Surgical Site Infection: A Single-Center Experience With Infection Prevention Bundle

Abstract

Surgical site infection (SSI) after lower extremity revascularization (LER) is a potentially preventable cause of major morbidity and health care expense. Perioperative SSI prevention bundles (SSI-PBs) have decreased infection rates for other surgical procedures but are not well studied in LER. The aim of this study was to determine the impact of a single-center SSI-PB for LER across risk-stratified patients. In 2014, an SSI-PB was implemented in our tertiary center for patients undergoing lower extremity bypass and later expanded to any LER requiring a groin or lower extremity incision. During the interim period, the bundle was revised to include a total of 22 best practice measures. A total of 764 patients were eligible to receive the bundle since 2014. The primary study end point was 90-day SSI. Patient and procedural characteristics from 313 consecutive LERs between January 2018 and August 2019 were analyzed to determine factors associated with SSI by univariate and multivariate analysis. A risk score was developed from the multivariate model to stratify patients. The effect of complete bundle compliance on SSI was compared across risk subgroups (low, medium, high). Of 764 patients who underwent LER and received an SSI-PB from 2014 to 2019, the SSI rate decreased from 14% to 7% (P = .01). Of 313 patients who underwent LER from 2018 to 2019, 101 (32%) were compliant with all 22 bundle measures. By a multivariate analysis, SSI was associated with procedure type (infragenicular bypass; odds ratio, 5.4, confidence interval [CI], 1.6-17.9; P = .005), critical limb ischemia (4.0; CI, 1.0-18.2; P = .05), and surgery time >240 minutes (2.3; CI, 1.0-5.9; P = .07). SSI-PB compliance was protective (0.4; CI, 0.1-1.3; P = .13) but did not reach statistical significance. An SSI-normalized risk score (surgery time >240 minutes = 1 point, critical limb ischemia = 1.5 points, infragenicular bypass = 2 points) was derived from the multivariate model, which correlated highly with SSI (P = .001; Fig). An SSI-PB may be effective in patients undergoing LER, although compliance with measures may be difficult. SSI rates after LER vary significantly on the basis of the type and length of procedure and degree of ischemia. Risk stratification is essential for appropriate benchmarking of quality improvement efforts aimed at SSI prevention.