Infection prevention in breast implant surgery – A review of the surgical evidence, guidelines and a checklist

Barr SP, Topps AR, Barnes NL, Henderson J, Hignett S, Teasdale RL, McKenna A, Harvey JR, Kirwan CC; Northwest Breast Surgical Research Collaborative

"We have produced a perioperative "Theatre Implant Checklist" for SSI prevention in implant-based breast surgery, with a set of pragmatic up to date guidelines, which allows the reader to evaluate the evidence upon which our recommendations are based."

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Tanner J, Kiernan M, Hilliam R, Davey S, Collins E, Wood T, Ball J, Leaper D

"The [Department of Health] care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs."

A bundle that includes active surveillance, contact precaution for carriers, and cefazolin-based antimicrobial prophylaxis prevents methicillin-resistant Staphylococcus aureus infections in clean orthopedic surgery

Kawamura H, Matsumoto K, Shigemi A, Orita M, Nakagawa A, Nozima S, Tominaga H, Setoguchi T, Komiya S, Tokuda K, Nishi J

"An infection-prevention bundle consisting of contact precautions for carriers and AMP stewardship in addition to active surveillance was associated with a significant decrease in the incidence of orthopedic MRSA SSIs."

Influence of a total joint infection control bundle on surgical site infection rates

Fornwalt L, Ennis D, Stibich M

"This study is unable to assess the influence on SSI rates of the individual components of the program. This was neither the design nor possible from the low number of events. Regardless, the overall cost of implementing the combined interventions was less than the estimated cost of the 7 SSIs that were prevented. Therefore, implementation of a similar combination of interventions and further investigations to maximize patient safety in total-joint procedures seems a logical recommendation."

Surgical site infection rates following implementation of a colorectal closure bundle in elective colorectal surgeries

Ghuman A, Chan T, Karimuddin AA, Brown CJ, Raval MJ, Phang PT

"There was no change in surgical site infection rates after implementation of the "Colorectal Closure Bundle." Smoking and diabetes mellitus were the only significant risk factors associated with increased surgical site infections. Our infection rates remain high and further change in our perioperative protocol is needed."

Achieving and sustaining zero: Preventing surgical site infections after isolated coronary artery bypass with saphenous vein harvest site through implementation of a staff-driven quality improvement process

Kles CL, Murrah CP, Smith K, Baugus-Wellmeier E, Hurry T, Morris CD

"A significant reduction in deep sternal wound infections was achieved by working at all levels of the organization through a multidisciplinary approach to create sustained change. Using real-time observations for current practices, areas for improvement were identified. By engaging frontline staff in the process, ownership of the outcomes and adherence to practice change were promoted. The result was a dramatic, rapid, and sustainable improvement in the prevention of deep sternal wound infection."

Organizational culture changes result in improvement in patient-centered outcomes: Implementation of an integrated recovery pathway for surgical patients

Wick EC, Galante DJ, Hobson DB, Benson AR, Lee KH, Berenholtz SM, Efron JE, Pronovost PJ, Wu CL

"Our trust-based accountability model, which included both senior hospital leadership and frontline providers, provided an enabling structure to rapidly implement an integrated recovery pathway and quickly improve outcomes, value, and experience of patients undergoing colorectal surgery. The study findings have significant implications for spreading surgical quality improvement work."

Improving outcomes in colorectal surgery by sequential implementation of multiple standardized care programs

Keenan JE, Speicher PJ, Nussbaum DP, Adam MA, Miller TE, Mantyh CR, Thacker JK

"Sequential implementation of the [enhanced recovery program] and [surgical site infection bundle] provided incremental improvements in [colorectal surgery] outcomes while controlling hospital costs, supporting their combined use as an effective strategy toward improving the quality of patient care."

Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery

Schweizer ML, Chiang HY, Septimus E, Moody J, Braun B, Hafner J, Ward MA, Hickok J, Perencevich EN, Diekema DJ, Richards CL, Cavanaugh JE, Perlin JB, Herwaldt LA

"In this multicenter study, a bundle comprising S. aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S. aureus SSIs."

