Colon Surgery Site Infections Reduced With Bundled Approach

Laurie Barclay, MD

August 28, 2014

The use of a bundled approach to prevent surgical site infections (SSIs) after colorectal surgery (CRS) was effective and should help to lower healthcare costs, according to a retrospective study published online August 27 in JAMA Surgery.

"[SSIs] are associated with increased morbidity, length of hospitalization, readmission rates, and health care costs," write Jeffrey E. Keenan, MD, from the Duke University Medical Center in Durham, North Carolina, and colleagues. "They represent a particularly important problem in [CRS], for which SSI rates are disproportionately high, ranging from 15% to 30%. Therefore, reduction in SSIs in CRS has become a major target of quality improvement initiatives."

The preventive SSI bundle used in this study was a multidisciplinary program spanning the phases of perioperative care, including evidence-based and commonsense measures such as educational materials, preoperative disinfecting showers, antibiotics, and wound care.

The study goal was to assess the effect of this bundle on SSI rates and costs in CRS, using institutional clinical and cost data from January 1, 2008, to December 31, 2012, at an academic tertiary referral center.

The investigators compared outcomes before and after implementation of the bundle on July 1, 2011, using a sample of 559 patients who had major elective CRS (346 [61.9%] before bundle implementation and 213 [38.1%] after).

To account for significant differences in clinical factors before and after implementation, the investigators matched groups on their propensity to be treated with the bundle (212 in each group).

After bundle implementation, the rate of superficial SSIs (the primary outcome) declined from 19.3% to 5.7% (P < .001), as did the rate of postoperative sepsis (declining from 8.5% to 2.4%; P = .009). The matched groups did not differ significantly in deep SSIs, organ-space SSIs, wound disruption, length of stay, 30-day readmission, or variable direct costs.

However, occurrence of superficial SSI was associated with a 35.5% increase in variable direct costs ($13,253 vs $9779; P = .001) and a 71.7% increase in length of stay (7.9 vs 4.6 days; P < .001), according to a subgroup analysis of the postbundle period.

"Further study is needed to assess whether the bundle can be effective with wider application and what level of compliance with bundle measures is needed to achieve good results," the authors write.

Limitations of this study include a possible lack of generalizability to other patient populations, specialties, and institutions; an inability to determine which specific aspects of the bundle were beneficial; and changes in medical practice over time serving as potential confounders.

"A series of recent studies, including [this study], support that colorectal [SSI] is a preventable harm with adherence to published evidence, best practice guidelines and culture change," Ira L. Leeds, MD, MBA, and Elizabeth C. Wick, MD, from Johns Hopkins University in Baltimore, Maryland, write in an accompanying invited commentary.

"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."

The study authors and editorialists have disclosed no relevant financial relationships.

JAMA Surg. Published online August 27, 2014. Article abstract, Commentary extract

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