Caroline Helwick

June 11, 2015

NEW ORLEANS — In colorectal surgery patients, a care bundle can dramatically reduce the risk for surgical-site infections, according to a nurse practitioner.

"Colorectal surgery patients are at a high risk for surgical-site infections. Some subsets of patients have a risk as high as 40%. Our goal was a 50% reduction, but we actually achieved a 77% reduction," said Donna Lester, DNP, a surgical clinical nurse practitioner at the Lakeland Regional Medical Center in Florida.

Dr Lester described the implementation of a risk-management protocol here at the American Association of Nurse Practitioners 2015 National Conference.

Because patients who have undergone colorectal surgery often develop ruptured diverticula, peritonitis, and bowel obstructions, they are at high risk for surgical-site infection. Up to a half million patients develop surgical-site infections each year in the United States, at a cost of more than $1.5 billion, she reported.

"A review of the literature on surgical-site infection reduction supported the use of a surgical care bundle," Dr Lester told Medscape Medical News.

A care bundle is a set of evidence-based interventions for a defined patient population and care setting that result in significantly better outcomes when implemented together than when implemented individually, she explained.

"It's a group of practices that may each have a positive effect, but when they are put all together, they give a bigger bang for the buck," she said.

Elements of the Lakeland Center Care Bundle
Using an antiseptic skin cleanser (Hibiclens) during showers the night before and the morning of surgery
Viewing of the Hand Hygiene Saves Lives video, developed by the Centers for Disease Control and Prevention, by the patient and family members
Clipping, not shaving, hair in the surgical-site area on the morning of surgery
Ensuring the optimal administration of antibiotics
Maintaining normothermia in operating room and up to 4 hours after surgery
Changing the operating room glove and tray at the closing of the fascia
Changing the incisional dressing at 48 hours and at postoperative shower
Educating the patient and family about infection prevention


A key change with the implementation of the bundle was providing the antiseptic skin cleanser to the patients, who often failed to obtain it on their own, Dr Lester explained. And nurses made follow-up phone calls 2 and 4 weeks after surgery to check on patients, she added.

Before and 6 weeks after the implementation, preadmission and surgical stepdown staff were evaluated for their knowledge of the care bundle elements and hand hygiene. In addition, hand hygiene audits using the iScrub app were conducted weekly over a 6-week period, and charts were audited weekly for care bundle compliance.

At 30 days, the rate of surgical-site infections was calculated from admissions, office visits, and patient phone calls. The evaluation involved 76 colorectal surgery patients who were attended by 146 surgical staff.

With the implementation of the care bundle, the infection rate decreased by 77%, far exceeding the goal of 50%. And at the completion of the study, knowledge scores had increased by 42% and staff compliance with hand hygiene was 86%, Dr Lester reported.

"Care bundle compliance will improve over time," she predicted. The goal is "more than 95%. Compliance was 100% at the office level, 98% at the preadmission level, 100% at the operating room level, and 80% at the stepdown level.

"Stepdown improved over time but did not meet the overall goal," she pointed out. "Barriers were related to electronic documentation."

After viewing the poster, Linda Staley, RN, from the Mayo Clinic in Scottsdale, Arizona, told Medscape Medical News that her own surgical team has developed interventions that reduce the risk for surgical-site infection.

"We did a quality project where we standardized our postoperative kits," she explained, adding that many patients will use these kits for years, not just in the immediate postoperative period, depending on the surgical procedure.

"We saw a significant reduction in our infection rate. While the national average might be around 25%, ours is down to around 10% with the standardized kit," she reported.

The kit contains chlorhexidine as the cleaning agent, or Betadine if the patient is allergic, and sterile gloves and masks. Staley said she thinks the inclusion of the antiseptic skin cleanser for presurgical showers in the Lakeland care bundle is a particularly good idea.

In both situations, she said, "we are just increasing the patient's access to supplies."

Dr Lester and Ms Staley have disclosed no relevant financial relationships.

American Association of Nurse Practitioners (AANP) 2015 National Conference: Abstract NP135. Presented June 10, 2015.


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