HTN was joined by a panel of leading experts in surgical site infection (SSI) care for an insightful discussion on how digital innovation is reshaping clinical practice and improving patient outcomes. The session shared practical advice on reducing SSIs with digital pathways, ensuring effective surveillance, how a digital approach to surgical site safety can reduce infection risk, and the role of automation in infection control.
Our panel included Melissa Rochon, trust lead for SSI surveillance, research and innovation at Guy’s and St Thomas’ NHS Foundation Trust; Kenneth McLean, innovation lead at The Association of Surgeons in Training; Ishtiaq Ahmed, cardiac surgeon at University Hospitals Sussex NHS Foundation Trust; and Pete Hansell, CEO and co-founder of Isla Health.
We kicked off the session with some introductions to our panel members and their experiences with digital pathways for SSI. “SSI surveillance or surgical wound monitoring is one of the most promising areas for digital transformation in healthcare,” said Melissa. “It’s a great example of how technology and automation can unlock efficiencies and allow us to scale care in ways that simply weren’t possible before.”
Guy’s and St Thomas’ uses the Isla platform for surveillance in many different surgical specialisms including breast, thoracic, renal, paediatric and vascular surgery, Melissa shared, providing 20,000 surgical patients with remote wound monitoring to date. “The real shift,” according to Melissa, “is that we’re transforming how we deliver care. This technology takes us beyond simply preventing SSIs within our hospital walls – it’s creating a powerful opportunity to involve patients in their own care and to improve self-management, reducing the risk of infection in the community setting.”
Most SSIs show up after a patient leaves hospital and represent a major cause of harm following surgery, Melissa went on. “SSIs contribute to over a third of postoperative deaths and lead to significant complications such as longer hospital stays, prolonged antibiotic use, emergency readmissions, and poor outcomes for patients. The NHS spends around £980 million each year managing surgical wounds, with almost half of that cost now falling on community services. A large proportion of these infections are considered preventable.”
In 2017, Getting It Right First Time (GIRFT) reported that less than ten percent of hospitals they visited knew their incidence of SSI, Melissa noted, largely due to the labour-intensive and costly nature of traditional surveillance. “SSI surveillance is where technology moves beyond simply enabling processes and becomes a true catalyst for transformation by using patient-generated health data, including photos taken on smart devices, fundamentally shifting the model of patient-reported post-discharge surveillance from a retrospective data-gathering exercise to a proactive, patient-centred approach.”
Using technology in this way can help detect complications, offer early support, and provide timely treatment, Melissa stated. At Guy’s and St Thomas’, Isla is used in cardiac surgery for post-discharge surveillance, supporting around 2,700 patients each year across three hospital sites and reducing patient-reported SSI rates by 35 percent. “We’ve decreased unplanned readmissions and reoperations, and we’ve found that patients with an SSI at our local sites are using healthcare services less frequently than the national average, which I think highlights the impact.”
Kenny highlighted that digital transformation including the integration of AI into practice is essential to meeting future healthcare demands. “My team in Edinburgh completed the first full-scale randomised controlled trial for the impact of remote postoperative wound monitoring on SSI. Comparing this to routine care, we found we can diagnose these surgical site infections earlier, reducing healthcare usage and improving patient experience.”
Despite these benefits, manually triaging responses received poses a huge burden to clinical teams, according to Kenny. A strength of digital healthcare interventions is the opportunity they provide to incorporate automated assessment, and with advances in machine learning, it’s possible to leverage neural networks to use multimodal data from patient responses to allow real-time SSI prediction. “We built our proof of concept model using real-world data from our clinical studies, incorporating patient-reported symptoms and wound images, to predict the probability of SSI, and this can also generate heat maps to highlight where the specific concern is.”
The combination of these inputs for this multimodal approach had an “equivalent performance” to clinician-led triage for predicting SSI within 48 hours of response, according to Kenny. All responses were classified by the model as moderate or high risk being reviewed by clinicians, reducing the time required to triage by more than 80 percent. “Overall, we were able to demonstrate that automated assessment can be successfully deployed within remote postoperative wound monitoring pathways, allowing resources to be appropriately directed to those at greatest risk of SSI,” he added. This work has been published in Nature Digital Medicine.
SSI is one of those complications that is prevalent in around two-to-five percent of cases, Ishtiaq said, “and although we wanted to try and reduce the impact of that and manage it in an appropriate way; before we had Isla, we didn’t have a good handle on the data”. His team also wanted to have a platform enabling them to advise patients on managing their wound care at home, he continued, “and Isla has given us that, as well as a robust platform to collect data, empowering patients to take control of their own care, giving them contact with a specialist within the hospital so they’re not drifting into community with a wound that should have been managed earlier”.
The platform has enabled the team to act quickly, highlighting the need for antibiotics or readmission, Ishtiaq reported. “Feedback has also been excellent, and we’ve found it has reduced some of the more serious complications that occur after having SSI, if we manage these issues very early on in the pathway.”
