Reduction and sustainability of cesarean section surgical site infection: An evidence-based, innovative, and multidisciplinary quality improvement intervention bundle program


      • Find, Organize, Clarify, Understand, Select–Plan, Do, Check, Act is used to identify opportunity for improvement of the cesarean section surgical site infection rate.
      • An innovative and evidence-based cesarean section surgical site infection reduction bundle is developed.
      • Implementing the bundle is associated with a 98.4% reduction of cesarean section surgical site infection rate.


      We found cesarean section (C-section) surgical site infection (SSI) at our institution was significantly higher than the national benchmark.


      A retrospective cohort study was conducted under 4 phases from January 2008-December 2014. The hospital infection control (IC) policies and a presurgical checklist were bundled and implemented. The study was conducted with 3,334 cesarean deliveries: phase A (January 1, 2008-January 31,2010): 1,250 patients without intervention (baseline SSI rate), phase B (February 1, 2010-July 31, 2011): 682 patients were intervened with IC policies, phase C (August 1, 2011-December 31, 2012): 591 patients with an SSI reduction bundle, and phase D (January 1, 2013-December 31, 2014): 811 patients were monitored for C-section SSI sustainability. Patients not following strict protocols because of emergency C-section deliveries were excluded. The χ2 test, Fisher exact test, and standard Z test were used for statistical analyses.


      C-section SSI rates were 6.2% (77/1,250) in phase A, 3.7% (25/682) in phase B, 1.7% (10/591) in phase C, and 0.1% (1/811) in phase D, respectively. By implementing the IC policies and bundle, the C-section SSI rate was reduced 40.3% (phase B vs phase A), 72.6% (phase C vs phase A), and 98.4% (phase D vs phase A). All statistics were significantly different.


      We conclude that implementing a C-section SSI reduction bundle was associated with reduced C-section SSI rate down toward zero. A future prospectively randomized controlled trial is warranted.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kirkland K.B.
        • Briggs J.P.
        • Trivette S.L.
        • Wilkinson W.E.
        • Sexton D.J.
        The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.
        Infect Control Hosp Epidemiol. 1999; 20: 725-730
        • Schneid-Kofman N.
        • Sheiner E.
        • Levy A.
        • Holcberg G.
        Risk factors for wound infection following cesarean deliveries.
        Int J Gynaecol Obstet. 2005; 90: 10-15
        • Ahmadzia H.K.
        • Patel E.M.
        • Joshi D.
        • Liao C.
        • Witter F.
        • Heine R.P.
        • et al.
        Obstetric surgical site infections: 2 grams compared with 3 grams of cefazolin in morbidly obese women.
        Obstet Gynecol. 2015; 126: 708-715
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        Centers for disease control and prevention (CDC) hospital infection control practices advisory committee. Guideline for prevention of surgical site infection, 1999.
        Am J Infect Control. 1999; 27: 97-132
        • Centers for Disease Control and Prevention
        Surgical site infection event.
        (Available from:) (Accessed June 22, 2015)
        • Deming W.E.
        The new economics for industry, government and education.
        Massachusetts Institution of Technology Center for Advanced Engineering Study, Cambridge (MA)1993
        • Vogel P.
        • Vassilev G.
        • Kruse B.
        • Cankaya Y.
        Morbidity and mortality conference as part of PDCA cycle to decrease anastomotic failure in colorectal surgery.
        Langenbecks Arch Surg. 2011; 396: 1009-1015
        • AORN
        Perioperative standards and recommended practices.
        AORN, Inc, Denver (CO)2009
        • Comprehensive Accreditation Manual for Hospitals (CAMH)
        National Patient Safety Goal 7 (NPSG 7): Reduce the Risk of Health Care-Associated Infections.
        Commission on Accreditation of Healthcare Organization, 2009
        • Boyce J.M.
        • Pittet D.
        • Healthcare Infection Control Practices Advisory Committee
        • HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
        Guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force.
        MMWR Recomm Rep. 2002; 51: 1-45
        • Duff P.
        A simple checklist for preventing major complications associated with cesarean delivery.
        Obstet Gynecol. 2010; 116: 1393-1396
        • Anorlu R.I.
        • Maholwana B.
        • Hofmeyr J.G.
        Methods of delivering the placenta at caesarean section.
        Cochrane Database Syst Rev. 2008; (CD004737)
        • Rousseau J.
        • Gierad K.
        • Turcot-Lemay L.
        • Thomas N.
        A Randomized study comparing skin closure in cesarean sections: staples vs. subcuticular sutures.
        Am J Obstet Gynecol. 2009; 200: 1-4
        • Clay F.
        • Walsh L.
        • Walsh S.
        Staples vs. subcuticular sutures for skin closure at Cesarean delivery: a metaanalysis of randomized controlled trials.
        Am J Obstet Gynecol. 2001; 204: 378-383
        • Witter F.R.
        • Lawson P.
        • Farrell J.
        Decreasing cesarean section surgical site infection: an ongoing comprehensive quality improvement program.
        Am J Infect Control. 2014; 42: 429-431
        • Institute for Healthcare Improvement
        What is a bundle?.
        (Available from:)