Return to the fundamentals: Implementing best practice reduces cardiac bypass surgical site infection rates

Abstract

BACKGROUND/OBJECTIVES: Surgical site infections (SSIs) are associated with increased morbidity and mortality and prolonged hospital stay. Risk for SSIs is associated with breaks from best practice recommendations promulgated by the Centers for Disease Control and Prevention (CDC) and endorsed by many other surgery-associated organizations. In 2002, routine SSI rates for coronary artery bypass grafts (CABGs) were over the National Nosocomial Infections Surveillance System (NNIS) 90th percentile. Rates for donor graft sites (leg) and the sternums were both too high. Cultures obtained from the former site grew largely gram-negative rods or were polymicrobial, and those from the latter site grew gram-positive organisms. METHODS: This 1000-bed tertiary-care hospital in Baltimore, Maryland, does approximately 600 CABGs each year. Best practices, including education of nurses, physician assistants, and surgeons, were implemented over a 2-year period to increase awareness of the data supporting these practices and compliance. Interventions included use of 2% chlorhexidine showers for patients the evening prior to and morning of CABG to reduce their bacterial burden. The pre-surgical skin prep in the operating room was changed to an alcohol/betadine combination for prepping. A water-free surgical hand scrub, as well as additional cleaning of the patient's groin area prior to individual leg skin prep, were instituted as well. Prophylactic antimicrobial choice and the timing were optimized and the use of flash sterilization decreased. RESULTS: The SSI rates for CABG procedures went from a high of 12.16 infections/100 cases in the first quarter of 2003 to a low of 5.15 infections/100 cases in the third quarter of 2004. This represents a 58% decrease in SSI for CABG in a period of approximately 18 months and translates into a minimum cost savings of $153,799. CONCLUSIONS: Interventions to prevent SSIs take a long time and a great deal of work and must be endorsed by many people. Implementation of the best practices within the cardiac surgery department resulted in a significant decrease in SSI (p = 0.02) and cost savings of $153,799. Continual reinforcement of best practices is needed to maintain a safe patient environment.