Reduction Of Surgical Site Infections Research Articles

Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis

BackgroundThe greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis.MethodsWe performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates’ heterogeneity with I2 index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns.ResultsAfter reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20–0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations.ConclusionThe most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery.Level of EvidenceII – Systematic Review with Meta-Analysis.

Oral Antibiotic Bowel Preparation Prior to Urgent Colectomy Reduces Odds of Organ Space Surgical Site Infections: a NSQIP Propensity-Score Matched Study

BackgroundPreoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity. ResultsOf 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516–0.903). ConclusionOABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible.

SP7.8 The SUNRRISE Trial – Single Use Negative pRessure dressing for Reduction in Surgical site infection following Emergency laparotomy

Abstract Background Surgical Site Infections (SSI) are common after abdominal surgery, and more so after emergency laparotomy. Despite Single Use Negative Pressure Dressings (SUNPDs) having mixed evidence regarding effectiveness, they are recommended in the WHO SSI Prevention guidelines. SUNRRISE is an international, multi-centre, trainee devised, led and delivered randomised controlled trial, funded by the NIHR (UK) and MRFF (Australia). It investigates whether a SUNPD reduces the risk of SSI within 30 days of emergency laparotomy. Method Patients were randomised between SUNPD (PICO7©, Smith and Nephew) and surgeon's preference of dressing. Patients were eligible if they underwent an emergency laparotomy with an incision of at least 5cm that was primarily closed at the end of the operation. SSI was assessed at day 5–10, via a patient diary while the patient was at home and at day 30–44 by a blinded, trained wound assessor. Results 840 patients were randomised from 34 centres across the UK and Australia. Intention to treat analysis showed no difference in SSI between the two groups (SUNPD-28%, Control-27%, p=0.75). There was also no difference in all secondary outcomes- length of stay (9 vs 11, p=0.14), hospital readmission for wound related complications (3% vs 3%, p-0.96, rates of wound related complications (19% vs 18%, p-0.79), pain (1.8 vs 1.8, p-0.61) and quality of life (SF-12 &amp; EQ5D-5L). Conclusion SUNRRISE is a multicentre, assessor blinded, phase III RCT that provides robust evidence that single-use negative pressure dressings are not effective in reducing surgical site infections in patients undergoing an emergency laparotomy.

SURGICAL SITE INFECTION IN OBG - PRE AND POST COVID -19 PANDEMIC -A COMPARATIVE STUDY

Introduction: Methods:Surgical site infection (SSI) accounts for major morbidity in post-operative patients. An observational study was carried st out in a tertiary health centre in Kerala, India, where SSI Rates were analyzed for a period of 24 months prior and 24 months after January 2020 (1 case of COVID-19) based on patient records. A drastic reduction in SSI rates was noted in post covid period in Gynaecological casesResults: (2.44%, p=0.004). Signicant reduction in SSI was also noted in Elective LSCS (0.70%, p=0.004) and Emergency LSCS cases (1.51%, p=0.039). Conclusion: The practice of wearing N-95 masks and frequent hand washing can be continued to reduce SSI rates in OBG wards.

Mechanical bowel preparation and oral antibiotic bowel preparation in patients undergoing combined hysterectomy and bowel resection (002)

Mechanical bowel preparation and oral antibiotic bowel preparation in patients undergoing combined hysterectomy and bowel resection (002)

Does the use of intrawound povidone-iodine irrigation and local vancomycin powder impact surgical site infection rate in adolescent idiopathic scoliosis surgery?

