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Implementing a systematic bundle of prevention strategies reduced the absolute rate of superficial surgical site infections after colorectal surgery by 14% at one institution.
The findings came from a retrospective study of data from 2008 through 2012 on 559 patients who underwent major elective colorectal surgery at Duke University, Durham, N.C., either before the implementation of the preventive bundle on July 1, 2011 (62% of patients) or afterward (38%). Among all patients, the rate of superficial surgical site infection was 25% before the bundled care and 6% afterward, Dr. Jeffrey E. Keenan and his associates reported.
To eliminate any significant differences in patient demographics, baseline characteristics, or procedure-specific factors that might affect the surgical site infection rate, they conducted a propensity-matched comparison of 212 patients from each of the pre- and postbundling groups. The surgical site infection rate was 19.3% before implementation of bundled preventive services and 5.7% with bundled care, a significant difference of 13.6%, reported Dr. Keenan of the university.
The results were published online in JAMA Surgery (2014 Aug. 27 [doi:10.1001/jamasurg.2014.346]).
Among secondary outcomes, sepsis rates were significantly higher in the pre–bundled-care period, compared with the bundled-care period, both in the unadjusted cohort (10% vs. 2%, respectively) and in the comparison of matched patients (8% vs. 2%, respectively).
The bundle of care was a multidisciplinary effort involving surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital midlevel providers led by a colorectal surgeon who met monthly with the various groups to review infection rates and address issues with delivering the bundled strategies.
Designed by colorectal surgeons at the university, the bundle included giving patients educational materials before surgery on preventing surgical site infection. The patients received instructions and materials for a full-body chlorhexidine gluconate shower the night before surgery. The bundled-care team adopted a standardized polyethylene glycol 33350 bowel preparation with oral antibiotics (neomycin sulfate and erythromycin). All patients without allergy received a single 1-g dose of ertapenem sodium for preoperative antibiotic prophylaxis within 1 hour of incision. Patients with an allergy received ciprofloxacin HCl and metronidazole phosphate as an alternative.
Standardized preparation of the surgical field involved use of a 2% chlorhexidine gluconate–70% isopropyl alcohol solution. A wound protector was used during surgery for open incision. Only essential personnel were allowed in and out of the operating room. Anesthesiologists paid close attention to maintaining normothermia and euglycemia. Surgeons and scrub staff changed gowns and gloves at the time of wound closure. A dedicated wound closure tray was used to close the fascia and skin, and a sterile occlusive dressing was placed over the incision following closure. The dressing was removed within 48 hours of surgery, and the wound was washed daily with chlorhexidine. Patients being discharged were given materials and instructions to continue the chlorhexidine washes for 1 week after surgery.
A subgroup analysis of patients who underwent surgery after implementation of the bundled care showed that variable direct costs were 36% higher (after multivariable adjustment) in patients who developed surgical site infection, and patients with infection stayed 72% longer in the hospital, Dr. Keenan reported. Average variable direct costs were $13,253 in patients with superficial surgical site infection and $9,779 in those who did not develop infection. Lengths of stay during the index admission averaged 8 days with infection and 5 days without infection.
It is unlikely that any one part of the preventive bundle was responsible for the reduced infection rate and costs, though it’s impossible to tell, the investigators said. More likely, the framework of bundling preventive strategies supported reliable delivery of multiple preventive measures with high fidelity, they suggested.
Dr. Keenan reported having no relevant financial disclosures.
On Twitter @sherryboschert
The study by Dr. Keenan and several separate recent studies support the idea that surgical site infections after colorectal surgery can be prevented by management based on published evidence, best practice guidelines, and culture change, according to Dr. Ira L. Leeds and Dr. Elizabeth C. Wick.
This involves implementing "processes that span the continuum of care from before surgery through postoperative recovery, and these interventions are far more complex than the Surgical Care Improvement Program measures now held as the gold standard for surgical quality reporting," they wrote (JAMA Surgery 2014 Aug. 27 [doi:10.1001/jamasurg.2014.389]).
The studies also suggest that the subspecialty of colorectal surgery is well situated for developing models of care starting from the patient care level rather than from a typical top-down approach, they added. "The tribelike culture of medicine means that many of the fixes to the health care system will need to come at the unit level rather than [through] institutional, systemic solutions," Dr. Leeds and Dr. Wick wrote.
Their remarks were published in a commentary simultaneously with the publication of Dr. Keenan’s study. Dr. Leeds and Dr. Wick are at the Johns Hopkins University, Baltimore. They reported having no financial disclosures.
The study by Dr. Keenan and several separate recent studies support the idea that surgical site infections after colorectal surgery can be prevented by management based on published evidence, best practice guidelines, and culture change, according to Dr. Ira L. Leeds and Dr. Elizabeth C. Wick.
