A year ago, in our June 2017 What's New in the Patient Safety World column “”, we noted there had been a flurry of updates on guidelines for prevention of SSI’s (surgical site infections). The American College of Surgeons (Ban 2016), the American College of Obstetricians and Gynecologists (Pellegrini 2016), and WHO (Allegranzi 2016a, Allegranzi 2016b) had published their updated guidelines in 2016 and the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) published their update in 2014 (Anderson 2014). And the Centers for Disease Control and Prevention had just published it’s new guidelines (Berríos-Torres 2017). See our June 2017 What's New in the Patient Safety World column “” for details of that CDC guideline.
So, are we seeing improvements in SSI rates as organizations implement all these recommendations? Statistics recently released by AHRQ show that national rates for surgical site infections have been flat between 2014 and 2016 But a few recent studies suggest that implementation of bundles using the key items from the guidelines mentioned above are, indeed, producing positive results.
Fifteen hospitals participated in a statewide collaborative in Hawaii to implement the Comprehensive-Unit-based-Safety-Program (CUSP) and individualized bundles of interventions to reduce SSI’s (Lin 2018). We consider the CUSP program, pioneered by Johns Hopkins and AHRQ, as a key to improving hospital safety culture and paving the way for success of many quality improvement projects (see our March 2011 What's New in the Patient Safety World column “Michigan ICU Collaborative Wins Big” for comments about CUSP and links to resources).
While the bundles were individualized by each hospital, the most common interventions implemented were: (1) reliable chlorhexidine wash/wipe before surgery/surgical prep; (2) appropriate antibiotic choice/dose/timing; (3) standardized post-surgical debriefing; (4) differentiating clean-dirty-clean with anastomosis tray/closing tray.
Over a 2-year period, the colorectal SSI rate for the collaborative decreased from 12.08 percent to 4.63 percent, a 61.7 percent reduction. Moreover, safety culture, measured by AHRQ Hospital Survey on Patient Safety Culture (HSOPS), improved in 10 of 12 domains.
A similar successful implementation of an SSI Bundle occurred for gynecological surgery at Yale New Haven Hospital. (Andiman 2018). Because of a higher-than-expected surgical site infection rate, a quality improvement program was implemented to address SSI’s after hysterectomy. A multidisciplinary team designed a surgical site infection prevention bundle that consisted of chlorhexidine-impregnated preoperative wipes, standardized aseptic surgical preparation, standardized antibiotic dosing, perioperative normothermia, surgical dressing maintenance, and direct feedback to clinicians when the protocol was breached. The program was associated with a more than 50% reduction in the SSI rate. Patients who underwent surgery after the bundle was fully implemented had a reduced risk for overall surgical site infection (4.5% vs 1.9%). After adjusting for clinical characteristics, patients who underwent surgery after full implementation were less likely to develop a surgical site infection (adjusted odds ratio [OR] 0.46). Superficial surgical site infection rate decreased from 2.1% before full
bundle implementation to 0.8% after full bundle implementation. The rate of deep and organ space infections fell from 3.0% to a mean of 1.2% (and was zero in some of these months) during the last 8 months.
Several components of the Yale bundle merit comment. Their antibiotic protocol added a provision to ensure re-dosing when the procedure duration exceeded 3 hours. They also added metronidazole for cases in which bowel involvement was anticipated or in cases considered especially high risk for infection.
Intraoperative normothermia was achieved using forced-air warming devices but patients were also provided with forced-air warming for their own use preoperatively.
Lastly, the authors attributed much of the success in changing behavior to the last item (direct feedback) since surgical site infection incidence continually decreased after formalization of feedback as a component to the bundle.
Because various components of the bundle were added incrementally, they used multivariable regression models to assess individual bundle components. But these showed no statistically significant difference in risk for surgical site infection associated with maintenance of intraoperative normothermia, antibiotic standardization, or direct feedback.
Previously, in our September 2016 What's New in the Patient Safety World column “”, we highlighted a study which utilized a bundle of evidence-based interventions in patients undergoing spine surgery (discectomy, decompression, spinal augmentation or spinal fusion) and found surgical site infections declined by 50% after implementation (. Components of the “bundle” were:
1. screening for Staphylococcus aureus nasal colonization and decolonization with mupirocin
2. self-preparation bath with chlorhexidine gluconate
3. self-preparation with chlorhexidine gluconate wipes
4. storage optimization of operating room supplies
5. preoperative antibiotic administration algorithm
6. staff training on betadine scrub and paint
7. intrawound vancomycin in instrumented cases
8. postoperative early patient mobilization
9. wound checks at 2 and 6 weeks postoperatively
The number needed to treat (NNT) to prevent one infection was 47 patients. In addition to the 50 percent decline in SSIs there was an $866 cost reduction per case.
When we discussed the CDC guideline in our June 2017 What's New in the Patient Safety World column “” we noted as striking the sheer number of practices for which there was insufficient evidence to make a recommendation. The CDC guideline focused heavily on antimicrobial prophylaxis, antiseptic prophylaxis, glucose control, and normothermia, all facets with a solid evidence base. So it is no surprise to see some variation in the components of the bundles used at individual hospitals. They all did include core elements related to antimicrobial prophylaxis and skin antiseptic techniques. It is almost impossible to determine which components of bundles are most responsible for success. But don’t overlook the role played by the improvement in safety culture seen when multiple disciplines come together in a project with a common goal.
AHRQ also has a new Patient Safety Primer on Surgical Site Infections (AHRQ 2018b). Also, a very interesting study was published on use of process mapping to improve infection prevention activities and surgical safety in countries with limited resources ( . A checklist-based quality improvement program was implemented to improve compliance with best practices and process mapping helped identify barriers to using best practices. The latter included things like barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. They found that enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. We dare say that such process mapping would likely have a positive impact even in those countries and settings that are resource-rich!
Ban KA, Minei JP, Laronga C, et al, American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons 2016; Published online: November 30, 2016
Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site Infections after Major Gynecologic Surgery. Obstetrics & Gynecology 2016; Published ahead of print (Post Author Corrections): December 02, 2016
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16(12): e276-e287
Allegranzi B, Zayed B, Bischoff P, et al; WHO Guidelines Development Group. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16(12): e288-e303
Anderson D, Podgornny K, Berrios-Torres S, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology 2014; 35(6): 605-627 (June 2014) electronically published May 5, 2014
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. for the Healthcare Infection Control Practices Advisory Committee . Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; Published online May 3, 2017
Lin DM, Carson KA, Lubomski LH, et al. Statewide Collaborative to Reduce Surgical Site Infection: Results of the Hawaii Surgical Unit-based Safety Program. J Amer Coll Surg 2018; Published online: May 18, 2018
Andiman SE, Xu X, Boyce JM, et al. Decreased Surgical Site Infection Rate in Hysterectomy: Effect of a Gynecology-Specific Bundle. Obstetrics & Gynecology 2018; Published Ahead of Print
Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery. JAMA Surgery 2016; Online First July 20, 2016