The implementation of complex infection control bundles to prevent colorectal surgical site infections: a survey of SHEA research network hospitals

TL;DR

This study surveyed hospitals to understand how often and how well infection control bundles are used to prevent surgical site infections in colorectal surgery.

Contribution

The study provides new insights into the real-world implementation of infection control bundles for colorectal surgical site infections.

Findings

Most hospitals use pre-operative antibiotics and alcohol-chlorhexidine skin prep for infection control.

Fewer hospitals consistently audit and feedback surgical staff on bundle compliance.

Resistance to change and clinician non-compliance are major barriers to bundle implementation.

Abstract

Surgical site infections (SSI) result in significant patient morbidity and excess healthcare costs. Colorectal surgeries have the highest SSI risk, as they manipulate the organ with the largest endogenous bioburden. This risk can be mitigated through complex prevention bundles, shown effective at reducing SSI in multiple studies, although little is known about their “real-world” use.

To obtain further insight into the implementation of SSI prevention bundles consisting of guideline-recommended infection control elements in colorectal surgery, we distributed a multiple-choice survey to the hospitals within the Society for Healthcare Epidemiology of America Research Network from November 2022 to December 2023.

A total of 42 (45%) hospitals completed the survey. The bundle elements most used were intravenous pre-operative antibiotic prophylaxis (88%) and skin prep with an alcohol-chlorhexidine solution (86%). Infection control elements of surgical closure such as glove change and separate instrument tray were reported by 67% and 64%, respectively. Combined oral antibiotics with mechanical bowel prep were reported by 52%. Less than 50% of hospitals reported consistent bundle audit and feedback to frontline surgical staff. The most persistent barriers to implementation were a general culture resistant to change (40%) and clinicians’ lack of compliance with the institutional bundle (38%).

Our study found significant variability in the implementation of bundles consisting of multiple infection control elements to prevent SSI in clinical practice. Further research is needed to determine the strategies most effective in optimizing high-fidelity adoption of complex prevention bundles and to study their effect on SSI in colorectal surgery.

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Full text

Introduction

Surgical site infections (SSI) have significant morbidity, healthcare costs greater than $3.3 billion per year in the United States, and prolonged hospitalizations by up to 9.7 days.^ 1,2 ^ Colorectal surgeries have the highest incidence of SSI, with rates ranging from 15-30% in some studies.^ 3–6 ^ Most hospitals have used the Society for Healthcare Epidemiology of America (SHEA), APIC, IDSA, or CDC clinical guidelines^ 2,7 ^ to design multi-element “SSI prevention bundles” to be implemented in the peri-, intra-, and post-operative periods.^ 8 ^ However, colorectal SSI persists in the clinical setting. For example, the most recent CDC report on nosocomial infections shows that 11 states still experienced more observed colorectal SSI than predicted (SIR > 1) in 2022, while the national SSI average has not significantly changed compared to prior years.^ 9 ^ This lack of progress may be due to “real-world” implementation difficulties for such complex bundles. Therefore, our objectives for this study were to assess the type of bundled infection control elements used for colorectal SSI prevention, and the strategies related to their implementation in the acute care setting.

Methods

We performed a cross-sectional study using an electronic survey distributed via Qualtrics to hospitals enrolled within the Society for Healthcare Epidemiology Research Network (SRN). The SRN includes a consortium of US and international institutions who participate in collaborative projects related to healthcare epidemiology and antimicrobial stewardship. The SSI survey consisted of 8 multiple choices and/or 5-point Likert scale-type responses assessing annual colorectal surgical volume, infection prevention bundle elements most often used, methods of auditing bundle compliance, perceived importance for each bundle element, and perceptions related to implementation barriers successfully mitigated or still persistent at the time of the survey. The survey was distributed initially on November 20, 2022, to all institutions participating in the SRN at that time, with 2 additional email reminders, each distributed several months apart, until survey closure on December 31, 2023. Institutions that completed < 75% of the survey questions were excluded from the analysis, and duplicate responses were removed. We used STATA SE (StataCorp, College Station, TX) for descriptive and univariate data analysis. Categorical variables were analyzed by the chi-square test, and continuous variables by the Student’s t-test, with a two-sided p value < 0.05 considered statistically significant.

