Postcesarean SSI rate declines with care bundle*

DALLAS – A surgical site infection care bundle reduced the rate of surgical site infections (SSIs) after cesarean delivery by more than half, according to a case-control study examining data from more than 2,000 patients.

At the health center where the SSI bundle was implemented, rates per 1,000 women undergoing cesarean delivery fell from 2.44 to 1.10 (P = .013).

Martin Valigursky/Thinkstock

The study showed the effectiveness of implementing evidence-based and -supported recommendations, and of having standardized protocols with little variation, said Christina Davidson, MD, presenting the pre-post findings during a plenary session at the meeting sponsored by the Society for Maternal-Fetal Medicine.

The bundle of interventions was developed over the course of 3 months in late 2013 and early 2014 by a multidisciplinary task force, drawing from colorectal surgery literature about SSI prevention. Both nurses and physicians were on the task force, and representatives came from the departments of obstetrics and gynecology, anesthesia, and infection prevention, said Dr. Davidson of the Baylor College of Medicine, Houston. All inpatient and outpatient clinical care sites had representation.

 

After the bundle elements were identified, a full month was devoted to education and team training, with full bundle implementation occurring in April 2014. “Visual aids were placed in close proximity to the operating rooms,” said Dr. Davidson. For example, antimicrobial prophylaxis cards were placed on all anesthetic carts.

“A surgical checklist was placed in the chart for each patient undergoing cesarean delivery and compliance was tracked for the first 12 months of implementation,” said Dr. Davidson. Additionally, members of the care team received feedback in the form of quarterly reports on SSI rates and statistics about bundle compliance.

Care bundle elements included a set of instructions for pre- and postoperative antiseptic skin cleaning, wound care, and glycemic control in patients. Women were given chlorhexidine cleanser and asked to use it when showering the day before and the morning of surgery for planned deliveries. Forced warm-air blankets maintained patient normothermia in the preoperative holding area.

A group of intraoperative interventions included use of antiseptic skin and vaginal preparations, double-gloving, and having all scrubbed members of the surgical team change their outer gloves for fascial closure. A new instrument tray also was used for fascial closure. Prophylactic antibiotics were administered within 1 hour of skin incision, and doses were readministered based on the length of the procedure.

 

Postoperatively, said Dr. Davidson, “a set of insulin orders within the electronic medical record [was] used to maintain euglycemia in all diabetic patients.”

After the surgical dressing was removed on the 2nd postoperative day, patients were given a handout and education about wound control and infection prevention.

Finally, all patients received postdischarge follow-up calls from nurses within 72 hours after discharge.

Patient characteristics generally were similar before (n = 1,085) and after (n = 1,261) SSI bundle implementation. Body mass index was slightly higher in the postbundle group, and women in this group also were less likely to have had a prior cesarean delivery. There were no significant differences in age, gravidity, ethnicity, or race.

 

The study showed that with continued tracking, data-sharing, and reeducation efforts, “The SSI rate was sustained after bundle implementation,” said Dr. Davidson. The implementation team, working with hospital departments, was able to achieve a high compliance rate. And, she said, the effect size of the intervention was large enough to show significant reduction from an already low SSI rate.

However, Dr. Davidson also noted some limitations: All of the bundle elements were implemented simultaneously, so it wasn’t possible to tell which components had the greatest effect. Also, not all demographic data were available, and the type of SSI was sometimes unavailable from the deidentified data repository used for analysis, she said. “We weren’t able to tease out individual patient-level characteristics” about the timing and type of SSI in a patient-by-patient fashion, she said during discussion following her presentation.

All in all, she said, the bundle’s effectiveness “supports the synergistic effects of multiple strategies and the impact of a multidisciplinary team approach.”

The study authors reported no conflicts of interest.

[email protected]

SOURCE: Davidson C et al. Am J Obstet Gynecol. 2018 Jan;218:S46.

Correction, 3/5/18: An earlier version of this article omitted the word "rate" from the headline and Vitals section.

DALLAS – A surgical site infection care bundle reduced the rate of surgical site infections (SSIs) after cesarean delivery by more than half, according to a case-control study examining data from more than 2,000 patients.

At the health center where the SSI bundle was implemented, rates per 1,000 women undergoing cesarean delivery fell from 2.44 to 1.10 (P = .013).

Martin Valigursky/Thinkstock

The study showed the effectiveness of implementing evidence-based and -supported recommendations, and of having standardized protocols with little variation, said Christina Davidson, MD, presenting the pre-post findings during a plenary session at the meeting sponsored by the Society for Maternal-Fetal Medicine.

The bundle of interventions was developed over the course of 3 months in late 2013 and early 2014 by a multidisciplinary task force, drawing from colorectal surgery literature about SSI prevention. Both nurses and physicians were on the task force, and representatives came from the departments of obstetrics and gynecology, anesthesia, and infection prevention, said Dr. Davidson of the Baylor College of Medicine, Houston. All inpatient and outpatient clinical care sites had representation.

 

After the bundle elements were identified, a full month was devoted to education and team training, with full bundle implementation occurring in April 2014. “Visual aids were placed in close proximity to the operating rooms,” said Dr. Davidson. For example, antimicrobial prophylaxis cards were placed on all anesthetic carts.

“A surgical checklist was placed in the chart for each patient undergoing cesarean delivery and compliance was tracked for the first 12 months of implementation,” said Dr. Davidson. Additionally, members of the care team received feedback in the form of quarterly reports on SSI rates and statistics about bundle compliance.

Care bundle elements included a set of instructions for pre- and postoperative antiseptic skin cleaning, wound care, and glycemic control in patients. Women were given chlorhexidine cleanser and asked to use it when showering the day before and the morning of surgery for planned deliveries. Forced warm-air blankets maintained patient normothermia in the preoperative holding area.

A group of intraoperative interventions included use of antiseptic skin and vaginal preparations, double-gloving, and having all scrubbed members of the surgical team change their outer gloves for fascial closure. A new instrument tray also was used for fascial closure. Prophylactic antibiotics were administered within 1 hour of skin incision, and doses were readministered based on the length of the procedure.

 

Postoperatively, said Dr. Davidson, “a set of insulin orders within the electronic medical record [was] used to maintain euglycemia in all diabetic patients.”

After the surgical dressing was removed on the 2nd postoperative day, patients were given a handout and education about wound control and infection prevention.

Finally, all patients received postdischarge follow-up calls from nurses within 72 hours after discharge.

Patient characteristics generally were similar before (n = 1,085) and after (n = 1,261) SSI bundle implementation. Body mass index was slightly higher in the postbundle group, and women in this group also were less likely to have had a prior cesarean delivery. There were no significant differences in age, gravidity, ethnicity, or race.

 

The study showed that with continued tracking, data-sharing, and reeducation efforts, “The SSI rate was sustained after bundle implementation,” said Dr. Davidson. The implementation team, working with hospital departments, was able to achieve a high compliance rate. And, she said, the effect size of the intervention was large enough to show significant reduction from an already low SSI rate.

However, Dr. Davidson also noted some limitations: All of the bundle elements were implemented simultaneously, so it wasn’t possible to tell which components had the greatest effect. Also, not all demographic data were available, and the type of SSI was sometimes unavailable from the deidentified data repository used for analysis, she said. “We weren’t able to tease out individual patient-level characteristics” about the timing and type of SSI in a patient-by-patient fashion, she said during discussion following her presentation.

All in all, she said, the bundle’s effectiveness “supports the synergistic effects of multiple strategies and the impact of a multidisciplinary team approach.”

The study authors reported no conflicts of interest.

[email protected]

SOURCE: Davidson C et al. Am J Obstet Gynecol. 2018 Jan;218:S46.

Correction, 3/5/18: An earlier version of this article omitted the word "rate" from the headline and Vitals section.

DALLAS – A surgical site infection care bundle reduced the rate of surgical site infections (SSIs) after cesarean delivery by more than half, according to a case-control study examining data from more than 2,000 patients.

At the health center where the SSI bundle was implemented, rates per 1,000 women undergoing cesarean delivery fell from 2.44 to 1.10 (P = .013).

Martin Valigursky/Thinkstock

The study showed the effectiveness of implementing evidence-based and -supported recommendations, and of having standardized protocols with little variation, said Christina Davidson, MD, presenting the pre-post findings during a plenary session at the meeting sponsored by the Society for Maternal-Fetal Medicine.

The bundle of interventions was developed over the course of 3 months in late 2013 and early 2014 by a multidisciplinary task force, drawing from colorectal surgery literature about SSI prevention. Both nurses and physicians were on the task force, and representatives came from the departments of obstetrics and gynecology, anesthesia, and infection prevention, said Dr. Davidson of the Baylor College of Medicine, Houston. All inpatient and outpatient clinical care sites had representation.

 

After the bundle elements were identified, a full month was devoted to education and team training, with full bundle implementation occurring in April 2014. “Visual aids were placed in close proximity to the operating rooms,” said Dr. Davidson. For example, antimicrobial prophylaxis cards were placed on all anesthetic carts.

“A surgical checklist was placed in the chart for each patient undergoing cesarean delivery and compliance was tracked for the first 12 months of implementation,” said Dr. Davidson. Additionally, members of the care team received feedback in the form of quarterly reports on SSI rates and statistics about bundle compliance.

Care bundle elements included a set of instructions for pre- and postoperative antiseptic skin cleaning, wound care, and glycemic control in patients. Women were given chlorhexidine cleanser and asked to use it when showering the day before and the morning of surgery for planned deliveries. Forced warm-air blankets maintained patient normothermia in the preoperative holding area.

A group of intraoperative interventions included use of antiseptic skin and vaginal preparations, double-gloving, and having all scrubbed members of the surgical team change their outer gloves for fascial closure. A new instrument tray also was used for fascial closure. Prophylactic antibiotics were administered within 1 hour of skin incision, and doses were readministered based on the length of the procedure.

 

Postoperatively, said Dr. Davidson, “a set of insulin orders within the electronic medical record [was] used to maintain euglycemia in all diabetic patients.”

After the surgical dressing was removed on the 2nd postoperative day, patients were given a handout and education about wound control and infection prevention.

Finally, all patients received postdischarge follow-up calls from nurses within 72 hours after discharge.

Patient characteristics generally were similar before (n = 1,085) and after (n = 1,261) SSI bundle implementation. Body mass index was slightly higher in the postbundle group, and women in this group also were less likely to have had a prior cesarean delivery. There were no significant differences in age, gravidity, ethnicity, or race.

 

The study showed that with continued tracking, data-sharing, and reeducation efforts, “The SSI rate was sustained after bundle implementation,” said Dr. Davidson. The implementation team, working with hospital departments, was able to achieve a high compliance rate. And, she said, the effect size of the intervention was large enough to show significant reduction from an already low SSI rate.

However, Dr. Davidson also noted some limitations: All of the bundle elements were implemented simultaneously, so it wasn’t possible to tell which components had the greatest effect. Also, not all demographic data were available, and the type of SSI was sometimes unavailable from the deidentified data repository used for analysis, she said. “We weren’t able to tease out individual patient-level characteristics” about the timing and type of SSI in a patient-by-patient fashion, she said during discussion following her presentation.

All in all, she said, the bundle’s effectiveness “supports the synergistic effects of multiple strategies and the impact of a multidisciplinary team approach.”

The study authors reported no conflicts of interest.

[email protected]

SOURCE: Davidson C et al. Am J Obstet Gynecol. 2018 Jan;218:S46.

Correction, 3/5/18: An earlier version of this article omitted the word "rate" from the headline and Vitals section.