Surgical site infection (SSI) is a major complication after adolescent idiopathic scoliosis (AIS) surgery, with an incidence ranging from 0.5 to 7%. Intraoperative wound decontamination with povidone-iodine (PVP-I) irrigation and/or vancomycin powder in adult spinal surgery has gained attention in the literature with controversial results. The aim of this study was to investigate the impact of using intrawound PVP-I irrigation and local vancomycin powder (LVP) on the incidence of early SSI in AIS surgery. All AIS patients who underwent posterior spinal fusion between October 2016 and December 2019 were retrospectively reviewed. The incidence of early SSI was reported and compared between 2 groups defined by the treating spinal surgeons' preferences: group 1-intrawound irrigation with 2L of PVP-I and application of 3g LVP before closure and control group 2-patients that did not receive either of these measures. Nine early cases of SSI (2.9%) were reported among the 307 AIS posterior spinal fusion patients. Incidence of SSI in group 1 (2/178 = 1.1%) was significantly lower than in group 2 (7/129 = 5.4%; p = 0.04). There were no adverse reactions to the use of PVP-I and LVP in our study. At latest follow-up, rate of surgical revision for mechanical failure with pseudarthrosis was significantly lower in group 1 (2/178 = 1.1%) than in group 2 (9/129 = 7.0%; p = 0.01). Intraoperative use of intrawound PVP-I irrigation and vancomycin powder is associated with a significant reduction of early SSI after AIS spine surgery. Retrospective study.

Effect of negative pressure wound therapy in exploratory laparotomies with coexisting ostomy

Background:&#x0D; Surgical site infection (SSI) is one of the most common healthcare-associated infections. The use of negative pressure wound therapy (NPWT) has shown to decrease the overall rate of SSI, wound dehiscence, and length of hospital stay in surgical conditions. This study aims to determine the impact of NPWT applied on closed surgical incisions on patients with coexisting ostomy undergoing exploratory laparotomy.&#x0D; &#x0D; Methods:&#x0D; A retrospective study on patients who underwent exploratory laparotomies from 2017 to 2019 was conducted. NPWT was compared to standard post-operative surgical wound dressing. A sub-analysis of patients with ostomies was performed.&#x0D; &#x0D; Results:&#x0D; A total of 286 patients who underwent exploratory laparotomy were identified; 51 patients received NPWT and 235 received standard dressing. The NPWT group had a higher percentage of patients with an ostomy (37.3% vs 20.4%, P=.016), of which 25.5% were colostomies (vs 12.3%) and 11.8% were ileostomies (vs 8.1%) with P=.002. No significant difference in the overall rate of SSI (7.8% vs 5.5%, P= .517), wound dehiscence (7.8% vs 2.1 %, P=.057), and seroma formation (3.9% vs 2.1%, P=.612) were observed. The mean length of ICU stay (3.5 vs 7.0, P=.051) and unplanned reoperation (5.9% vs 16.6%, P=.051) were lower in the NPWT group compared to the control group. Sub analysis of patients with stoma found no significant difference in SSI.&#x0D; &#x0D; Conclusions:&#x0D; In our study, the use of NPWT on closed surgical incision wound was not associated with the reduction of SSI in patients with ostomies. Large studies are needed to ascertain significant benefits in patients with ostomies.&#x0D; &#x0D; Keywords: negative pressure wound therapy, surgical site infection, ostomy, exploratory laparotomy

Putting patient value first: Using a modified nominal group technique for the implementation of enhanced recovery after cardiac surgery recommendations

ObjectiveIn 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective. MethodsUsing a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities. ResultsSeven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively. ConclusionsExploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.

Unbundling Bundles: Evaluating the Association of Individual Colorectal Surgical Site Infection Reduction Bundle Elements on Infection Rates in a Statewide Collaborative.

Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. The purpose of this study was to evaluate the association of individual surgical site infection reduction bundle elements with infection rates. This was a post-hoc analysis of a prospective cohort study. This study took place at Illinois Surgical Quality Improvement Collaborative hospitals. Patients who had elective colorectal resections at participating hospitals from 2016 to 2017. The intervention was a 16-element colorectal surgical site infection reduction bundle. Surgical site infection rates were compared among patients by adherence with each bundle element using χ 2 tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. Among 2722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41-0.97]), wound protectors (OR 0.55 [95% CI 0.37-0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51-1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of oral antibiotics, wound protector, or redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation was associated with the absence of infection (consistency = 0.94, coverage = 0.96). Four of the 5 principal component composites in various combinations were associated with the absence of surgical site infection, whereas the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/B808 . ANTECEDENTES:Los paquetes de reducción de infecciones del sitio quirúrgico son efectivos pero pueden ser complejos y requieren muchos recursos. Comprender qué elementos del paquete están asociados con la reducción de las infecciones del sitio quirúrgico puede guiar la implementación concisa del paquete.OBJETIVO:Evaluar la asociación de los elementos individuales del paquete de reducción de infecciones del sitio quirúrgico con las tasas de infección.DISEÑO:Análisis post-hoc de un estudio de cohorte prospectivo.ESCENARIO:Hospitales colaborativos para la mejora de la calidad quirúrgica de Illinois.PACIENTES:Resecciones colorrectales electivas en los hospitales participantes entre 2016 y 2017.INTERVENCIONES:Paquete de reducción de infección del sitio quirúrgico colorrectal de 16 elementos.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las tasas de infección del sitio quirúrgico entre los pacientes según la adherencia con cada elemento del paquete mediante pruebas de Chi cuadrado y regresión logística multivariable. El análisis de componentes principales identificó compuestos de elementos de paquete correlacionados. El análisis de coincidencia identificó combinaciones de elementos del haz o compuestos de componentes principales asociados con la ausencia de infección del sitio quirúrgico.RESULTADOS:Entre 2722 pacientes, 192 (7,1%) desarrollaron una infección del sitio quirúrgico. Las infecciones fueron menos probables cuando se administraron antibióticos orales (OR 0,63 (IC 95% 0,41-0,97)), protectores de heridas (OR 0,55 (IC 95% 0,37-0,81)) y vendajes oclusivos (OR 0.71 (IC 95% 0,51-1,00]) fueron usados. Los elementos del paquete se redujeron a 5 grupos de componentes principales. La adherencia a la combinación de (1) antibióticos orales, (2) protector de heridas o (3) redosificación de profilaxis antibiótica intravenosa más preparación de la piel intraoperatoria con clorhexidina-alcohol se asoció con la ausencia de infección (consistencia = 0,94, cobertura = 0,96). Cuatro de los cinco grupos de componentes principales en varias combinaciones se asociaron con la ausencia de infección del sitio quirúrgico, mientras que el grupo que consiste en la colocación del apósito oclusivo, la remosión del apósito en posoperatorio y la limpieza incisional posoperatoria diaria con clorhexidina no tuvo asociación con el resultado.LIMITACIONES:La inclusión de hospitales que participan en iniciativas de mejora de la calidad puede limitar la generalización de estos datos.CONCLUSIONES:Los elementos del paquete tuvieron una asociación variable con la reducción de la infección. La implementación de paquetes de reducción de infecciones del sitio quirúrgico colorrectal debe centrarse en los elementos específicos asociados con pocas infecciones del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B808 . (Traducción-Juan Carlos Reyes ).

Preventing caesarean section wound complications: use of a silver-impregnated antimicrobial occlusive dressing.

To investigate the role of an adherent soft silicone antimicrobial occlusive foam silver-impregnated dressing for reduction of surgical site infections (SSI) in primary low-transverse caesarean section (1°LTCS) delivery. Women aged 18-45 years admitted to the labour and delivery or the antepartum unit undergoing a 1°LTCS were recruited. Exclusion criteria included repeat caesarean, vertical skin incision, intrapartum fever and closure with staples. Consented participants delivered by scheduled or unscheduled 1°LTCS received the silver-impregnated dressing. Those who declined to participate and were delivered by scheduled or unscheduled caesarean received a standard gauze with tape dressing (controls). Surgical preparation and preoperative antibiotics were administered as per hospital policy. A total of 362 participants were consented for use of the silver-impregnated dressing, with 190 participants undergoing 1°LTCS, of whom 185 were included in the final analysis. Of those who declined to participate, 190 ultimately underwent 1°LTCS during the same time period. Cases and controls were similar in demographics, body mass index, diabetes status, labour and procedure length, and tobacco use. The overall incidence of SSI was 3.7%. A 50% reduction in incidence of SSI was observed in the silver-impregnated dressing group compared with control group (2.7% versus 4.7%, respectively), but this was not statistically significant (p=0.08; odds ratio 0.55; 95% confidence interval: 0.18-1.67). Among women undergoing 1°LTCS with subcuticular closure of a transverse incision, use of a silver-impregnated dressing reduced the rate of SSI by >50% but was not statistically significant.

