the amount of risk factors an individual has, they could be rated at a low, moderate, or high-risk. This screening result should be visible in a patient's chart where any health care provider could see it.

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There may be many barriers or challenges that aid in the production of sternal wound infections in the hospital environment. The most substantial barriers witnessed were ineffective communication between staff, as well as not following proper prevention protocol.
Ineffective communication
Kraut (2018) states, "Nurses are at the forefront of patient care; therefore, they are responsible for communicating patient information to any providers involved in a patient’s plan of care" (para. 1). For successful prevention and treatment of sternal wound infections to occur, clear and concise communication is vital. "Poor communication between nurses and providers can occur for a variety of reasons, either intentionally or unintentionally" (Kraut, 2018, para. 2). The fast paced atmosphere and unpredictability of healthcare may make sufficient communication challenging. Each nurse should make time to provide a detailed assessment of the incision site, and note any early signs of infection. Once assessment is complete, findings should be documented in a timely manner so other healthcare providers can view this information. Unexpected or alarming findings should be immediately reported to the health care provider. It is also crucial that the nurse explains their assessment of the patient's incision site and any abnormal findings during shift report. Nurses tend to skip or glaze over pertinent information when rushing to go home. Adequate hand-off allows for a continuous cycle of effective communication.
Not following proper protocol
The work environment of a nurse is hectic, as their schedule is filled with a lengthy to-do list. Often times, certain aspects of care take priority over others, especially while having multiple patients. For patients who are at risk for SWI's, a daily cleanse with a disinfectant swab may not be top priority in the eyes of a busy nurse. Additionally, the protective precautions that are put into place may not be strictly followed as they rush from each patient's room. These simple tasks that may become neglected can have a huge effect on a post-op patient's well-being. Making time to perform these essential steps will help prevent poor patient outcomes, and help establish a desired healing path.

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Cleansing surgical incision with ChloraPrep swab.