Surgical site infection: Poor compliance with guidelines and care bundles

Leaper DJ, Tanner J, Kiernan M, Assadian O, Edmiston CE Jr

"Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon-specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients."

A new surgical site infection improvement programme for New Zealand: Early progress

Morris AJ, Panting AL, Roberts SA, Shuker C, Merry AF

"Through a combined package of surveillance and improvement interventions the SSII Programme aims to reduce the incidence of SSIs in New Zealand hospitals, beginning initially with hip and knee arthroplasties. Within one year of the programme starting there has been a significant nationwide improvement in the timing of surgical antimicrobial prophylaxis (p<0.0001), and the administration of the correct dose (p<0.0001). National compliance with an alcohol-based skin preparation remains high at > 95 %. In this paper we describe the purpose, background, structure and rationale of the programme and provide results to date. "

Evidence update on prevention of surgical site infection

Leaper D, Ousey K

"The incidence of SSI after surgery is not falling. Based on this review of published trials and evidence-based systematic reviews some advances might be included into these care bundles. More research is needed together with improved compliance with care bundles."

The preventive surgical site infection bundle in colorectal surgery: An effective approach to surgical site infection reduction and health care cost savings

Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR

"The preventive SSI bundle was associated with a substantial reduction in SSIs after colorectal surgery. The increased costs associated with SSIs support that the bundle represents an effective approach to reduce health care costs."

Back to basics: Preventing surgical site infections

Spruce L

"The benefits of preventing SSIs are preventing patient mortality and decreasing the burden that SSIs pose on the national health care system. It is up to health care leaders to drive and support SSI prevention initiatives."

Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery

Waits SA, Fritze D, Banerjee M, Zhang W, Kubus J, Englesbe MJ, Campbell DA Jr, Hendren S

"This multi-institutional study shows that patients who received all 6 perioperative care measures attained a very low, risk-adjusted SSI rate of 2.0%. These results suggest the promise of an SSI reduction intervention for quality improvement; however, prospective research are required to confirm this finding."

Prevention of surgical site infection: Beyond SCIP

Anderson DJ

"Most hospitals have achieved great successes in improving adherence to the basic quality measures recommended by SCIP. Yet, patients continue to have SSIs. Evidence-based strategies—optimizing antimicrobial prophylaxis dosing, preparing the colon with mechanical bowel preparation and oral antibiotics, optimizing tissue oxygenation, and using a surgical safety checklist—can help high performing hospitals and health care providers move beyond SCIP to ensure that they provide the best care possible to their surgical patients and decrease the rate of SSI."

Surgical site infection after cesarean section: Implementing 3 changes to improve the quality of patient care

Corcoran S, Jackson V, Coulter-Smith S, Loughrey J, McKenna P, Cafferkey M

A study of 1,534 patients evaluated change in surgical site infection rates for Cesarean section after implementation of a 3-intervention bundle. With a total of 710 patients in the pre-intervention period and 824 patients in the post-intervention group, the bundle included the use of nonabsorbable sutures for skin closure, clippers instead of razors and 2% ChloraPrep for skin disinfection before incision. The study concluded that surveillance of SSI rates after Cesarean section followed by 3 interventions contributed to a significant reduction in the rate of SSI.

Implementation of a bundle of care to reduce surgical site infections in patients undergoing vascular surgery

van der Slegt J, van der Laan L, Veen EJ, Hendriks Y, Romme J, Kluytmans J

"The implementation of the bundle was associated with improved compliance over time and a 51% reduction of the SSI-rate in vascular procedures. The bundle did not require expensive or potentially harmful interventions and is therefore an important tool to improve patient safety and reduce SSI’s in patients undergoing vascular surgery."

