Substantial Reductions in Surgical Site Infections After Colorectal Surgery With Bundling Approach

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Use of a preventive surgical site infection bundle that spanned the phases or perioperative care “was associated with a substantial reduction in [surgical site infections] after colorectal surgery,” according to results of a retrospective study of 559 patients who underwent major elective colorectal surgery. “The elements of the bundle included existing evidence-based measures as well as commonsense measures that were thought to pose minimal risk and hold potential for benefit,” Jeffrey E. Keenan, MD, and colleagues from Duke University Medical Center, Durham, North Carolina, reported in JAMA Surgery.

Surgical infections “represent a particularly important problem in colorectal surgery, for which [surgical site infection] rates are disproportionately high, ranging from 15% to 30%,” the authors noted. “The use of the bundle involved a systematic approach to improve the use of [surgical site infection] preventive measures across the phases of perioperative care. It was a multidisciplinary effort, calling on surgeons, anesthesiologists, clinic nurses, operating room staff, unit nurses, house staff, and hospital mid-level providers to enact the prescribed elements.” Patients were also involved and received educational materials and instructions for preventing surgical site infections, such as taking disinfecting showers before surgery.

The investigators identified a sample group of patients undergoing major colorectal surgery at Duke from January 2008 through December 2012. Procedures included low anterior resection, abdominoperineal resection, partial or total abdominal colectomy with or without proctectomy, proctectomy, pelvic exenteration, or Hartmann-type procedure, the author explained. Open and laparoscopic cases were included. The primary outcome was the rate of superficial surgical site infections before and after implementation of the surgical site infection bundle in July 2011.

Of 559 patients in the study, 346 (61.9%) had surgery before and 213 (38.1%) after implementation of the bundle. The median age was older in the prebundle group (62.2 vs 58.7 years, P = .04),” the study report noted. “In addition, a higher percentage of patients in the prebundle group received preoperative radiation therapy (19.1% vs 12.2%, P = .04). In contrast, a lower percentage of patients in the prebundle group had received recent chemotherapy (5.5% vs 14.6%, P < .001). The proportion of laparoscopic cases was lower in the prebundle group (38.4% vs 58.7%, P < .001) as well.” Other factors included in the analysis did not differ significantly between the two groups.

Due to the differences that might affect the rate of surgical site infections, propensity matching for the bundling was performed. “No significant difference was observed in patient demographics, baseline characteristics, or procedure-specific factors between the matched groups. Evaluation of outcomes indicated a significant reduction in superficial [surgical site infection] (19.3% vs 5.7%, P < .001) and postoperative sepsis (8.5% vs 2.4%, P = .009) in the postbundle period,” the researchers reported.

“No significant difference was observed in deep [surgical site infections], organ-space [surgical site infections], wound disruption, length of stay, 30-day readmission, or variable direct costs between the matched groups. However, in a subgroup analysis of the postbundle period, superficial [surgical site infection] occurrence was associated with a 35.5% increase in variable direct costs ($13,253 vs $9,779, P = .001) and a 71.7% increase in length of stay (7.9 vs 4.6 days, P < .001),” the authors added. They concluded that the “increased costs associated with [surgical site infections] support that the bundle represents an effective approach to reduce health care costs.”

Several recent studies, including the one by Keenan et al, “support that colorectal surgical site infection is a preventable harm with adherence to published evidence, best practice guidelines, and culture change,” according to an accompanying editorial. “In all of these studies, significant surgical site infection reduction stems from implementation of processes that span the continuum of care from before surgery through postoperative recovery,” noted Ira L. Leeds, MD, MBA, and
Elizabeth C. Wick, MD, of the Department of Surgery at Johns Hopkins University, Baltimore. ■

Keenan JE, et al: JAMA Surg. August 27, 2014 (early release online).

Leeds IL, Wick EC: JAMA Surg. August 27, 2014 (early release online).