This involves implementing "processes that span the continuum of care from before surgery through postoperative recovery, and these interventions are far more complex than the Surgical Care Improvement Program measures now held as the gold standard for surgical quality reporting," they wrote (JAMA Surgery 2014 Aug. 27 [doi:10.1001/jamasurg.2014.389]).
The studies also suggest that the subspecialty of colorectal surgery is well situated for developing models of care starting from the patient care level rather than from a typical top-down approach, they added. "The tribelike culture of medicine means that many of the fixes to the health care system will need to come at the unit level rather than [through] institutional, systemic solutions," Dr. Leeds and Dr. Wick wrote.
Their remarks were published in a commentary simultaneously with the publication of Dr. Keenan’s study. Dr. Leeds and Dr. Wick are at the Johns Hopkins University, Baltimore. They reported having no financial disclosures.
The study by Dr. Keenan and several separate recent studies support the idea that surgical site infections after colorectal surgery can be prevented by management based on published evidence, best practice guidelines, and culture change, according to Dr. Ira L. Leeds and Dr. Elizabeth C. Wick.
This involves implementing "processes that span the continuum of care from before surgery through postoperative recovery, and these interventions are far more complex than the Surgical Care Improvement Program measures now held as the gold standard for surgical quality reporting," they wrote (JAMA Surgery 2014 Aug. 27 [doi:10.1001/jamasurg.2014.389]).
The studies also suggest that the subspecialty of colorectal surgery is well situated for developing models of care starting from the patient care level rather than from a typical top-down approach, they added. "The tribelike culture of medicine means that many of the fixes to the health care system will need to come at the unit level rather than [through] institutional, systemic solutions," Dr. Leeds and Dr. Wick wrote.
Their remarks were published in a commentary simultaneously with the publication of Dr. Keenan’s study. Dr. Leeds and Dr. Wick are at the Johns Hopkins University, Baltimore. They reported having no financial disclosures.
Implementing a systematic bundle of prevention strategies reduced the absolute rate of superficial surgical site infections after colorectal surgery by 14% at one institution.
The findings came from a retrospective study of data from 2008 through 2012 on 559 patients who underwent major elective colorectal surgery at Duke University, Durham, N.C., either before the implementation of the preventive bundle on July 1, 2011 (62% of patients) or afterward (38%). Among all patients, the rate of superficial surgical site infection was 25% before the bundled care and 6% afterward, Dr. Jeffrey E. Keenan and his associates reported.
To eliminate any significant differences in patient demographics, baseline characteristics, or procedure-specific factors that might affect the surgical site infection rate, they conducted a propensity-matched comparison of 212 patients from each of the pre- and postbundling groups. The surgical site infection rate was 19.3% before implementation of bundled preventive services and 5.7% with bundled care, a significant difference of 13.6%, reported Dr. Keenan of the university.
The results were published online in JAMA Surgery (2014 Aug. 27 [doi:10.1001/jamasurg.2014.346]).
Among secondary outcomes, sepsis rates were significantly higher in the pre–bundled-care period, compared with the bundled-care period, both in the unadjusted cohort (10% vs. 2%, respectively) and in the comparison of matched patients (8% vs. 2%, respectively).
The bundle of care was a multidisciplinary effort involving surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital midlevel providers led by a colorectal surgeon who met monthly with the various groups to review infection rates and address issues with delivering the bundled strategies.
Designed by colorectal surgeons at the university, the bundle included giving patients educational materials before surgery on preventing surgical site infection. The patients received instructions and materials for a full-body chlorhexidine gluconate shower the night before surgery. The bundled-care team adopted a standardized polyethylene glycol 33350 bowel preparation with oral antibiotics (neomycin sulfate and erythromycin). All patients without allergy received a single 1-g dose of ertapenem sodium for preoperative antibiotic prophylaxis within 1 hour of incision. Patients with an allergy received ciprofloxacin HCl and metronidazole phosphate as an alternative.
Standardized preparation of the surgical field involved use of a 2% chlorhexidine gluconate–70% isopropyl alcohol solution. A wound protector was used during surgery for open incision. Only essential personnel were allowed in and out of the operating room. Anesthesiologists paid close attention to maintaining normothermia and euglycemia. Surgeons and scrub staff changed gowns and gloves at the time of wound closure. A dedicated wound closure tray was used to close the fascia and skin, and a sterile occlusive dressing was placed over the incision following closure. The dressing was removed within 48 hours of surgery, and the wound was washed daily with chlorhexidine. Patients being discharged were given materials and instructions to continue the chlorhexidine washes for 1 week after surgery.
