16: Bundled interventions and an institutional focus on infection prevention significantly reduces post-hysterectomy infectious morbidity

Abstract

To determine the impact of bundled interventions to prevent infectious morbidity after hysterectomy. An Infection prevention bundle was developed utilizing elements of previously published checklists as well as several data-driven measures developed from the Michigan Surgical Quality Collaborative (MSQC) to reduce post-hysterectomy infectious morbidity. These Michigan specific interventions included: addition of Metronidazole to first-generation cephalosporins for antibiotic prophylaxis, administration of beta-lactam antibiotics (unless the patient had documented anaphylactic reaction to penicillin), subcuticular closure of open incisions, early removal of Foley catheter. Moreover, an institutional focus on reducing infections consisted of a dedicated multi-disciplinary surgical site infection prevention committee consisting of infection prevention specialists, operating room nursing, surgeons and departmental leadership. Simultaneously, institution-wide efforts to increase handwashing and implement enhanced recovery were launched. All patients undergoing hysterectomy between 10/08/2015 - 10/07/2018 were divided into 3 equal yearly time frames for the analysis. Clinicopathologic data, operative details, and 30-day outcomes were obtained from three sources: electronic medical record, MSQC outcome dataset, and departmental infection prevention committee database. The primary outcome of interest was overall infection rate. This included superficial surgical site infection, deep and organ space infections, Clostridium difficile infection, culture proven urinary tract infections and others. A total of 1,867 hysterectomies were included in the analysis. Baseline demographic and operative details were similar between the patients in the three timeframes. Overall, 30-day infection rate fell from 4.5% (29/644) during year-1 to 2.6% (16/607) during year-2 to 2.1% (13/616) in year-3 (p = 0.036). Details of each category of infection included are presented in Table 1. On multivariate analysis, after adjusting for age, race, body mass index, malignancy and surgical approach, year of surgery remained an independent predictor with lower odds of infection (year-2 vs. year-1: OR 0.364 [95% CI 0.14 – 0.95]; year-3 vs. year-1: OR 0.281[95% CI 0.095 – 0.84]). A systemwide approach of implementing bundled interventions with an emphasis on infection prevention can significantly reduce infectious morbidity after hysterectomy.