Bundle Decreases Infections in High-Risk Surgeries

Troy Brown, RN

May 10, 2016

An evidence-based surgical site infection (SSI) reduction bundle significantly reduced the overall SSI rate from 6.0% to 1.1% (P = .01) in patients with high-risk gynecologic cancer surgeries, according to a new study.

"[SSI] is a key factor in the vitally important measures of patient morbidity and mortality. After bundle implementation, our overall rate of [SSI] decreased significantly, exceeding our goal and supporting this institutional practice change," write Megan P. Johnson, PA-C, from the Mayo Clinic, Rochester, Minnesota, and colleagues. The authors published their findings online May 4 and in the June issue of Obstetrics & Gynecology.

The researchers studied SSIs in patients who underwent staging laparotomy for uterine cancer, ovarian cancer debulking without bowel resection, or ovarian cancer debulking with bowel resection.

"The high-complexity surgery often required to cytoreduce ovarian cancer carries a substantial risk for [SSI], which is associated with worse overall survival," the researchers write. "For patients with uterine cancer, staging performed through laparotomy, rather than a minimally invasive approach, increases the risk of surgical site infection 15-fold."

They adapted an intervention bundle proven to reduce SSI in patients with colorectal surgery. "Our aim was to evaluate whether implementing a bundle of interventions that spans the entire surgical encounter...could reduce 30-day [SSI] rates by 50% in high-risk gynecologic cancer operations," the authors write.

For the preintervention period, the researchers determined SSI rates retrospectively among 635 patients who underwent one of the three surgeries between January 1, 2010, and December 31, 2012. During this baseline period, the SSI reduction bundle included a patient education pamphlet on SSI prevention, Hibiclens (4% chlorhexidine gluconate) shower before surgery, prophylactic antibiotic administration, coverage of the incisional area with ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol), and cefazolin redose within 3 to 4 hours after incision. Compliance with SSI guidelines was high.

The investigators then added new elements to the SSI bundle for 190 patients treated between August 1, 2013, and September 30, 2014 (the intervention period). Those elements were sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24 to 48 hours, discharge with 4% chlorhexidine gluconate, and follow-up telephone call from a nurse within 24 to 72 hours.

The overall SSI rate among patients with ovarian cancer without bowel resection fell from 4.8% to 1.0% (relative risk reduction, 79.3%; P = .12), whereas the rate among those who underwent ovarian cancer surgery with bowel resection dropped from 10.6% to 2.4% (relative risk reduction, 77.6%; P = .19). The SSI rate among those who underwent hysterectomy for uterine cancer fell from 5.1% to 0.0% (P = .23), even though patients in the intervention group were more likely to have advanced-stage disease.

The superficial incisional SSI relative risk reduction was 100% (from 1.7% to 0.0%; P = .08). The relative risk reduction for organ and space SSI was 73.3% (from 3.9% to 1.1%; P = .05). That rate fell from 3.0% to 1.0% (P = .45) among ovarian cancer without bowel resection, from 8.8% to 2.4% (P = .29) among ovarian cancer with bowel resection, and from 2.8% to 0.0% (P = .60) among uterine cancer.

Only two deep incisional SSIs occurred, and these were in ovarian cancer without bowel resection in the preintervention group.

The overall odds of SSI during the intervention period relative to the preintervention period were 0.17 (95% confidence interval [CI], 0.04 - 0.70). The adjusted odds ratio was 0.13 (95% CI, 0.03 - 0.71).

Among all patients who underwent gynecologic surgery at Mayo Clinic Rochester, the National Surgical Quality Improvement Program SSI decile ranking rose from the 10th decile during the preintervention period to the first decile after implementing the bundle. During the same periods, the risk-adjusted odds ratio for SSI dropped from 1.6 (95% CI, 1.0 - 2.6) to 0.6 (95% CI, 0.3 - 1.1).

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;127:1135-1144. Full text

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