Cedars-Sinai Medical Center

Los Angeles, California

Citation

Murthy R. Implementing a bundle to reduce colorectal surgical site infection. Talk presented at: Reducing SSI: Take action with evidence; May 2, 2014; Baltimore, MD.

Results

Pre-Bundle Post-Bundle
Colorectal SSI Rate: 15.5% Colorectal SSI Rate: 5.5%

SSI Prevention Bundle for Colorectal Surgery

Preoperative
CHG Shower*

During the last pre-surgery visit, instruct your patients to shower with a special antiseptic soap that contains Chlorhexidine.

Bowel Prep (OPTIONAL)

Use of bowel prep may vary by surgeon.

On day prior to surgery: Mechanical Prep +/- Oral Antibiotic Prep

Choice of antibiotics:
(First antibiotic dose to be taken AFTER completing mechanical prep, and second 4h later)

Neomycin Sulfate 1g, two doses in the evening
AND EITHER
Erythromycin Base 1g, two doses in the evening
OR
Metronidazole 1g, two doses the evening before OR the morning of surgery

Intraoperative
Antibiotics*

Use Cefotetan 1g alone for all procedures.
-If >80kg,use 2g
-If allergic, use Levofoxacin/Metronidazole 500mg/500mg.

If patient is already receiving IV antibiotics (Cefotetan, Zosyn or Flagyl) for treatment, give a pre-incision dose if the last dose was administered more than 1hr prior.

Antibiotic Redosing*

Re-dose antibiotics if the case is prolonged beyond 4hrs (examples include Cefotetan, Zosyn, and Flagyl)

CHG Skin Prep*

ALWAYS USE: Chloraprep

EXCEPT: Betadine
-Permanent Stoma
-Open wound (optional)

Wound Protector*

Wound protectors are clinically proven to decrease the risk of wound infection and maintain moisture at the incision site.

Observe Hand Hygiene*

Gel in prior to entry to OR room
Wash your hands with soap and water after degowning and degloving.

Skin Closure Protocol*

  1. Surgeon announces "Time to Close."
  2. Surgeon confirms Wound Classification (clean-contaminated, contaminated, or dirty)
  3. Scrub Nurse removes all dirty instruments, including:
    -Forceps, Needle holder
    -Suction tip
    -Bovie cautery pen
    -Light handles
  4. Sterile gloves and gown change by all team members
  5. Clean closure instruments are brought to field.
  6. Saline irrigation of wound after fascia is closed
  7. Dressing application of occlusive dry dressing (e.g. island dressing, gauze with tape or Tegaderm).

Postoperative
Wound Dressing/Care

Daily post-operative CHG bathing and discharge patient with CHG*

Maintain dry occlusive dressing; change dressing as needed

Dressing removal within 48 hours after surgery*

Consider wound probing or wicks if dirty or contaminated wound

Culture wounds if concern for infection

*Required bundle elements