Pete gave an introduction to Isla, reflecting on how far the company has come over the last few years. “We’re now a team of just over 50 people based in London,” he said. “We’re working quite broadly across the NHS and HSE in Ireland, covering 30 organisations and supporting more than 40 different specialties. Isla can be deployed into any speciality, and from there we select different pathways which we can help transition to a much more scalable digital model. I remember when we were excited to have hit 10 patient submissions in a day, and now we have reached over 2 million annually.”
The things the team are most proud of is their delivery of cash-positive implementations and their impact on patient safety, Pete went on. “The change we’re trying to create for the health system is to move away from predominantly collecting information from patients by seeing them in person, to being able to collect information about a patient’s condition asynchronously.” That information can be collected from anyone involved in a patient’s care, and could be in many forms, including any media types, DICOM imaging, PROMs, and blood results.
“The benefit for clinical teams is that instead of being presented with these moments in time from seeing a patient, perhaps every three months, they can have real longitudinal visibility of the way a condition is developing,” Pete considered. Isla’s analytics capabilities also mean that the platform can do some of the work in identifying patterns and trends, with the aim being to enable clinicians and help them make “more confident, faster decisions about the next step for patients”.
The pathway starts at the point of surgery, with Isla typically being integrated with an EHR or PAS system to allow information to be received to trigger it. After discharge, a personalised timeframe is automatically created that requests wound images from patients and a wound assessment form at days 7, 14, and 28. “We can tailor that to suit any speciality, ensuring we maintain visibility of patient recovery and flag much more quickly if there’s a problem,” Pete said. There are also a range of automated steps that can be built into the pathway, to trigger specific advice or next steps for patients and clinicians.
Engaging the workforce with digital pathways
Starting small and using a quality improvement approach are two pieces of advice for anyone looking to engage their teams on digital pathways, Melissa shared. “Once you start to generate the outcomes and you have those to share, it enables those discussions with colleagues to explore the benefits. Engaging with them about what to expect from Isla, like looking out for certain text messages, is also helpful, because you’re bringing them into the patient’s pathway.”
Having standard operating procedures for staff who are receiving submissions from Isla, making sure all of the benefits are being taken advantage of for things like automating onboarding and template responses to patients, is also key, Melissa told us. “In cardiac at St Thomas’, the advanced nurse practitioners respond to Isla submissions, and the training was really quick, because Isla provided it, and when we offered to take over for them they said that they wanted to keep it, because it’s fantastic to have that follow-up with patients. Once it’s embedded, I think it really flies.”
“In our case it was more in the research context, and we had surgeons reviewing things,” Kenny shared. “We asked patients, clinicians and nurses who they thought was the best person to be reviewing, and the feeling was that nurses would be best placed to have the most experience with wounds, and I guess people just wanted the ability to escalate cases that were a bit more complex.”
“Change is always difficult,” Ishtiaq considered, “but I think the way we set this up is that we got the local data and presented it at local governance meetings, and it was clear we didn’t have a handle on our infection rate, particularly after patients went home.” Initially there were some challenges with embedding the service, he continued, “but we are very lucky to have a group of engaged associate nurse practitioners who manage patients postoperatively with consultant clinical guidance every day”.
The discharge process was the same, and integrating it into Isla was “a very iterative approach”, according to Ishtiaq. “We designed the parameters of what we wanted to ask patients and when. So we took a photo at day zero, then at day five to seven when they were discharged home. We decided to interact with patients at 14 days, 30 days, four weeks, six weeks, and then other time periods after that, and then we designed questions together with support from Isla.”
The digital side of integrating Isla was a challenge, Ishtiaq said, “but there are specific frameworks, and once you jump through each one and take your time doing that, the team becomes very confident in using it”. Feedback from patients has been “overwhelming”, he continued, “and although many of our patients fall into the older category, 90 percent have a mobile device and they’ve all engaged really well with the process”. Having a specified person to deal with any queries at the beginning and then cascading that across the rest of the team worked well, he concluded.
“I don’t think any sort of service fits every single patient,” Melissa said, “so you’re always going to have workarounds and you can still pick up the phone, but what I love about digital is that previously we could only provide a follow-up in English, whereas now patients can select the language to complete the form, and those responses are translated so we can still provide the advice, reassurance, or referral.” Some patients might also prefer to designate someone else to receive requests on their behalf, and Isla offers the option to nominate someone as their next of kin. “Whilst you might find some who won’t engage or send the images, there will be those who can’t take time off work who the service works better for,” she considered.
Exploring the benefits of digital pathways
Ishtiaq shared how when initially engaging with Isla, his team thought the service would just be used for the first six weeks post-op, but that since submitting data nationally requests the first year for surveillance, they are now completing surveillance for twelve months. “Since we started with Isla, we’ve managed to secure the funds for a surgical site surveillance nurse, and the advantage of having the platform is that the nurse workload isn’t so heavy. If they didn’t have it, there’d be multiple phone calls, clinic visits, and many patients missed out, but because patients are taking control and we have 90 to 95 percent using Isla, her main work is trying to reach that remaining five percent.”
