Despite an increased recognition of evidence-based interventions, surgical site infections
(SSIs) remain a source of patient harm. Our 280 bed acute care hospital had an elevated
colon SSI rate (18.6%) and SIR (3.81) which was higher than predicted. The purpose
of this quality improvement project was to decrease colorectal surgery SSI through
the implementation of a formal, measurable bundle of evidence-based actions.
Our hospital lacked specific actions for colon SSI prevention. We hypothesized that
the SSI rate would be reduced by adherence to an evidence-based bundle. Consensus
was developed to implement a 7 element prevention bundle involving all phases of perioperative
care and a “stop the line” culture to promote compliance. The 7 element bundle included
standardization of: 2 step surgical skin preparation, glucose management, active warming,
preoperative antibiotics, wound protector use and bowel isolation technique was fully
implemented in December 2018. Compliance was actively measured and reported to frontline
stakeholders weekly. Full compliance took close to 4 months.
There was a substantial reduction in colon SSI's between the periods T1 (April – December
2018) and T2 (January – September 2019). An SIR of 4.31 (95% Confidence Interval [2.50,
6.95], p-value: 0.00), with a statistical interpretation of higher than predicted,
has been reduced to 0.87 (95% Confidence Interval [0.22, 2.38], p-value: 0.88), or
no different than predicted. When comparing periods, an 80% reduction in colon SSI's
(T1: 15 infections, T2: 3 infections) was observed. Fisher's Exact Test shows a statistically
significant difference between T1 and T2 (p-value: 0.005).
The SSI rate was significantly reduced by the implementation of the 7 element bundle.
Improved patient outcomes was sustained over an 8-month timeframe with over 95% compliance
to each component. Successful implementation of the bundle required support from all
levels of the organization and empowerment of frontline staff in full bundle compliance.