abstract
OBJECTIVE:
To
investigate whether implementing a bundle, defined as a set of
evidence-based practices performed collectively, can reduce 30-day
surgical site infections.
METHODS:
Baseline surgical site infection rates were determined retrospectively for cases of open uterine cancer, ovarian cancer without bowel resection, and ovarian cancer
with bowel resection between January 1, 2010, and December 31, 2012, at
an academic center. A perioperative bundle was prospectively
implemented during the intervention period (August 1, 2013, to September
30, 2014). Prior established elements were: patient education, 4%
chlorhexidine gluconate shower before surgery, antibiotic
administration, 2% chlorhexidine gluconate and 70% isopropyl alcohol
coverage of incisional area, and cefazolin redosing 3-4 hours after
incision. New elements initiated were: sterile closing tray and staff
glove change for fascia and skin closure, dressing removal at 24-48
hours, dismissal with 4% chlorhexidine gluconate, and follow-up nursing
phone call. Surgical site infection rates were examined using control
charts, compared between periods using χ or Fisher exact test, and
validated against the American College of Surgeons National Surgical
Quality Improvement Program decile ranking.
RESULTS:
The
overall 30-day surgical site infection rate was 38 of 635 (6.0%) among
all cases in the preintervention period, with 11 superficial (1.7%), two
deep (0.3%), and 25 organ or space infections (3.9%). In the
intervention period, the overall rate was 2 of 190 (1.1%), with two
organ or space infections (1.1%). Overall, the relative risk reduction
in surgical site infection was 82.4% (P=.01). The surgical site
infection relative risk reduction was 77.6% among ovarian cancer with bowel resection, 79.3% among ovarian cancer without bowel resection, and 100% among uterine cancer.
The American College of Surgeons National Surgical Quality Improvement
Program decile ranking improved from the 10th decile to first decile;
risk-adjusted odds ratio for surgical site infection decreased from 1.6
(95% confidence interval 1.0-2.6) to 0.6 (0.3-1.1).
CONCLUSION:
Implementation
of an evidence-based surgical site infection reduction bundle was
associated with substantial reductions in surgical site infection in
high-risk cancer procedures.
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