Sustained Reduction in Surgical Site Infection after Abdominal Hysterectomy

Young H, Knepper B, Vigil C, Miller A, Carey JC, Price CS

A retrospective study of 276 patients undergoing abdominal hysterectomy compared pre- and post- periods of a multifaceted intervention to determine which interventions were most valuable in decreasing SSI. With 192 patients in the pre-intervention period and 84 patients in the post-intervention period, the interventions included reporting SSI rates to gynecology faculty, re-educating OR staff about antibiotics and changing sterile preparation from povidone-iodine to chlorhexidine gluconate. The study concluded that a multifaceted intervention dramatically decreased the rate of SSI after abdominal hysterectomy, but the single component of the intervention most responsible for the improvement could not be identified.

Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis

Schweizer M, Perencevich E, McDanel J, Carson J, Formanek M, Hafner J, Braun B, Herwaldt L

"Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria."

Reducing surgical site infections in hepatopancreatobiliary surgery

Ceppa EP, Pitt HA, House MG, Kilbane EM, Nakeeb A, Schmidt CM, Zyromski NJ, Lillemoe KD

"High SSI rates following complex HPB operations can be improved by a multifactorial approach that features process improvements, individual surgeon feedback and reduced variation in patient management."

Colorectal Surgery Surgical Site Infection Reduction Program: A National Surgical Quality Improvement Program-Driven Multidisciplinary Single-Institution Experience

Cima R, Dankbar E, Lovely J, Pendlimari R, Aronhalt K, Nehring S, Hyke R, Tyndale D, Rogers J, Quast L; Colorectal Surgical Site Infection Reduction Team

A multidisciplinary team developed and implemented a surgical site infection reduction bundle of multiple interventions including 5,120 abdominal colon and rectal patients between 2009 to 2011. This team's SSI bundle resulted in a substantial and sustained reduction in SSIs.

Reduction of Surgical Site Infections after Implementation of a Bundle of Care

Crolla RM, van der Laan L, Veen EJ, Hendriks Y, van Schendel C, Kluytmans J

A prospective quasi experimental cohort study including 1,537 patients undergoing colorectal surgery concluded that the implementation of the bundle was associated with improved compliance over time and a 36% reduction of the SSI rate after adjustment for confounders.

Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections

Wick EC, Hobson DB, Bennett JL, Demski R, Maragakis L, Gearhart SL, Efron J, Berenholtz SM, Makary MA

A study evaluated the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP), which consists of a multidisciplinary team of front-line providers, and one year of pre and post-CUSP intervention SSI rates using a high risk pilot model. It demonstrated a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population.

Surgical site infections and their prevention

Schweizer ML, Herwaldt LA

A review concluded that while there is some evidence that bundled interventions can reduce SSIs, more research and robust methodologies should be undertaken to evaluate the effectiveness of these interventions.

Perioperative Surgical Care Bundle Reduces Pancreaticoduodenectomy Wound Infections

Lavu H, Klinge MJ, Nowcid LJ, Cohn HE, Grenda DR, Sauter PK, Leiby BE, Croker SP, Kennedy EP, Yeo CJ

A retrospective cohort study compared clinical data from 233 pancreaticoduodenectomies (PD) on patients who underwent routine preoperative preparation with 233 consecutive PDs following implementation of the surgical care bundle. A significant decline in wound infection followed the implementation of the surgical care bundle.

Prevalence of surgical site infections before and after the implementation of a multimodal infection control programme

Barchitta M, Matranga D, Quattrocchi A, Bellocchi P, Ruffino M, Basile G, Agodi A

"The approach used in this study remains a feasible method of evaluating the burden of SSIs using repeated prevalence surveys. The results provide evidence of a significant decreasing trend in the SSI rate following the infection control intervention. Furthermore, our study underlines the need to develop evidence-based guidelines in collaboration with surgeons, to achieve consensus before implementation in order to improve compliance with antimicrobial prophylaxis and, finally, decrease SSI rates."

Chasing zero: the drive to eliminate surgical site infections

Thompson KM, Oldenburg WA, Deschamps C, Rupp WC, Smith CD

Deployment of multiple interventions (SSI Bundle) among other methods at a nationally recognized academic health center resulted in significant declines in SSIs for patients with Class I and Class II wounds along with substantial cost savings.

