Skip to main content Accessibility help
×
Home
Hostname: page-component-5c569c448b-9hjnw Total loading time: 0.255 Render date: 2022-07-05T01:55:01.838Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

A comprehensive unit-based safety program for the reduction of surgical site infections in plastic surgery and hand surgery

Published online by Cambridge University Press:  14 October 2019

Laura Lenherr Ramos
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital and University of Zurich, Zurich, Switzerland
Rainer Weber
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital and University of Zurich, Zurich, Switzerland
Hugo Sax
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital and University of Zurich, Zurich, Switzerland
Pietro Giovanoli
Affiliation:
Department of Plastic Surgery and Hand Surgery, University Hospital and University of Zurich, Zurich, Switzerland
Stefan P. Kuster*
Affiliation:
Division of Infectious Diseases and Hospital Epidemiology, University Hospital and University of Zurich, Zurich, Switzerland
*
Author for correspondence: Stefan P. Kuster MD, Email: stefan.kuster@usz.ch

Abstract

Objective:

To reduce surgical site infection (SSI) incidence in plastic surgery and hand surgery.

Design:

Uncontrolled before-and-after study.

Setting:

Department of plastic surgery and hand surgery of a tertiary-care teaching hospital.

Patients:

Patients undergoing surgery between January 2016 and April 2018.

Intervention:

A comprehensive unit-based safety program (CUSP) consisting of a bundle of evidence-based SSI prevention strategies and a change in safety culture was fully implemented after a 14-month baseline surveillance and implementation period. SSI surveillance was performed over an intervention period of another 14 months, and differences in SSI rates between the 2 periods were calculated. Adherence with bundle components and risk factors for SSI were further evaluated in a case-cohort analysis.

Results:

Of 3,321 patients, 63 (1.9%) developed an SSI, 38 of 1,722 (2.2%) in the baseline group and 25 of 1,599 (1.6%) in the intervention group (P = .20). The CUSP was associated with an adjusted relative SSI risk reduction of 41% (95% confidence interval [CI], 0.4%–65%; P = .048) in multivariable analysis, whereas the need for revision surgery increased SSI risk (odds ratio [OR], 2.63; 95% CI, 1.31–5.30; P = .007). During the intervention period, the proportion of checklists completed was 62.4%, and no difference in adherence with bundle components between patients with and without SSI was observed.

Conclusions:

This CUSP helped reduce SSI in a surgical specialty with a low baseline SSI incidence, even though adherence with checklist completion was moderate and the main modifiable risk factors remained unchanged over time. Programs that include safety culture change may more effectively promote SSI reduction than prevention bundles alone.

Type
Original Article
Copyright
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

a

Authors with equal contribution.

