BMJ Quality Improvement Reports 2015; u205401.w3279 doi: 10.1136/bmjquality.u205401.w3279 Performance improvement initiative: prevention of surgical site infection (SSI)

Mafraq Hospital performs an average of 10,000 surgeries every year. The impact of having high volume high risk surgical procedures calls for the need to ensure safe surgery and a prevention of surgical site infection (SSI). SSI represents a significant portion of healthcare-associated infections (HAIs). The impact on morbidity, mortality, and cost of care has resulted in identifying the need to reduce SSI as a top priority to prevent healthcare associated infections. The good news is that the majority of SSIs are preventable. Mafraq Hospital performs a range of surgical procedures that covers 14 surgical specialties. The infection prevention and control team performs surveillance for SSI for all patients who undergo operative procedure included in Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Operative Procedure Category (40 surgical procedures). Out of the 40 CDC NHSN listed, 33 operative procedures were performed at Mafraq Hospital, of which 17 were reported with SSI for 2013 and 2014. Surgical site infection has implicated an increase average length of stay from seven to 10 additional postoperative hospital days and additional costs of AED 10,000 to AED 100,000/SSI depending on procedure and pathogen. A multidisciplinary team was formed to develop and implement measures to reduce/eliminate surgical site infection, as well as evaluate and monitor compliance. Hence a group of multidisciplinary teams were initiated to analyse the results, find out the gaps, and implement a quality improvement project to correct the deficits. Recommendations for appropriate improvement measures were formed on evidence-based international guidelines from the Institute for Healthcare Improvement (IHI) and CDC. Evidence based practice supports that many of th