A bundled intervention lowers surgical site infection in hysterectomy for benign and malignant indications

Decreasing post hysterectomy surgical site infections with the implementation of a hysterectomy-specific bundle

BACKGROUND

Surgical site infections (SSI) are a common complication of hysterectomy. Surgical bundles have been shown to reduce SSIs. Here we describe a bundle that was used to combat an abnormal rise in SSI events that resulted in a greater than 75% reduction at our institution.

METHODS

A hysterectomy-specific bundle was developed based on the prior success of SSI prevention bundles. Development involved longitudinal education and training to ensure accuracy and compliance. All inpatient abdominal, laparoscopic, and vaginal hysterectomies performed at a tertiary referral center were included. The preintervention, intervention, and postintervention periods were each one year in length. SSI rates were peer-reviewed monthly and overall trends were tracked, including compliance with bundle guidelines.

RESULTS

Preintervention, an abnormal rise in SSI was identified at 3.76%. During the intervention, 309 inpatient hysterectomies were completed. In this period, 6 posthysterectomy SSI events occurred (3.76% vs 1.94%, P = .21). Four SSIs followed laparotomy and 2 followed laparoscopy. Compliance during the intervention period ranged from 79% to 89% with a mean of 85%. In the postintervention period, there were 6 SSI following 689 hysterectomies (3.76% vs 0.87%, P = .004). The majority of SSI occurred after abdominal hysterectomy.

CONCLUSIONS

Implementation of a hysterectomy-specific surgical bundle allowed for a significant reduction in post hysterectomy SSI during a yearlong intervention period and a sustained, further reduction in the postintervention period.

Surgical Field Separation in Total Laparoscopic Hysterectomy

We aimed to study whether separating the vaginal and abdominal surgical fields during total laparoscopic hysterectomy (TLH) is associated with surgical site infection rates. This was a retrospective cohort study of all patients who underwent TLH and any concomitant procedures with two minimally invasive gynecologic surgery subspecialists between January 2016 and May 2023. Among 680 included patients, the rate of infection was 0.8% with surgical field separation and 1.3% without (3/377 vs 4/303; odds ratio 0.60, 95% CI, 0.13-2.70). There was no statistical difference between groups; however, the difference in infection rates between groups was extremely small, which led to inadequate power. Our findings suggest that rates of infection after TLH are low, with or without surgical field separation. Treating the vagina, perineum, and abdomen as a single, continuous operative field during TLH may be an acceptable practice.

Implementing a Bundle to Improve Surgical Site Infection Rates for Patients Undergoing Nonvaginal-Approach Hysterectomy at a Midwestern Teaching Hospital

Accrediting organizations, third-party payers, and patients review the surgical site infection (SSI) rates of health care organizations. Infection preventionists collaborate with perioperative personnel to decrease SSI rates; they also monitor and report SSI information to national organizations. The standard infection ratio is a comparison of the observed number of SSIs to the predicted number of SSIs based on national benchmark data. Leaders of a midwestern teaching hospital convened an interdisciplinary team (eg, surgeons, perioperative leaders, infection preventionists) to address a standard infection ratio after hysterectomies that was greater than 1.0. The team reviewed national guidelines and published articles on decreasing SSIs (including recommendations for vaginal preparation) before developing and implementing a hysterectomy-specific bundle for SSI prevention. The rate of SSIs decreased 68% after the implementation of the bundle. Perioperative personnel at this facility continue to use the bundle and infection preventionists monitor and report compliance with the bundle's elements.

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival

Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.

Translation of Evidence-Based Interventions Into Oncology Care Settings: An Integrative Review

BACKGROUND

Adoption of evidence remains slow, leading to variations in practices and quality of care. Examining evidence-based interventions implemented within oncology settings can guide knowledge translation efforts.

OBJECTIVE

This integrative review aimed to (1) identify topics implemented for oncology-related evidence-based practice (EBP) change; (2) describe frameworks, guidelines, and implementation strategies used to guide change; and (3) evaluate project quality.

METHODS

PubMed and CINAHL were searched to identify published practice change projects. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Fifty articles met the inclusion criteria. Data were extracted; content analysis was conducted. The Quality Improvement Minimum Quality Criteria Set guided quality assessment.

RESULTS

Topics included infection control/prevention (n = 18), pain/palliative care (n = 13), psychosocial assessment (n = 11), and medication adherence (n = 8). Among the projects, Plan, Do, Study, Act (n = 8) and Lean Six Sigma (n = 6) frameworks were used most. Thirty-six projects identified guidelines that directed interventions. Multiple implementation strategies were reported in all articles with planning, education, and restructuring the most common. Reach, sustainability, and ability to be replicated were identified as quality gaps across projects.

CONCLUSION

The EBP topics that emerged are consistent with the oncology nursing priorities, including facilitating integration of EBP into practice. The studies identified used national guidelines and implementation strategies to move evidence into practice. Heterogeneity in measurement made synthesis of findings difficult across studies, although individual studies showed improvement in patient outcomes.

IMPLICATIONS FOR PRACTICE

Development of an interprofessional oncology consortium could facilitate a standardized approach to implementation of high-priority topics that target improved patient outcomes, harmonize measures, and accelerate translation of evidence into practice.

Surgical site infections in gynecology: the latest evidence for prevention and management

PURPOSE OF REVIEW

Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount.

RECENT FINDINGS

Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies.

SUMMARY

Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.