Results

Of the 93 institutions surveyed, a total of 42 (36 US, 6 international) hospitals provided complete responses and were included in the analysis (45% response rate). Seven participants were excluded from the analysis due to incomplete responses (< 75% of the survey). Baseline characteristics for responding institutions are included in Table 1. Approximately half of the participants (52%) were academic medical centers. Figure 1 shows the SSI prevention bundle elements reported as consistently used by the hospital survey participants. The most frequently used elements were intraoperative antibiotic prophylaxis and intraoperative skin preparation using alcohol-based chlorhexidine, used by 88% and 86% of hospitals, respectively. There were no statistically significant differences in the use of specific bundle elements among hospitals with high versus medium or low surgical volume.

Table 1.Baseline characteristics of the 42 hospitals who completed the surveyInstitution typeN (%)Academic medical center22 (52)Community teaching hospital13 (31)Community non-teaching hospital3 (7)Other (VA, Public, outpatient surgical center)4 (10) Annual colorectal surgical volume Low: < 25011 (26)Medium: 250 - 50021 (50)High: > 50010 (24)

Figure 1.Surgical site infection prevention bundle elements reported as consistently used by participating hospitals. Numbers are reported as a percentage of the total 42 hospitals responding to the survey. Bundle elements deemed “essential practice” by SHEA/IDSA/APIC are shown in dark color; bundle elements additionally recommended in the literature (see references 7, 20) are shown in lighter color. *Updated guidelines recommend combined parenteral and oral antibiotics as essential practice, see discussion for this bundle element.

Table 2 shows the proportion of hospitals that performed audits on at least a yearly basis as an effort to enhance compliance with SSI bundle elements. Intraoperative antibiotic prophylaxis and skin prep with an alcohol-chlorhexidine-containing solution were audited most frequently (71% and 52% of the hospitals respectively), while all other bundle elements were consistently audited in less than 50% of the hospitals. Feedback to frontline clinicians on bundle adherence was performed most frequently for intraoperative antibiotic prophylaxis (57% of the hospitals), while consistent feedback for all other bundle elements was reported by less than 40% of the hospitals. Most hospitals (71%) used the electronic health record to audit compliance, while 33% of the hospitals also reported direct observations as a method for auditing compliance. Hospitals with higher surgical volume were more likely to audit compliance with correct antibiotic prophylaxis (P = 0.04) and use of combined mechanical bowel prep with oral antibiotics (P = 0.02).

Table 2.Percent of hospitals who reported conducting audit and feedback for adherence to certain surgical site infection prevention bundle element on at least a yearly basis. Numbers are reported as a percentage of a total of 42 hospitals responding to the surveySSI Prevention Bundle ElementAuditedFeedbackIntraoperative antibiotic prophylaxis71%57%Skin prep with chlorhexidine-alcohol-containing solution52%33%Maintaining intraoperative normothermia48%33%Maintaining intraoperative normoglycemia43%31%Appropriate hair removal36%21%Glove change prior to surgical closure31%19%Separate instrument tray for surgical closure29%19%Combined mechanical bowel prep with oral antibiotics21%19%Standardized wound dressing change at 48 h postop12%7%

Table 3 shows perceived barriers to bundle implementation—successfully mitigated or still persistent—at the time of the survey. An institutional culture resistant to change and the absence of consistent auditing and feedback were perceived as the most common persistent barriers by 40% and 33% of hospitals, respectively.

Table 3.Perceived barriers to surgical site infection (SSI) prevention bundle implementation. Numbers are reported as a percentage of a total of 42 hospitals responding to the surveyBarriers to bundle implementationSuccessfully mitigatedPersistentLack of clinicians’ compliance with bundle49%38%Lack of clinicians’ knowledge regarding bundle38%24%Inadequate audit and feedback for bundle compliance38%33%Skepticism about bundle effectiveness29%36%Supplies and equipment not easily available26%7%Patient difficulty with bundle compliance at home26%29%Inadequate institutional leadership support for SSI prevention26%19%Not enough automatic reminders or computerized orders19%21%General culture resistant to change24%40%Insufficient patient education with bundle21%14%Inadequate supervision to ensure compliance12%19%Not enough visual aids or reminders10%12%

Institutions were asked to rank the bundle elements felt to be most important for SSI prevention in colorectal surgery on a 5-point Likert scale. Intraoperative antibiotic prophylaxis was ranked as either “most important” or “very important” by 76% of participants; intraoperative skin prep with alcohol-CHG containing solution by 52%; combined mechanical bowel prep with oral antibiotics by 33%; and patient preoperative bathing with chlorhexidine by 26% of hospitals participating in the survey.

