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Decreasing Colon Surgical Site Infections Through Multidisciplinary Engagement Using a Practice Bundle

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      Background

      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.

      Methods

      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.

      Results

      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).

      Conclusions

      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.
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