Clinical Outcomes & Quality Lead Children's Hospital Colorado Denver, Colorado, United States
Abstract:
Introduction: Surgical site infection (SSI) is a complication of cardiac surgery associated with increased incidence of morbidity, mortality, hospital length of stay, readmission rate, & hospital cost. Since 2019, we observed a steady increased incidence of SSI . Identified causal factors included: • In 2019, the SSI Prevention Bundle was modified to reduce the number of postoperative doses of mupirocin • In 2020 the Heart Institute increased utilization of float and contract nurses who had limited orientation to hospital policies and procedures. • Increase in patients with delayed sternal closure • A low compliance with bedside hygiene and lack of standardized approach to delayed sternal closure patients was identified. • Bundle compliance audits and interviews with staff revealed inconsistencies between written policy, SSI Prevention bundle and clinical practice leading to knowledge gaps and low compliance with expected bathing and incision care protocols
The aim of this project was to decrease the SSI rate through implementation of a revised and clarified SSI bundle. We hypothesized that increased compliance with basic hygiene practices and targeted interventions for patients with delayed sternal closure would decrease the SSI incidence. Methods A multidisciplinary team performed apparent cause analyses of 2020-2021 SSIs to identify practice patterns including bundle compliance. Key interventions included: • Revised & standardized all SSI prevention resources available to staff including policies, bundles, and order sets to ensure consistency with standards of practice for all disciplines. • Standardized hygiene elements including pre-operative and post-operative bathing, intra-operative sequence of preparation, incision care after echocardiograms, & shielding incisions from potentially dirty items • Developed & implemented a bedside surgical procedure guideline and orderset that emphasized room preparation, surgical scrubs, restricted access to room during procedure, & additional antibiotic dose given prior to procedure • Modified mupirocin peri-operative dosing schedule from 2 days QD to 5 days BID
Results: SSI Prevention bundle revision & widespread re-education yielded a decreased incidence of SSI, from a baseline of 2.4 to a post-intervention rate of 1.04. See Measures Table for more details. SSI Bundle prevention compliance increased from 17% pre-intervention to 77% post-intervention.
Conclusion: The improved understanding and compliance of post-operative incision care, including standardized hygiene elements, led to a 56% decrease in SSI. The decreased SSI incidence translates to an estimated cost savings of nearly 1 million dollars annually. Concurrence between clinical policies (“work as imagined”) and clinical practice (“work as performed”) and regular auditing of performance are essential to maintain consistency in practice.
