Development of an Evidence Based Surgical Site Infection Bundle in Patients Undergoing Colorectal Surgery: A Quality Improvement Initiative

BACKGROUND: Surgical site infections (SSI) are among the leading healthcare-acquired infections that negatively impact patient outcomes and increase total cost of healthcare and the patient’s length of stay. At a community hospital in West Virginia, trends in SSI rates and the standardized infection ratio (SIR) increased for patients undergoing colorectal surgery. The purpose of this quality improvement project was to identify and implement permanent evidence-based practice changes to reduce SSI rates in colon surgery patients. METHODS: Baseline rates of SSI and the SIR for the facility was calculated from October 2021 to September 2022. Colon surgery SSI reduction measures were identified based on practice guidelines set forth by the American College of Surgeons (ACS) and the Association of periOperative Registered Nurses (AORN). Measures shown to have the greatest statistical benefit for improving SSI rates were included in a paper bundle checklist. Measures were then divided into three phases including: Preoperative, intra-operative, and post-operative. A baseline assessment of SSI prevention measures was performed for operating room (OR) staff using best practice guidelines by AORN. INTERVENTION: OR staff received education on new SSI reduction measures including the use of a separate closing table and sterile glove change during colon surgery cases. A post-intervention assessment was performed to evaluate learning. The Colon Surgery SSI Bundle checklist was distributed for each colon surgery patient for Registered Nurse (RN) completion during all perioperative phases. Education was performed regarding surgical dressings and documentation for all perioperative departments. RESULTS: Implementation of an evidence-based SSI reduction bundle reduced the rate of colon surgery SSI from 0.06 to 0.03 and reduced the SIR from 1.5 to 0.77. Components of the SSI bundle were successfully integrated into all colon surgery cases utilizing the PDSA cycle. Post-intervention assessment showed a 22% improvement in knowledge scores for OR staff. Low bundle compliance was associated with missing SSI checklist documentation. CONCLUSIONS: Development of a concise, evidence-based SSI reduction bundle is a reasonable method to improve rates of SSI in patients undergoing colon surgery. Specific SSI bundle education for OR staff participating in bundle use improves knowledge of SSI reduction methods and appropriate bundle measures. Completion of paper checklists to document bundle compliance was not conducive to nurse workflow and efforts should be made to integrate SSI bundles into the EMR. The PDSA cycle is a useful quality improvement method to improve patient care and outcomes. Keywords: Colon Surgery, SSI Reduction, Bundle, Quality Improvement, PDSA cycl