That reduced workload then offers the capacity to have the granularity of that data and take ownership of it, Ishtiaq shared. “Because it’s all digitised, we know how many people are taking antibiotics postoperatively, which cohorts might be having problems, which regional patients are having issues accessing their GP, and any kind of wound care issues. We now do that for twelve months, and I think it’s probably unnecessary to be any longer than that.”
Kenny noted earlier points made around the lack of visibility of data on SSIs, highlighting the benefits of having an accurate picture, particularly from a quality improvement angle. “From a patient’s perspective, with many facing barriers accessing their GP or not knowing who to contact, it’s being able to get that advice in a timely manner. Getting infections diagnosed earlier can also mean they’re less severe and have less morbidities for them.”
There are also benefits to be seen in the improved communication and coordination between primary and secondary care, Kenny told us. “Where I am, we don’t necessarily have access to community records, so actually having a central platform where you can share that information easily, where you can see what a wound looked like initially in the hospital versus 30 days later, is a huge benefit to the diagnostic process.”
The future of digital pathways
Pete urged progress in the adoption of digital pathways, saying: “The research is incredibly solid now, and there’s a core group of people who are driving this topic forward, but this is something that should be part of standard practice. The challenge is often the implementation and being able to do that across a complicated system, but it’s a massive opportunity for health systems, and one that is overlooked.” Moving to a more proactive model which can pick up on patients who might become more unwell is “low-hanging fruit”, he continued, “and I’d love to see more of a national conversation about how we can standardise this model of postoperative care”.
There is a wealth of evidence that this approach works, agreed Melissa, “and you have a model which reduces community visits and increases patient satisfaction. I think part of it was that there wasn’t a system to do this well, and we didn’t want to look to the community experience, because we didn’t know how to without bringing patients back in”. Now, with this technology, the opportunity is there to go back and have those conversations. “I think in cardiac surgery, the cost saving is something like £18,000 per patient if you prevent those more serious infections, but it’s the appetite, as having one thing extra to do can be a big blocker.”
Although we are early on in this journey, we need to look at workforce solutions as well as leaning into AI, Melissa considered. “We realised early on that if we wanted to scale this, we needed a centralised team who could respond to patients, re-profiling staff, so you don’t need higher bands responding to simple submissions; we’re going to use that model we developed at Guy’s and St Thomas’ to provide support for national study.” The ROSSINI platform started in January, and over the next five years will be recruiting 26,000 patients, she shared, “and the hub will be using Isla to provide that service”.
“The issue we had historically was that everybody was asked to do a little bit around wound reviews or SSIs,” Ishtiaq told us. “The key thing is to get some ownership, so a dedicated team or group of individuals, and we set up a team involving a surgeon, an SSI nurse, a plastic surgeon, and a microbiologist. You need inertia within a department to drive the change, as well as support from industry for technical help when it comes to negotiating DPIA agreements, cloud, network, IT, and so on. Wound issues will always be there, you just need a way of managing those early.”
From his experience, “all you need is 10 patients within a year who develop a deep sternal wound issue”, Ishtiaq shared, “as those 10 patients could end up spending an average of 30 days extra in hospital, going to theatre on average 5 extra times to sort that wound issue out”. That could equate to an extra 150 hours in theatre from just 10 patients, he said, “and we can stop that tap and stop patients suffering at home with a wound because we don’t know what that looks like. COVID has driven acceptance of remote consultations, and that has needed to happen safely for a long time, but I think we’re getting there”.
It’s not a technological issue, Kenny said, and for the most part there’s really solid evidence that this approach can offer clinical improvement whilst remaining cost-effective. “It’s more institutional change and the fact we’re overstretched, along with having the funds for these things, even when they would work out to be cost-effective in the longer term.” Once more people are doing it and sharing their success, that should help accelerate change. “As a clinician, being able to correlate symptoms with the appearance of a wound and not just relying on patients reporting things is huge,” he went on, “and there are emerging technologies such as infrared which could play a role in future.”
Key takeaways
As well as recognising the “fantastic opportunities” for efficiency that automation can create, it’s important to consider acceptability and patient safety, Kenny considered. “It’s about how we can make it work for everyone in the community.”
“If you’re thinking about this, we would recommend taking it to IT teams as early as possible to try and get buy-in to doing it in an integrated way,” Pete said. “Isla can both sit standalone or integrate with EPR and PAS systems, with HL7 and FHIR enabling integration into things like EMIS. But getting the IT team on board sets us up for a much more scalable and easy-to-use experience.”
SSI surveillance is an important driver for surgical wound management, Melissa said, “and we need ways of following up with patients, so we have that important information to help drive improvement”.
Ishtiaq also highlighted the importance of getting teams on board early in the process, adding: “Stick with it, because once you get through the initial unfamiliarity, everyone starts to realise the benefits, the reliability of the data you’re getting, and the feedback from patients is overwhelmingly good.”
We’d like to thank our panellists for taking the time to share their insights and experience with us on this topic.
