SSI bundle reduces post-cesarean sections infections by 84% Infection Control Weekly Monitor, May 5, 2010

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1 USE OF BUNDLE TO PREVENT SURGICAL SITE INFECTIONS IN COLORECTAL SURGERY: THE MODEL OF PIEMONTE HOSPITALS Massimiliano Caccetta, Pier Angelo Argentero*, Enzo Carlo Farina**, Silvia Romagnoli, Carla Maria Zotti*** Surgical Department Rivoli Hospital Regione Piemonte, *Infection Control Unit Rivoli Hospital Regione Piemonte, **Surgical Department Molinette Hospital, Turin, ***Department of Public Health and Microbiology, University of Turin, Regional Health Autority Regione Piemonte, Italy.

2 Prevention of SSI Systems for monitoring surgical site infections (SSIs) and control models are keystones in infection prevention. Because SSI surveillance is often costly and time-consuming, many countries have recently begun to flank it with monitoring of healthcare-associated associated infections in an effort to obtain information at lower cost and with more rapid program implementation

3 Bundle The term bundle is often used to describe the construction of measurement modules for controlling SSIs. Hospitals collaborate to decrease surgical site infections Dellinger EP, Hausmann SM, Bratzler DW, et al. American Journal of Surgery. 2005;190(1):9-15. This paper describes the results of the National Surgical Infection Prevention Collaborative designed to decrease surgical site infections through improving the use of proven surgical infection prevention practices: appropriate antimicrobial agent selection, timing, and duration; normothermia; oxygenation; euglycemia; and appropriate hair removal. Sponsored by the Centers for Medicare & Medicaid Services (CMS), this year-long collaborative improvement effort involved 44 hospitals and demonstrated a 27 percent decrease in infection rates. SSI bundle reduces post-cesarean sections infections by 84% Infection Control Weekly Monitor, May 5, 2010

4 A new SSI prevention program for general surgery departments in Piemonte 2007: data started to be collected and analized from nosocomial infection programs in Piemonte; 2010: the general surgery departments were selected for surveillance by bundle measurement of SSI prevention as applied to colorectal surgeries; Main risk factors for SSI based on published evidence were chosen for bundle measurement.

5 A Bundle for colorectal surgery surveillance of infection rates according to the U.S. CDC model (active surveillance, NNIS Risk Index, postdischarge surveillance 30 days after surgery); preoperative bathing or showering; trichotomy; surgical antibiotic prophylaxis; monitoring of intraoperative temperature and glycemia in the 48 hours after surgery.

6 A Bundle for colorectal surgery Reference protocols were created and discussed with the healthcare workers involved. Specifically, the protocols included: showering with the use of a detergent or an antiseptic at least once the day before the operation trichotomy as needed and only with an electric shaver with disposable heads or with a depilatory cream Surgical antibiotic prophylaxis in application of protocols conforming to the National Guidelines Project recommendations the standard reference temperature was defined as a minimum intraoperative temperature of 36 as monitored by the anesthetist the mean glycemia threshold was defined as 200 mg/dl as measured immediately after the operation and then four times over the next 48 hours (twice per day).

7 Criticalities The main criticalities of data collection were: quality of and accessibility to information systems for patient classification (classification according to ASA scores, classification of surgery according to risk of infection, determination of operating times) surveillance system sensitivity (accurate identification of signs of SSIs, data from outpatient clinics on postdischarge surveillance 30 days after surgery) organizational problems in performing trichotomy or having patients bath or shower the day before the operation timing of preoperative antibiotic prophylaxis and its duration organizational problems with monitoring postsurgical glycemia levels

8 work in progress? Data were collected by the department physician, the nursing staff and the infection control nurse according to standard models; data analysis was carried out by the Regional Work Group for Nosocomial Infection Prevention in Healthcare Facilities in Piemonte. The final data analysis is scheduled for completion in early 2011.

9 Conclusion Advanced healthcare systems share the need to apply outcome and process indicators to the assessment of surgical care quality. With the use of bundle measurement, prevention measures can be cost-effectively implemented, while increasing the involvement of SSI control program operators as well as aiding in the early identification of critical areas in medical care which may be targeted for future improvement actions.