A subgroup analysis of patients who underwent surgery after implementation of the bundled care showed that variable direct costs were 36% higher (after multivariable adjustment) in patients who developed surgical site infection, and patients with infection stayed 72% longer in the hospital, Dr. Keenan reported. Average variable direct costs were $13,253 in patients with superficial surgical site infection and $9,779 in those who did not develop infection. Lengths of stay during the index admission averaged 8 days with infection and 5 days without infection.
It is unlikely that any one part of the preventive bundle was responsible for the reduced infection rate and costs, though it’s impossible to tell, the investigators said. More likely, the framework of bundling preventive strategies supported reliable delivery of multiple preventive measures with high fidelity, they suggested.
Dr. Keenan reported having no relevant financial disclosures.
On Twitter @sherryboschert
Implementing a systematic bundle of prevention strategies reduced the absolute rate of superficial surgical site infections after colorectal surgery by 14% at one institution.
The findings came from a retrospective study of data from 2008 through 2012 on 559 patients who underwent major elective colorectal surgery at Duke University, Durham, N.C., either before the implementation of the preventive bundle on July 1, 2011 (62% of patients) or afterward (38%). Among all patients, the rate of superficial surgical site infection was 25% before the bundled care and 6% afterward, Dr. Jeffrey E. Keenan and his associates reported.
To eliminate any significant differences in patient demographics, baseline characteristics, or procedure-specific factors that might affect the surgical site infection rate, they conducted a propensity-matched comparison of 212 patients from each of the pre- and postbundling groups. The surgical site infection rate was 19.3% before implementation of bundled preventive services and 5.7% with bundled care, a significant difference of 13.6%, reported Dr. Keenan of the university.
The results were published online in JAMA Surgery (2014 Aug. 27 [doi:10.1001/jamasurg.2014.346]).
Among secondary outcomes, sepsis rates were significantly higher in the pre–bundled-care period, compared with the bundled-care period, both in the unadjusted cohort (10% vs. 2%, respectively) and in the comparison of matched patients (8% vs. 2%, respectively).
The bundle of care was a multidisciplinary effort involving surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital midlevel providers led by a colorectal surgeon who met monthly with the various groups to review infection rates and address issues with delivering the bundled strategies.
Designed by colorectal surgeons at the university, the bundle included giving patients educational materials before surgery on preventing surgical site infection. The patients received instructions and materials for a full-body chlorhexidine gluconate shower the night before surgery. The bundled-care team adopted a standardized polyethylene glycol 33350 bowel preparation with oral antibiotics (neomycin sulfate and erythromycin). All patients without allergy received a single 1-g dose of ertapenem sodium for preoperative antibiotic prophylaxis within 1 hour of incision. Patients with an allergy received ciprofloxacin HCl and metronidazole phosphate as an alternative.
Standardized preparation of the surgical field involved use of a 2% chlorhexidine gluconate–70% isopropyl alcohol solution. A wound protector was used during surgery for open incision. Only essential personnel were allowed in and out of the operating room. Anesthesiologists paid close attention to maintaining normothermia and euglycemia. Surgeons and scrub staff changed gowns and gloves at the time of wound closure. A dedicated wound closure tray was used to close the fascia and skin, and a sterile occlusive dressing was placed over the incision following closure. The dressing was removed within 48 hours of surgery, and the wound was washed daily with chlorhexidine. Patients being discharged were given materials and instructions to continue the chlorhexidine washes for 1 week after surgery.
A subgroup analysis of patients who underwent surgery after implementation of the bundled care showed that variable direct costs were 36% higher (after multivariable adjustment) in patients who developed surgical site infection, and patients with infection stayed 72% longer in the hospital, Dr. Keenan reported. Average variable direct costs were $13,253 in patients with superficial surgical site infection and $9,779 in those who did not develop infection. Lengths of stay during the index admission averaged 8 days with infection and 5 days without infection.
It is unlikely that any one part of the preventive bundle was responsible for the reduced infection rate and costs, though it’s impossible to tell, the investigators said. More likely, the framework of bundling preventive strategies supported reliable delivery of multiple preventive measures with high fidelity, they suggested.
Dr. Keenan reported having no relevant financial disclosures.
On Twitter @sherryboschert
FROM JAMA SURGERY
Key clinical point: Bundled preventive care significantly reduced surgical site infection after colorectal surgery.
Major finding: Superficial surgical site infection occurred in about 19% before and about 6% after implementing bundled care.
Data source: A retrospective study of 559 patients undergoing colorectal surgery, 62% before bundled-care implementation.
Disclosures: Dr. Keenan reported having no relevant financial disclosures.
