Careful Teamwork Reduces Colorectal Surgery Infections

A multidisciplinary program (called a “bundle”) that spanned the phases of perioperative care helped reduce surgical-site infections (SSIs) in patients undergoing colorectal surgery (CRS) at Duke University Hospital.

“We reduced infections through a series of initiatives across the board, so there isn’t any one thing we can point to that says, 'this is it',” says senior author Christopher R. Mantyh, MD, a colon and rectal surgeon and surgical oncologist who published findings in JAMA Surgery on August 27, 2014. “Instead, it’s the sum of the parts.”

The findings highlight the role of multidisciplinary care before, during, and after CRSs in significantly reducing SSIs among patients. A concerted effort among surgeons, anesthesiologists, clinic nurses, operating room staff, and others to use innovative practices and common-sense measures worked.

The authors evaluated an SSI bundle that was implemented at an academic medical center in 2011. They examined data that were gathered from 2008 through 2012 so that before-and-after outcomes could be assessed. Elements of the bundle included evidence-based and common-sense measures. The study included 559 CRS cases (346 cases before and 213 after the bundle was implemented). Matched pre- and post-bundle groups each had 212 patients.

Patients received educational information, preoperative disinfecting showers, antibiotics, and wound care. A wound protector covered open incisions, and temperature and glucose readings were monitored. At wound closure, surgeons and scrub staff underwent a gown/glove change, and a dedicated wound-closure tray was used. A sterile occlusive dressing was used, and disinfectant washes continued during recovery and afterward at the patient’s home for 1 week.

The bundle was associated with a reduction in superficial SSIs (19.3% vs. 5.7%) and postoperative sepsis (8.5% vs. 2.4%). No significant differences were seen in deep SSIs, organ-space SSIs, wound disruption, length of stay, 30-day readmission, or variable direct costs.

Further study is needed to assess whether the bundle can be effective with wider application, the authors noted. During the post-bundle period, superficial SSIs were associated with a 35.5% increase in variable direct costs ($13,253 vs. $9,779) and a nearly 72% increase in length of stay (7.9 days vs. 4.6 days).

In an accompanying editorial, Ira L. Leeds, MD, MBA, and Elizabeth C. Wick, MD, of The Johns Hopkins University, Baltimore, wrote that the (Duke) Keenan et al study supports that CRS site infection “is a preventable harm with adherence to published evidence, best-practice guidelines, and culture change.”

They concluded, “These studies demonstrate ways in which the field is naturally placed to develop high-reliability organizational models that build up from patient care units rather than conventional efforts that typically come down from administrative institutional mandates.”