References

Dimick, JB, Chen, SL, Taheri, PA, Henderson, WG, Khuri, SF, Campbell, DA Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004;199:531537.CrossRefGoogle ScholarPubMed
Perencevich, EN, Sands, KE, Cosgrove, SE, Guadagnoli, E, Meara, E, Platt, R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003;9:196203.CrossRefGoogle ScholarPubMed
Astagneau, P, Rioux, C, Golliot, F, Brucker, G. Morbidity and mortality associated with surgical site infections: results from the 1997–1999 INCISO surveillance. J Hosp Infect 2001;48:267274.CrossRefGoogle ScholarPubMed
de Lissovoy, G, Fraeman, K, Hutchins, V, Murphy, D, Song, D, Vaughn, BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 2009;37:387397.CrossRefGoogle ScholarPubMed
Mu, Y, Edwards, JR, Horan, TC, Berrios-Torres, SI, Fridkin, SK. Improving risk-adjusted measures of surgical site infection for the national healthcare safety network. Infect Control Hosp Epidemiol 2011;32:970986.CrossRefGoogle ScholarPubMed
Annual Epidemiological Report 2016–Surgical site infections. European Centre for Disease Prevention and Control website. https://ecdc.europa.eu/sites/portal/files/documents/AER-HCAI-SSI.pdf. Published 2016. Accessed July 25, 2018.Google Scholar
Whitehouse, JD, Friedman, ND, Kirkland, KB, Richardson, WJ, Sexton, DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002;23:183189.CrossRefGoogle Scholar
Swissnoso. Nationaler Vergleichsbericht Programm zur Überwachung postoperativer Wundinfektionen, Juni 2018. https://results.anq.ch/fileadmin/documents/anq/11/20180822_ANQAkut_SSI_Nationaler_Vergleichsbericht_2016_2017.pdf. Published 2018. Accessed January 7, 2019.Google Scholar
Kaoutzanis, C, Gupta, V, Winocour, J, Shack, B, Grotting, JC, Higdon, K. Incidence and risk factors for major surgical site infections in aesthetic surgery: analysis of 129,007 patients. Aesthet Surg J 2017;37:8999.CrossRefGoogle ScholarPubMed
Menendez, ME, Lu, N, Unizony, S, Choi, HK, Ring, D. Surgical site infection in hand surgery. Int Orthop 2015;39:21912198.CrossRefGoogle ScholarPubMed
Umscheid, CA, Mitchell, MD, Doshi, JA, Agarwal, R, Williams, K, Brennan, PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101114.CrossRefGoogle ScholarPubMed
Schreiber, PW, Sax, H, Wolfensberger, A, Clack, L, Kuster, SP, Swissnoso. The preventable proportion of healthcare-associated infections 2005–2016: systematic review and meta-analysis. Infect Control Hosp Epidemiol 2018;39:12771295.CrossRefGoogle ScholarPubMed
Lenfant, C. Shattuck lecture—clinical research to clinical practice—lost in translation? N Engl J Med 2003;349:868874.CrossRefGoogle ScholarPubMed
Pronovost, PJ, Berenholtz, SM, Needham, DM. Translating evidence into practice: a model for large-scale knowledge translation. BMJ Clin Res 2008;337:a1714.CrossRefGoogle Scholar
Pronovost, P, Weast, B, Rosenstein, B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:3340.CrossRefGoogle Scholar
Sawyer, M, Weeks, K, Goeschel, CA, et al. Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. Crit Care Med 2010;38(8 suppl):S292S298.CrossRefGoogle ScholarPubMed
Download the CUSP Toolkit. Agency for Healthcare Research and Quality website. http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/download/index.html. Published 2012. Accessed December 17, 2018.Google Scholar
Wick, EC, Hobson, DB, Bennett, JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg 2012;215:193200.CrossRefGoogle ScholarPubMed
Surgical complication prevention guide. Agency for Healthcare Research and Quality website. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-surgcomp.pdf. Published 2017. Accessed December 17, 2018.Google Scholar
The Surgical Complication Prevention Toolkit: Your Technical Work Plan for Translating Evidence into Practice. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine; 2012.Google Scholar
Berenholtz, SM, Pham, JC, Thompson, DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011;32:305314.CrossRefGoogle ScholarPubMed
Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:27252732.CrossRefGoogle ScholarPubMed
Zahlen & Fakten UniversitätsSpital Zürich. http://www.usz.ch/ueber-uns/seiten/zahlen-fakten.aspx. Published 2017. Accessed December 29, 2018.Google Scholar
Geschäftsbericht 2015 UniversitätsSpital Zürich. http://www.usz.ch/ueber-uns/Documents/geschaeftsbericht_2015.pdf. Published 2015. Accessed December 5, 2018.Google Scholar
Horan, TC, Gaynes, RP, Martone, WJ, Jarvis, WR, Emori, TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606608.CrossRefGoogle ScholarPubMed
Sorensen, LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012;255:10691079.CrossRefGoogle Scholar
Sorensen, LT, Karlsmark, T, Gottrup, F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 2003;238:15.CrossRefGoogle ScholarPubMed
Warner, DO. Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology 2006;104:356367.CrossRefGoogle ScholarPubMed
Allen, J, David, M, Veerman, JL. Systematic review of the cost-effectiveness of preoperative antibiotic prophylaxis in reducing surgical-site infection. BJS Open 2018;2:8198.CrossRefGoogle ScholarPubMed
Bratzler, DW, Houck, PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:17061715.Google ScholarPubMed
Stone, HH, Hooper, CA, Kolb, LD, Geheber, CE, Dawkins, EJ. Antibiotic prophylaxis in gastric, biliary and colonic surgery. Ann Surg 1976;184:443452.CrossRefGoogle ScholarPubMed
Wainberg, SK, Santos, NCL, Gabriel, FC, et al. Clinical practice guidelines for surgical antimicrobial prophylaxis: qualitative appraisals and synthesis of recommendations. J Eval Clin Pract 2019;25:591602.CrossRefGoogle ScholarPubMed
