Challenges Related to Surgical Site Infection Prevention—Results after Standardized Bundle Implementation

Abstract

Aim: The aim of this study was to assess the implementation of an intraoperative standardized surgical site infection (SSI) prevention bundle. Methods: The multimodal, evidence-based care bundle included nine intraoperative items (antibiotic type, timing, and re-dosing; disinfection; induction temperature control > 36.5°; glove change; intra-cavity lavage; wound protection; and closure strategy). The bundle was applied to all consecutive patients undergoing colonic resections. The primary outcome, SSI, was independently assessed by the National Infection Surveillance Committee for up to 30 postoperative days. A historical, institutional pre-implementation control group (2012–2017) with an identical methodology was used for comparison. Findings: In total, 1,516 patients were included, of which 1,256 (82.8%) were in the control group and 260 (17.2%) were in the post-implementation group. After 2:1 propensity score matching, the groups were similar for all items (p > 0.05). Overall compliance with the care bundle was 77% (IQR 77–88). The lowest compliance rates were observed for temperature control (53% overall), intra-cavity lavage (64% overall), and wound protection and closure (68% and 63% in the SSI group, respectively). Surgical site infections were reported in 58 patients (22.2%) vs. 21.4% in the control group (p = 0.79). Infection rates were comparable throughout the Centers for Disease Control and Prevention (CDC) categories: superficial, 12 patients (4.5%) vs. 4.2%, p = 0.82; deep incisional, 10 patients (3.7%) vs. 5.1%, p = 0.34; organ space, 36 (14%) vs. 12.4%, p = 0.48. After propensity score matching, rates remained comparable throughout all comparisons (all p > 0.05). Conclusions: The implementation of an intraoperative standardized care bundle had no impact on SSI rates. This may be explained by insufficient compliance with the individual measures.

Prospective compliance assessment of surgical site infection prevention measures in colorectal surgery

“…While the SSI rate of 20 per cent could not be substantially decreased after colonic resections, a beneficial impact in patients undergoing appendicectomy was observed 2 , 3 . However, compliance with the standardized care bundle was a modest 77 per cent 2 . To identify areas for improvement, the present study aimed to assess the impact of challenging circumstances on bundle compliance.…”

“…In the authors' institution, a multimodal SSI prevention bundle was introduced as the standard of care in November 2018 for colorectal resections and appendicectomies. The bundle consists of eight evidence based items including antibiotic prophylaxis, skin disinfection, induction and perioperative core temperature control >36.5 ° C, intracavity lavage, selective abdominal drain placement, systematic use of a double-ring wound protection device, glove change before closure and predefined closure strategy 2 . While the SSI rate of 20 per cent could not be substantially decreased after colonic resections, a beneficial impact in patients undergoing appendicectomy was observed 2 , 3 .…”

Sustaining Improvements of Surgical Site Infections by Six Sigma DMAIC Approach

“…A meta-analysis has indicated that the effects of perioperative care bundles for the prevention of SSIs are inconsistent among many randomized control trials [ 12 ]. Prevention bundle will not result in decreased SSI rates, if the overall compliance or systemic adaptation by healthcare organizations is insufficient [ 13 , 14 ]. Therefore, a more comprehensive quality improvement approach is needed to achieve the goal of reduction in SSIs [ 13 , 14 , 15 , 16 ].…”

“…Prevention bundle will not result in decreased SSI rates, if the overall compliance or systemic adaptation by healthcare organizations is insufficient [ 13 , 14 ]. Therefore, a more comprehensive quality improvement approach is needed to achieve the goal of reduction in SSIs [ 13 , 14 , 15 , 16 ].…”

Open and Closed Approaches to Skin Closure After Nonelective Open Colorectal Operations

“…In a 5-year propensity score matched study of 1263 elective and emergent colorectal surgeries, a 9item bundle including antibiotic type, timing, and re-dosing; disinfection; induction temperature control >36.5; glove change; intra-cavity lavage; wound protection; and closure strategy algorithm resulted in variable levels of compliance with bundle components and had no impact on superficial, deep incisional, or organ space SSI rates. 8 In addition to the interventions described, wound closure technique is an important consideration in SSI prevention. To date, variability in practice remains between leaving skin open or performing primary closure.…”