Development and Validation of a Model for Predicting Surgical Site Infection After Pelvic Organ Prolapse Surgery.

Surgical site infection (SSI) is a common and costly complication. Targeted interventions in high-risk patients may lead to a reduction in SSI; at present, there is no method to consistently identify patients at increased risk of SSI. The aim of this study was to develop and validate a model for predicting risk of SSI after pelvic organ prolapse surgery. Women undergoing surgery between 2011 and 2017 were identified using Current Procedural Terminology codes from the Centers for Medicare and Medicaid Services 5% Limited Data Set. Surgical site infection ≤90 days of surgery was the primary outcome, with 41 candidate predictors identified, including demographics, comorbidities, and perioperative variables. Generalized linear regression was used to fit a full specified model, including all predictors and a reduced penalized model approximating the full model. Model performance was measured using the c-statistic, Brier score, and calibration curves. Accuracy measures were internally validated using bootstrapping to correct for bias and overfitting. Decision curves were used to determine the net benefit of using the model. Of 12,334 women, 4.7% experienced SSI. The approximated model included 10 predictors. Model accuracy was acceptable (bias-corrected c-statistic [95% confidence interval], 0.603 [0.578-0.624]; Brier score, 0.045). The model was moderately calibrated when predicting up to 5-6 times the average risk of SSI between 0 and 25-30%. There was a net benefit for clinical use when risk thresholds for intervention were between 3% and 12%. This model provides estimates of probability of SSI within 90 days after pelvic organ prolapse surgery and demonstrates net benefit when considering prevention strategies to reduce SSI.

Perioperative care bundles for the prevention of surgical-site infections: meta-analysis.

Care bundles are used widely to prevent surgical-site infections (SSIs). Recent systematic reviews suggested larger effects from bundles with more interventions. These reviews were largely based on uncontrolled before-after studies and did not consider their biases. The aim of this meta-analysis was to determine the effectiveness of care bundles to prevent SSIs and explore characteristics of effective care bundles. A systematic review, reanalysis, and meta-analysis of available evidence were undertaken. RCTs, controlled before-after studies, and uncontrolled before-after studies with sufficient data for reanalysis as interrupted time series studies (ITS) were eligible. Studies investigating the use of a care bundle, with at least one intraoperative intervention, compared with standard care were included. Four RCTs, 1 controlled before-after study, and 13 ITS were included. Pooled data from RCTs were heterogeneous. Meta-analysis of ITS resulted in a level change of -1.16 (95 per cent c.i.-1.78 to -0.53), indicating a reduction in SSI. The effect was larger when the care bundle comprised a higher proportion of evidence-based interventions. Meta-regression analyses did not show statistically significant associations between effect estimates and number of interventions, number of evidence-based interventions, or proportion of evidence-based interventions. Meta-analysis of ITS indicated that perioperative care bundles prevent SSI. This effect is inconsistent across RCTs. Larger bundles were not associated with a larger effect, but the effect may be larger if the care bundle contains a high proportion of evidence-based interventions. No strong evidence for characteristics of effective care bundles was identified.

Fraction of inspired oxygen during general anesthesia for non-cardiac surgery: Systematic review and meta-analysis.

BackgroundControversy exists regarding the effects of a high versus a low intraoperative fraction of inspired oxygen (FiO2) in adults undergoing general anesthesia. This systematic review and meta‐analysis investigated the effect of a high versus a low FiO2 on postoperative outcomes.MethodsPubMed and Embase were searched on March 22, 2022 for randomized clinical trials investigating the effect of different FiO2 levels in adults undergoing general anesthesia for non‐cardiac surgery. Two investigators independently reviewed studies for relevance, extracted data, and assessed risk of bias. Meta‐analyses were performed for relevant outcomes, and potential effect measure modification was assessed in subgroup analyses and meta‐regression. The evidence certainty was evaluated using GRADE.ResultsThis review included 25 original trials investigating the effect of a high (mostly 80%) versus a low (mostly 30%) FiO2. Risk of bias was intermediate for all trials. A high FiO2 did not result in a significant reduction in surgical site infections (OR: 0.91, 95% CI 0.81–1.02 [p = .10]). No effect was found for all other included outcomes, including mortality (OR = 1.27, 95% CI: 0.90–1.79 [p = .18]) and hospital length of stay (mean difference = 0.03 days, 95% CI −0.25 to 0.30 [p = .84). Results from subgroup analyses and meta‐regression did not identify any clear effect modifiers across outcomes. The certainty of evidence (GRADE) was rated as low for most outcomes.ConclusionsIn adults undergoing general anesthesia for non‐cardiac surgery, a high FiO2 did not improve outcomes including surgical site infections, length of stay, or mortality. However, the certainty of the evidence was assessed as low.

Addressing Surgical Site Infections: Development and Implementation of an Apparent Cause Analyses Process for Hospital and System-Level Improvement

Background Surgical site infections (SSIs) are the most costly type of healthcare-associated infection and remain one of the most complicated infection types to reduce. The need for bundled interventions, agreement from multiple parties, and difficulty assessing proven reduction methods makes sustaining improvement processes difficult. To help drive improvement work, a standardized SSI review process centered around apparent case analysis (ACA) was implemented. This review process was paired with a data dashboard to assess overall compliance with the Centers for Disease Control and Prevention (CDC) category IA recommendations. Methods Surgical services, surgeons, and infection prevention agreed to use CDC category IA recommendations to reduce SSIs as standard benchmarks to identify gaps in best practice. A standardized ACA template specific to SSIs was created to review infections. Deviations in care were communicated to site leadership and system perioperative committees. Process improvement tactics were generated at the hospital level based on site needs. Needs were determined through a baseline assessment of compliance with CDC category IA recommendations. Deficiencies were tracked systematically across each hospital and analyzed for trends through the use of a data dashboard. Results Implementation of the ACA process has led to increased surgeon understanding of SSI reduction elements and the value of infection prevention case review and surveillance. All hospitals within the healthcare system have implemented the CDC SSI reduction guidelines and are working toward 90% compliance with category IA recommendations. Conclusions Apparent cause analysis has shown to be a reliable and engaging tool to bridge communication between infection prevention and surgical services at a multi-hospital healthcare system. Using a standardized ACA reporting tool in conjunction with real-time data has allowed surgical leadership to drive change and increase compliance with CDC category IA recommendations. Surgical site infections (SSIs) are the most costly type of healthcare-associated infection and remain one of the most complicated infection types to reduce. The need for bundled interventions, agreement from multiple parties, and difficulty assessing proven reduction methods makes sustaining improvement processes difficult. To help drive improvement work, a standardized SSI review process centered around apparent case analysis (ACA) was implemented. This review process was paired with a data dashboard to assess overall compliance with the Centers for Disease Control and Prevention (CDC) category IA recommendations. Surgical services, surgeons, and infection prevention agreed to use CDC category IA recommendations to reduce SSIs as standard benchmarks to identify gaps in best practice. A standardized ACA template specific to SSIs was created to review infections. Deviations in care were communicated to site leadership and system perioperative committees. Process improvement tactics were generated at the hospital level based on site needs. Needs were determined through a baseline assessment of compliance with CDC category IA recommendations. Deficiencies were tracked systematically across each hospital and analyzed for trends through the use of a data dashboard. Implementation of the ACA process has led to increased surgeon understanding of SSI reduction elements and the value of infection prevention case review and surveillance. All hospitals within the healthcare system have implemented the CDC SSI reduction guidelines and are working toward 90% compliance with category IA recommendations. Apparent cause analysis has shown to be a reliable and engaging tool to bridge communication between infection prevention and surgical services at a multi-hospital healthcare system. Using a standardized ACA reporting tool in conjunction with real-time data has allowed surgical leadership to drive change and increase compliance with CDC category IA recommendations.

Post-operative Wound Care Protocol Prevents Surgical Site Infection After Craniotomy

<h3>Background</h3> Surgical Site Infections (SSIs) following craniotomy may be affected by extensive head vasculature. Attentive post-operative wound care to keep hair away, cleanse skin, and remove incisional clots that provide nutrients for organisms may help prevent SSIs. <h3>Methods</h3> In 2018, 72% of craniotomy SSIs at an academic medical center were related to post-operative wound disruption, drainage, and compromised wound healing. These SSIs involved Gram-positive organisms, consistent with skin flora. In January 2019, a post-operative wound care protocol developed by neurosurgical nurse and wound care specialists, and the infection prevention program was initiated, involving 1) soft bands to keep the incision clear of hair, and 2) 2% chlorhexidine gluconate (CHG) cloths to clean the incision and the proximal 6-inches of any drains, remove incisional clots, and clean adjacent skin and hair within 2 inches of the incision. Twice-weekly photos were taken of post-operative craniotomy wounds with protocol lapses and real-time feedback was provided to the bedside nurse, wound care nurse, and surgeon from February 2019-February 2020. Due to the Coronavirus Disease 2019 pandemic (COVID-19), the program progressively lapsed until January 2021, when it was reinstated. SSI rates were compared during the periods with and without the intervention using a chi-square test. <h3>Results</h3> Baseline Craniotomy SSI rate prior to January 2019 was 3.8% (5/133, SIR=2.6) and 1.7% (16/952, SIR=1.1) during the first intervention period. During COVID-19 surge, SSIs increased to 3.6% (5/140, SIR=2.3) without the intervention, and were restored to a lower rate, 1.6% (2/128, SIR=0.9) after the intervention was reinstituted. SSI rates were lower in intervention (1.7% (18/1080)) versus non-intervention periods (3.7% (10/273)), p=0.04. <h3>Conclusions</h3> A post-operative inpatient craniotomy wound care protocol involving hair care, incisional CHG cleansing and clot removal, plus photo documentation and feedback for protocol adherence was associated with SSI reduction.

Reduction of Instrumentation-Related Spine Surgical Site Infections After Optimization of Surgical Techniques. A Single Center Retrospective Analysis.

Retrospective cohort study. Although surgical risk factors for developing spine surgical site infections (S-SSI) have been identified, the impact of such knowledge in its prevention has not been demonstrated. We evaluated in 500 patients undergoing spine surgery between 2011 and 2019 at Hospital 12 de Octubre the changes in S-SSI rates over time. Surgical variables independently related to S-SSI were analyzed by univariate and multivariate analysis using binary logistic regression models. A case-control sub-analysis (1:4), matched by the surgical variables identified in the overall cohort was also performed. Twenty cases of S-SSI were identified (4%), with a significant decrease in the incidence rate across consecutive time periods (6.6% [2011-2014] vs .86% [2015-2019]; P-value <.0001)). Multivariate analysis identified arthrodesis involving sacral levels (odds ratio [OR]: 2.57; 95% confidence interval [95%CI]: 1.02-6.47; P-value = .044) and instrumentation over 4-8 vertebrae (OR: 2.82; 95%CI: 1.1-7.1; P-value = .027) as independent risk factors for S-SSI. The reduction in the incidence of S-SSI concurred temporally with a reduction in instrumentations involving 4-8 vertebrae (55% vs 21.8%; P-value <.0001) and sacral vertebrae (46.9% vs 24.6%; P-value <.0001) across both periods. The case-control analysis matched by these surgical variables failed to identify other factors independently related to the occurrence of S-SSI. Spinal fusion of more than 4 levels and the inclusion of sacral levels were independently related to the risk of S-SSI. Optimization of surgical techniques by reducing these two types of instrumentation could significantly reduce S-SSI rates.

Meta-analysis of randomized controlled trials comparing minimal-invasive versus open pancreatic surgery

Abstract Objective To compare perioperative outcomes of minimal-invasive pancreatic surgery (MIPS) to open pancreatic surgery (OPS) using data obtained from randomised controlled trials (RCTs). Methods Literature search was done in CENTRAL, Medline and Web of Science; all currently available RCTs comparing MIPS and OPS in adult patients requiring elective distal pancreatectomy (DP) or partial pancreatoduodenectomy (PD) were included in the analysis. Outcomes were mortality, general and pancreatic surgery specific morbidity and length of hospital stay (LOS). Subgroup analysis between PD and DP was performed. A random-effects model for Mantel-Haenzsel and inverse variance analysis was used. Cochrane RoB 2.0 tool and GRADE approach was used for assessment of risk of bias and certainty of evidence. Results A total of 166 patients for DP (80 MIPS vs. 86 OPS) in two RCTs and 856 for PD (429 MIPS vs. 427 OPS) in five RCTs were analysed. Meta-analysis showed a reduction of LOS by 1.2 days (-2 to -0.3, p&amp;lt;0.01) and intraoperative blood loss by 143 ml (-186 to -101, p&amp;lt;0.01) in MIPS. In the subgroup analysis reduction of LOS was only present for minimal-invasive DP (-2 days, -2.3 to -1.7, p&amp;lt;0.01). A minimal-invasive approach showed reduction of surgical site infections (odds ratio 0.4, 0.1 to 0.96, p=0.04) and intraoperative blood loss (-141 ml, -181 to -101, p&amp;lt;0.01) only in PD. Duration of surgery was about 96 min longer in minimal-invasive PD (56 to 137 min, p&amp;lt;0.01), but not in DP. Analysis showed no significant difference between MIPS and OPS, as well as between subgroups, in mortality, complications according to Clavien-Dindo &amp;gt;=3 and pancreatic surgery specific complications like postoperative pancreatic fistula and delayed gastric emptying. Certainty of evidence according to the GRADE approach was moderate to low. Conclusion This meta-analysis of level 1 evidence shows reduced LOS and intraoperative blood loss in MIPS compared to OPS. Morbidity and mortality did not differ between MIPS and OPS. Longer duration of surgery in minimal-invasive PD hints that minimal-invasive technique in PD is more challenging than in DP. However, patients undergoing minimal-invasive PD seem to benefit from lower surgical site infections and less intraoperative blood loss.

The Strike Team as an implementation strategy for surgical infection prevention

Background: Surgical site infections (SSIs) incur up to $10 billion annually due to their excessive morbidity. SSI prevention bundles have had variable success in colorectal surgery. For example, at the University of Wisconsin Hospital, a 505-bed regional referral center, SSI rates have remained high despite the introduction of a 14-element SSI prevention bundle in 2016. To aid in the implementation of this complex bundle, the hospital started Strike Teams in 2019. We have described the impact of Strike Teams on colorectal SSI rates in our tertiary-care hospital. Methods: A Strike Team with key stakeholders from colorectal surgery (ie, surgeon, OR director, nurses, surgical technicians), anesthesia, pharmacy, infection prevention, and infectious disease was formed, supported by the hospital’s executive leadership. The Strike Team met monthly throughout 2019 to review each SSI case, discussed barriers to adherence for the SSI prevention bundle elements with implementation difficulties (Table 1), and proposed actionable feedback to increase adherence. The latter was disseminated to frontline clinicians by the teams’ surgical leaders during everyday clinical practice. The Strike Team was paused in 2020 due to resource reallocation in response to the COVID-19 pandemic. Monthly and quarterly SSI surveillance was conducted according to CDC guidance. Results: Colorectal SSI rates before, after, and during Strike Team activity are shown in Fig. 1. Adherence rates to the bundle elements targeted by the Strike Team are shown in Fig. 2. Conclusions: Adherence to the preferred antibiotic prophylaxis increased, although adherence to other bundle elements of focus did not change significantly. SSI rates decreased below our expectation while the Strike Team was active in our hospital, although SSI reduction was not sustained. Further research should study the effectiveness of Strike Teams as a long-term implementation strategy for SSI prevention in colorectal surgery.Funding: NoneDisclosures: None

Reducing surgical site infections after colectomy: bundle item compliance, process, and outlier identification.

The purpose of this study was to implement a checklist monitoring system and identify critical surgical checklist items associated with post-colectomy surgical site infections (SSI). The relationship between checklist compliance, infection rates, and identification of non-compliant surgeons was explored. National Health Safety Network (NHSN) data were imported annually to establish baseline incidence of post-colectomy SSI from 2016 to 2019. A colectomy checklist was used to monitor compliance for 1694 random colectomies (1274 elective; 420 emergency). Reports were generated monthly to profile system, hospital, surgeon-specific infection, and checklist compliance rates. Checklist compliance improved in elective and emergent colectomies to > 90% for all items except oral antibiotic and mechanical bowel prep in elective cases. Annualized total SSI and organ space infection rates in elective cases decreased by 33% and 45%, respectively. Elective and emergency SSI's were reduced for Superficial Incisional Primary (SIP), Deep Incisional Primary (DIP), and Intra-Abdominal Abscess (IAB) by 66%, 60.4%, and 78.3%, respectively. Checklist compliance between low (< 3%) and high (> 3%) infection rate surgeons demonstrated significantly lower utilization of oral antibiotic prep (p < 0.03) and mechanical bowel prep (p < 0.02) in high infection rate surgeons. Surgeons compliant with colectomy checklists decreased elective and emergency colectomy infection rates. Ceiling compliance rates > 95% for bundle items are suggested to achieve optimal reductions in SSIs and efforts should be focused on surgeons with NHSN infection rates > 3%. Oral antibiotic prep and mechanical bowel prep compliance rates in elective colectomy appeared to differentiate high infection rate surgeons from low infection rate surgeons.

MP25-18 SEPARATE ABDOMINAL CLOSURE TRAYS SIGNIFICANTLY IMPROVE CYSTECTOMY SURGICAL SITE INFECTION; OUTCOMES FROM A PRE-POST IMPLEMENTATION NATIONAL SURGICAL QUALITY INPATIENT PROGRAM (NSQIP) PROJECT

You have accessJournal of UrologyCME1 May 2022MP25-18 SEPARATE ABDOMINAL CLOSURE TRAYS SIGNIFICANTLY IMPROVE CYSTECTOMY SURGICAL SITE INFECTION; OUTCOMES FROM A PRE-POST IMPLEMENTATION NATIONAL SURGICAL QUALITY INPATIENT PROGRAM (NSQIP) PROJECT Kevin Krughoff, Christopher Mantyh, Charles D. Scales, and Andrew C. Peterson Kevin KrughoffKevin Krughoff More articles by this author , Christopher MantyhChristopher Mantyh More articles by this author , Charles D. ScalesCharles D. Scales More articles by this author , and Andrew C. PetersonAndrew C. Peterson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While surgical site infection (SSI) prevention bundles have gained popularity across many disciplines, the urologic experience remains underreported. Our goal was to assess the impact of an abdominal closure protocol (ACP) on the incidence of SSI, UTI and procedure duration for cystectomy with urinary diversion. METHODS: A standardized abdominal closure protocol (ACP) was adopted at our institution in 2021 which included re-prep and re-drape of the abdomen, change of surgeon gowns and gloves and utilization of a separate abdominal closure tray. Utilizing the National Surgical Quality Inpatient Program (NSQIP) database, patients who underwent cystectomy and urinary diversion between 2016-2021 were identified for assessment. Cases incorporating the ACP were matched to cases pre-dating the incorporation of the ACP through propensity score matching based on 16 NSQIP-derived predictor variables. The optimal matching algorithm was determined based on greatest resulting reductions in standardized mean differences and variance ratios between groups. Counterfactual outcomes were generated using logistic regression to determine the average treatment effect of ACP incorporation. Standard errors and the 95% confidence intervals were calculated from 1,000 bootstrap samples. RESULTS: A total of 327 cases at our facility were reviewed. Twenty-three of 24 ACP cases were successfully matched to 245 of 303 non-ACP cases using a kernel-matching algorithm (Figure 1). Matching resulted in standardized mean differences below 0.1 for 14 of 16 NSQIP predictor variables and variance ratios of less than 2.0 for all NSQIP predictor variables. Following ACP incorporation, there was a raw SSI reduction of 5.7%, a raw UTI reduction of 5.6% and a raw increase in procedure duration of 38.4 minutes. The estimated treatment effect after modeling was a 4.1% reduction in SSI (p<0.02, CI 0.6% to 7.5%), with no significant effect on UTI incidence or procedure duration. CONCLUSIONS: Using a treatment effects model, the incorporation of an abdominal closure protocol was associated with a significant reduction in surgical site infection with minimal increase in surgical time. Source of Funding: Boston Scientific Fellowship Grant © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e435 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Krughoff More articles by this author Christopher Mantyh More articles by this author Charles D. Scales More articles by this author Andrew C. Peterson More articles by this author Expand All Advertisement PDF DownloadLoading ...