Introduction: Incidence of surgical site infections (SSIs) after pediatric cardiac surgery in the United States is reported between 0.25% and 6%. Associated mortality with SSIs is even greater and ranges between 7% and 20%, with the highest risk patients being those with lengthy cardiopulmonary bypass runs, delayed sternal closures, and a long post-operative length of stay.1 In addition to increased mortality risk, patients with SSIs experience an increased hospital length of stay and increase in associated care costs.(1) In observing nursing practices in the Pediatric Intensive Care Unit (PICU) at our hospital, there were notable inconsistencies in the post-operative nursing care of sternal incisions in pediatric cardiac surgery patients. In order to reduce post-operative sternal wound infections within our institution, a daily checklist for sternal wound care was developed. The goal of this checklist was to provide consistency in the post-operative care of patients after a sternotomy with the aim to reduce rates of SSIs.
Methods: This quality improvement project was conducted at a tertiary, pediatric academic center with an 8-bed PICU, and approved by the Institutional Review Board. Historical control data from April 1, 2019 to March 31, 2021 was collected and intervention data from April 1, 2021 to August 2, 2022 recorded. A multidisciplinary team consisting of pediatric cardiothoracic surgery representatives, PICU intensivists, cardiologists, and RNs, was developed. The multidisciplinary team developed and implemented a sternal incision care bundle for the post-operative care of sternotomy wounds consisting of thirteen daily assessments of the wound and care tasks. The PICU Clinical Nurse Coordinator (CNC) was responsible for educating PICU nursing staff on how to utilize the daily cardiac incision care checklist, and the practices that were to be implemented as part of the post-operative care. After implementation of the daily checklist, the CNC was responsible for daily assessment of checklist implementation and compliance amongst PICU nursing and staff. Once the daily cardiac incision care checklist was integrated into the routine, daily care of post-operative patients, face-to-face meetings and email check-ins occurred at regular intervals to
Results: Sternal wound was defined as wound erythema, discharge, or dehiscence requiring the initiation of post-op antibiotics with or without surgical intervention. Prior to implementation of the daily checklist, the incidence of sternal wound infection was 6.3% (4/63) in the control data set of 63 congenital cardiac surgery cases. After implementation of the daily checklist, the sternal wound infection incidence fell to 0 (0/36) in the intervention data set. Secondary outcomes included decreased hospital LOS and decreased costs to the patient and hospital. The mean hospital LOS decreased from 10.7 days prior to the implementation of the checklist to 7 days after.
Conclusion: The sternal incision care bundle provides a standardized approach to the care of sternal wounds after congenital heart surgery in the PICU, resulting in a significant reduction of SSIs following surgery. In addition to reduction in SSIs, decreased hospital LOS, was also documented.