A bundle of care to reduce colorectal surgical infections: an Australian experience

Bull A, Wilson J, Worth LJ, Stuart RL, Gillespie E, Waxman B, Shearer W, Richards M

A single-institution study including 275 patients undergoing colorctal surgery assessed the feasibility of implementing a bundle of care with the aim of reducing surgical site infections. Although the small sample size did not allow definitive conclusions to be drawn, the infection rate did fall from 15% to 7% 12 months after the project.

Reducing the risk of surgical site infections: did we really think SCIP was going to lead us to the promised land?

Edmiston CE, Spencer M, Lewis BD, Brown KR, Rossi PJ, Henen CR, Smith HW, Seabrook GR

A review of English-language literature suggests that the Surgical Care Improvement Project (SCIP) has had little efficacy in reducing the overall risk of SSI. Future efforts to improve surgical outcomes should embrace an enhanced version of SCIP including a multi-faceted, tiered interventional strategy.

Strategies to prevent surgical site infections

(in German)
Chaberny IF, Graf K

A review discusses strategies and key points aiding in surgical site infection prevention. Infection control measures, such as compliance observations and instruction/training of healthcare workers, clipping instead of shaving and adherence to perioperative antibiotic prophylaxis, are presented as essential for a comprehensive bundle in order to prevent SSI.

Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: Problem solution with the bundle approach

Acklin YP, Widmer AF, Renner RM, Frei R, Gross T

During a 2-year observation period, 370 patients who underwent surgical stabilization of proximal femur fractures were consecutively followed using a standardized case report form. Implementation of an intervention bundle resulted in a significant reduction of what was previously an increased SSI incidence.

Preventing surgical site infections

Uçkay I, Harbarth S, Peter R, Lew D, Hoffmeyer P, Pittet D

A review discusses how there is insufficient evidence to show whether one method of preventing SSI is superior to any other, which highlights the need for a multimodal approach involving measures at every step of the care process. Bundles are likely to be globally beneficial, although the maximum realistic extent by which SSI can be decreased remains unknown.

Outcome of a strategy to reduce surgical site infection in a tertiary-care hospital

Liau KH, Aung KT, Chua N, Ho CK, Chan CY, Kow A, Earnest A, Chia SJ

A study conducted on 2,408 patients who underwent elective gastrointestinal and hernia operations concluded that with a bundle of interventions, the overall SSI rate was reduced by 84% within two years, while also resulting in cost savings for both the patients and the hospital.

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections

Awad SS, Palacio CH, Subramanian A, Byers PA, Abraham P, Lewis DA, Young EJ

A review of data surrounding a hospital-wide implementation of a Methicillin-resistant Staphylococcus aureus (MRSA) bundle demonstrated that successful implementation of the MRSA bundle significantly decreases MRSA transmission between patients, the overall number of nosocomial MRSA infections, and MRSA SSIs.

Reducing surgical site infections at a pediatric academic medical center

Ryckman FC, Schoettker PJ, Hays KR, Connelly BL, Blacklidge RL, Bedinghaus CA, Sorter ML, Friend LC, Kotagal UR

After the Cincinnati Children's Hospital Medical Center implemented surgical site infection prevention bundles, their Class I and II SSI rates decreased by 64%. Sharing data with the improvement team, organizational leadership and the hospital's patient safety intranet site on individual and collective provider performance was an important factor contributing to the decrease in SSI rates. Daily examination on failures allowed assessment and correction, facilitating rapid-cycle improvement.

Surgical site infections: epidemiology, microbiology and prevention

Owens CD, Stoessel K

A review discusses how the risk of SSI is heavily influenced by numerous patient-related and procedure-related factors, thus requiring a 'bundle' approach for SSI prevention. A strong case exists for evaluating emerging technologies and implementing them into routine clinical practice as appropriate.

The use of bundles in clinical practice

Ruscitti LE, Puro V

A review that examines a variety of bundles, including one concerning the prevention of surgical site infection, concluded that while studies show a reduction in mortality rates, infection rates and length of hospital stay, some of those studies had a small patient population examined, and thus had a low statistical significance; future studies are necessary.