Anderson, DJ, Podgorny, K, Berrios-Torres, SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:605627.CrossRefGoogle ScholarPubMed
Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334:12091215.CrossRefGoogle ScholarPubMed
Melton, GB, Vogel, JD, Swenson, BR, Remzi, FH, Rothenberger, DA, Wick, EC. Continuous intraoperative temperature measurement and surgical site infection risk: analysis of anesthesia information system data in 1008 colorectal procedures. Ann Surg 2013;258:606612.CrossRefGoogle ScholarPubMed
Sax, H, Uckay, I, Balmelli, C, et al. Overall burden of healthcare-associated infections among surgical patients: results of a national study. Ann Surg 2011;253:365370.CrossRefGoogle ScholarPubMed
Dohmen, PM. Influence of skin flora and preventive measures on surgical site infection during cardiac surgery. Surg Infect 2006;7 suppl 1:S13S17.CrossRefGoogle Scholar
Pereira, LJ, Lee, GM, Wade, KJ. An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts. J Hosp Infect 1997;36:4965.CrossRefGoogle ScholarPubMed
Parienti, JJ, Thibon, P, Heller, R, et al. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. JAMA 2002;288:722727.CrossRefGoogle ScholarPubMed
Poirot, K, Le Roy, B, Badrikian, L, Slim, K. Skin preparation for abdominal surgery. J Visc Surg 2018;155:211217.CrossRefGoogle ScholarPubMed
Lefebvre, A, Saliou, P, Lucet, JC, et al. Preoperative hair removal and surgical site infections: network meta-analysis of randomized controlled trials. J Hosp Infect 2015;91:100108.CrossRefGoogle ScholarPubMed
Webster, J, Osborne, S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2015(2):Cd004985.Google ScholarPubMed
Berrios-Torres, SI, Umscheid, CA, Bratzler, DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784791.CrossRefGoogle Scholar
WHO guidelines approved by the Guidelines Review Committee. In: Global Guidelines for the Prevention of Surgical Site Infection. Geneva: World Health Organization; 2016. PMID: 27929621.Google Scholar
Rutala, WA, Weber, DJ. A review of single-use and reusable gowns and drapes in health care. Infect Control Hosp Epidemiol 2001;22:248257.CrossRefGoogle ScholarPubMed
Andersson, AE, Bergh, I, Karlsson, J, Eriksson, BI, Nilsson, K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control 2012;40:750755.CrossRefGoogle Scholar
Birgand, G, Saliou, P, Lucet, JC. Influence of staff behavior on infectious risk in operating rooms: what is the evidence? Infect Control Hosp Epidemiol 2015;36:93106.CrossRefGoogle ScholarPubMed
Healey, AN, Primus, CP, Koutantji, M. Quantifying distraction and interruption in urological surgery. Qual Saf Health Care 2007;16:135139.CrossRefGoogle ScholarPubMed
Healey, AN, Sevdalis, N, Vincent, CA. Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics 2006;49:589604.CrossRefGoogle ScholarPubMed
Roth, JA, Juchler, F, Dangel, M, Eckstein, FS, Battegay, M, Widmer, AF. Frequent door openings during cardiac surgery are associated with increased risk for surgical site infection: a prospective observational study. Clin Infect Dis 2019;69:290294.CrossRefGoogle ScholarPubMed
Isik, O, Kaya, E, Dundar, HZ, Sarkut, P. Surgical site infection: reassessment of the risk factors. Chirurgia (Bucharest). 2015;110:457461.Google Scholar
Harrell, FE Overview of Maximum Likelihood Estimation. Regression Modeling Strategies: With Applications to Linear Models, Logistic Regression, and Survival Analysis. New York: Springer; 2001. Pp. 179213.CrossRefGoogle Scholar
Amri, R, Dinaux, AM, Kunitake, H, Bordeianou, LG, Berger, DL. Risk stratification for surgical site infections in colon cancer. JAMA Surg 2017;152:686690.CrossRefGoogle Scholar
Lin, DM, Carson, KA, Lubomski, LH, Wick, EC, Pham, JC. Statewide collaborative to reduce surgical site infections: results of the Hawaii surgical unit-based safety program. J Am Coll Surg 2018;227:189197.CrossRefGoogle ScholarPubMed
Anthony, T, Murray, BW, Sum-Ping, JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg 2011;146:263269.CrossRefGoogle ScholarPubMed
Lavallee, JF, Gray, TA, Dumville, J, Russell, W, Cullum, N. The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implement Sci 2017;12:142.CrossRefGoogle ScholarPubMed
Pastor, C, Artinyan, A, Varma, MG, Kim, E, Gibbs, L, Garcia-Aguilar, J. An increase in compliance with the surgical care improvement project measures does not prevent surgical site infection in colorectal surgery. Dis Colon Rectum 2010;53:2430.CrossRefGoogle Scholar
Martin, ET, Kaye, KS, Knott, C, et al. Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2016;37:8899.CrossRefGoogle ScholarPubMed
Goltsman, D, Morrison, KA, Ascherman, JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open 2017;5:e1461.CrossRefGoogle ScholarPubMed
Supplementary material: File

Lenherr Ramos et al. supplementary material

Table S1

Download Lenherr Ramos et al. supplementary material(File)
File 15 KB
2
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

A comprehensive unit-based safety program for the reduction of surgical site infections in plastic surgery and hand surgery
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

A comprehensive unit-based safety program for the reduction of surgical site infections in plastic surgery and hand surgery
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

A comprehensive unit-based safety program for the reduction of surgical site infections in plastic surgery and hand surgery
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *