Evaluation of a bundle of care to reduce incisional surgical site infection after gastrointestinal surgery

Abstract

Background: Surgical site infection (SSI) is associated with morbidity, mortality and increased care costs; many SSIs are considered preventable. The aim of the present study was to test implementation of a pragmatic, evidence-based bundle designed to reduce incisional SSI after emergency laparotomy and elective major lower gastrointestinal surgery. Method: This was a prospective before-and-after study. Data were collected before the intervention and for two separate subsequent time periods. An evidence-based bundle of care (BOC) was implemented; the primary outcome measure was incisional SSI at 30 days. The secondary outcome measure was 30-day unplanned readmissions. The initial post-intervention group, Group 2, assessed a variable number of potential impacting factors; however, due to funding and staffing levels the second post-bundle group, Group 3, focused on the core aspects of the BOC and rates of incisional SSI and readmission. Results: In total, 99 patients were included in the ‘before’ group; and 71 in Group 2 and 92 in Group 3, the post-intervention groups. The incisional SSI rate was 29.3% (29/99) before and 28.2% (20/71) in Group 2 ( P=0.873) and 21.7% (20/92) in Group 3 ( P=0.234) after the intervention. After adjustment for confounders, the care bundle was associated with a non-significant reduction in SSI (Group 2: odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.45–1.93, P=0.0843). However, it was associated with significantly reduced readmissions 18.1% (18/99) before versus 5.6% (4/71) in Group 2 (OR = 0.236, 95% CI = 0.077–0.72, P=0.012) and 8.7% (8/92) in Group 3 (OR = 0.38, 95% CI = 0.16–0.9, P=0.029). Comparing the pre-bundle group to the post-bundle groups, there was an overall significant reduction in readmissions ( P=0.003). This implies a number needed to treat of 8–11 patients to prevent one readmission. Adherence to antibiotic prophylaxis with the Trust guidelines increased from 91% to 99% (1 vs. 2, P=0.047). Conclusion: Introduction of the bundle was associated with a reduction in the observed rate of incisional SSI from 29.3% to 21.7%; significantly fewer patients required unplanned readmission. Use of the bundle was associated with significantly improved compliance with appropriate antimicrobial prophylaxis.

The Impact of Care Bundles on the Incidence of Surgical Site Infections: A Systematic Review

“…Nine of the included studies reported compliance with the SSI prevention bundle (Table 2). Overall, SSI prevention bundle compliance increased over time 19,29,32,34,35,52,53 …”

Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement

“…Ruiz-Tovar then studied the effects of closure sutures on deep SSI rates, comparing triclosan-coated barbed suture 6.4% with the control of polydioxanone loop suture 16.3% [ 40 ]. Phelan and his cohort of 83 patients, examined the rate of SSI with bundles 26.7% and without bundles 28.3% [ 39 ]. Lastly, Yamamoto, similarly to Phelan, examined the effects of bundles on SSIs, identifying an SSI rate of 20% with a bundle and 42.6% without [ 41 ].…”

“…Four of the studies’ information on patient demographics and indications for surgery were unobtainable as elective and emergency cohorts were not sub categorized [ 31 , 34 , 36 , 39 ].…”

“…The meta-analysis, while showing a reduction in the risk of SSIs by 32% following the implementation of a wound bundle (23.6%, 13/55) versus no bundle (35%, 35/100) (Figure 3), was not statistically significant (RR = 0.68; CI, 0.39-1.17; p = 0.16). The contents of the wound bundles varied and Phelan used the following elements to his wound bundle, divided into three phases [39]: pre-op (patients advised against hair removal, an on-table "social wash" and prophylatic antibiotics); intra-op (ensure normothermia, reduce movement theatre (door locks), Chloraprep scrub, antibacterial sutures and glove/gown/instrument/drape change for skin closure); post-op (wound care advice leaflet, best practise guidelines for SSI treatment and wound inspection stickers for assessment at discharge).…”

The Hidden Pandemic: the Cost of Postoperative Complications

“…Equally, the incidence of SSI may respond to bundles of care. For example, a small before and after study, whilst not finding a statistically significant decrease in infections, did find a significant decrease in (costly) re-admissions [ 49 ]. Re-admissions may reflect well the consequences of overall reduced complications rates and costs [ 35 ] as do derived parameters such as days-at-home after surgery (DAH) [ 50 ••].…”