Discussion

The surgical infection control literature shows colorectal bundles to be effective in SSI prevention. A 2020 meta-analysis found an overall SSI reduction of 44%, with complex, ≥ 11 element-bundles consisting of both traditional and newer interventions demonstrating the greatest SSI reduction.^ 10 ^ Our survey suggests variable success in the implementation of guideline-recommended SSI prevention bundle elements in acute care hospitals. Intra-operative antibiotic prophylaxis and skin prep with alcohol-chlorhexidine solutions, recognized as very important elements of SSI prevention, were reported as consistently used by most participating hospitals. On the other hand, mechanical bowel prep combined with oral antibiotics was reported to be consistently used by only half of the participating hospitals and was considered important by less than one-third of participants. Perhaps this finding reflects reticence in fully adopting an intervention that has been a debated topic in the surgical literature. The controversy has primarily centered around the use of mechanical bowel prep, viewed by some experts as minimally effective,^ 11 ^ while associated with potential abdominal discomfort and dehydration for some patients. However, in combination with oral antibiotics, mechanical bowel prep has been shown to reduce SSI, postoperative ileus, anastomotic leak, and 30-day mortality in colorectal surgery by multiple studies.^ 12–14 ^ The recent MOBILE2 randomized clinical trial, conducted to help clarify this dispute, reinforced the effectiveness of mechanical bowel prep combined with oral antibiotics in preventing SSI and anastomotic dehiscence in surgeries involving rectal resection.^ 15 ^ There is a growing consensus, emphasized in the most recent updated guidelines^ 7 ^ that the essential practice for prevention is the combination of oral and intravenous antibiotics rather than the mechanical bowel prep component,^ 16,17 ^ which by itself has not been shown effective in randomized trials.^ 18,19 ^ Further research is needed to elucidate the form of bowel prep that is most effective in preventing SSI in colorectal surgery.

Expert consensus in colorectal surgery also supports the use of a mini bundle dedicated to incision closure (sterile tray, pre-closure glove change, antimicrobial sutures), besides impervious wound protectors/retractors and antiseptic wound lavage.^ 20 ^ Our survey indicates that many hospitals have implemented some of these elements (pre-closure glove change 69%, separate instrument tray 63%, wound edge protectors or retractors 55%), although there is room for improvement. The use of antimicrobial-impregnated sutures was low, which may reflect cost constraints in some settings.

Our study found that few hospitals monitored bundle adherence through routine audit and feedback, which is recommended as an essential practice in SSI prevention.^ 7 ^ Audit and feedback has long been recognized as an effective strategy in changing professional practice, especially when delivered frequently in settings with low adherence,^ 21 ^ and has been associated with significant reduction in SSI rates.^ 22 ^ In colorectal surgery, audit and feedback are generally well regarded, being perceived as important in increasing individual awareness and accountability and helpful in adopting recommended SSI prevention interventions.^ 23 ^

Of course, successfully implementing complex SSI prevention bundles in clinical practice requires a multifaceted, multidisciplinary approach,^ 24,25 ^ preferably under the leadership of a surgeon-champion.^ 26,27 ^ While audit and feedback have been cited as the most frequently used strategy, organizational culture, monitoring the performance of healthcare delivery, using reminders, and increasing education have also been recognized among the “top five” implementation strategies to prevent SSI.^ 28 ^ Employed together in a multi-modal implementation approach, these strategies were associated with a 52% risk reduction in SSI, as reported in the systematic review by Tomsic et al.^ 28 ^ In our study, respondents identified lack of audit and feedback, need to change organizational culture, and need for more educational support as persistent implementation barriers in 25%–40% of the participating hospitals, underscoring the need for further work in improving these aspects of SSI prevention bundle implementation.

Our study has several limitations. Since the survey was anonymous, we do not have data on the colon SSI rates for each participating hospital and cannot analyze how any of the bundle elements and implementation strategies studied are correlated with SSI prevention. The lower survey response rate and the survey distribution to only hospitals participating in the SRN are shortcomings, as the findings may not be generalizable to all acute care settings. In addition, the limitations inherent to survey studies, such as potential for response bias, inability to verify the accuracy of self-reported data, and difficulty capturing the complexity of the implementation of SSI prevention through discrete survey questions apply here as well.

In conclusion, our study highlights variability in the implementation of complex SSI prevention bundles in acute care hospitals. Further research is essential to refine the strategies needed to optimize the effectiveness of these bundles by increasing their adoption in the clinical setting.