Prevention Bundle Halves Rate of Surgical Site Infections, Study Suggests

Troy Brown, RN

May 18, 2018

Posthysterectomy surgical site infections (SSIs) fell by more than half after a hospital implemented a seven-step surgical site bundle, new data show.

A multidisciplinary steering committee was formed at the Yale New Haven Hospital when it became clear the institution had a higher-than-expected rate of posthysterectomy SSIs. "Before formation of the committee, individual groups had piloted single interventions for [SSI] prevention.... Nevertheless, these interventions had yielded disappointing results because of inconsistency of education, adherence, and monitoring processes," the researchers write.

Therefore, the committee developed and introduced the multipart bundle to reduce infection rates, with implementation occurring in a step-wise fashion. The bundle included chlorhexidine-impregnated preoperative wipes that were given to patients before surgery; standardized aseptic surgical preparation of the abdomen, vagina, and perineum; standardized antibiotic dosing before and during surgery; maintenance of intraoperative normothermia; surgical dressing maintenance 24 to 48 hours postoperatively; and the provision of direct feedback from peers to physicians and other staff when the protocol was breached.

Hospital staff were educated about the bundle before its implementation.

Sarah E. Andiman, MD, from the Department of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine and Hospital Epidemiology and Infection Control and Perioperative Services and Patient Safety at Yale New Haven Hospital in Connecticut, and colleagues conducted a retrospective analysis of the bundle's effect, analyzing infection rates before and after implementation. They report their findings in an article published online May 7 in Obstetrics & Gynecology.

Of 2099 hysterectomies performed during the 33-month study period, there were 61 SSIs (4.51%; 61 of 1352 surgeries) that occurred before implementation of the full bundle and 14 (1.87%; 14 of 747) that occurred after implementation. Superficial SSI, the most common type of SSI, fell from 2.1% to 0.8% after implementation of the full bundle (P = .02).

After adjustment for patient clinical characteristics, patients were significantly less likely to develop SSI after implementation of the full bundle (adjusted odds ratio, 0.46; 95% confidence interval, 0.25 - 0.82; P = .01).

"Additional multivariable regression models to assess individual bundle components showed no statistically significant difference in risk for [SSI] associated with maintenance of intraoperative normothermia, antibiotic standardization, or direct feedback," the researchers explain.

Postoperative days of hospital stay (adjusted mean ratio, 0.95; 95% confidence interval [CI], 0.90 - 1.01; P = .09) and rate of readmission for an SSI-specific indication (adjusted odds ratio, 2.65; 95% CI, 0.90 - 7.81; P = .08) did not differ significantly in an adjusted model.

Feedback to physicians is an important but sometimes challenging component of the bundle, Nancy C. Chescheir, MD, editor-in-chief, Obstetrics & Gynecology, said in a journal podcast.

When done well, with data and reasons for the changes being made, feedback can foster teamwork and improve physician buy-in.

"[W]e all know there are going to be exceptions to the protocol.... But those exceptions to the rule sometimes help us make the rules better so that they're more inclusive when there's common outliers. There's a lot of room for individual physician judgment in taking care of patients, and there always will be,"' Cheshire said.

Study limitations included data collection challenges such as medical record system changes that occurred during implementation of the first bundle components, which made data comparison before and after the bundle implementation difficult. The researchers were also unable to collect data on outpatient encounters or hospital readmissions for SSIs that occurred outside the health system being studied. In addition, certain socioeconomic and preoperative health variables, as well as operative variables such as surgeon experience level, were unavailable; therefore, the overall generalizability of the findings is unclear.

"Although additional analyses are needed to further elucidate the relationships among adherence rates, specific bundle components, hysterectomy routes, length of hospital stay, and [SSI] reduction and overall surgical costs, we believe that a multidisciplinary, gynecology-specific approach to implementation and maintenance of the [SSI] prevention bundle serves patients well and will become a mainstay of gynecologic surgical care," the authors conclude.

One coauthor has served as a consultant and scientific advisory board member to 3M, which markets patient warming devices. He does not consult for 3M on patient warming issues. He is also a consultant to, and received research and travel support from, Diversey Healthcare, GOJO Industries, PDI, and Sodexo. The other authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online May 7, 2018. Abstract

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