Surgical site infection: Poor compliance with guidelines and care bundles

International Wound Journal

Volumn 12, Issue 3, 2015, Pages 357-362

  Leaper, David J ^a   Tanner, Judith ^b   Kiernan, Martin ^c   Assadian, Ojan ^d   Edmiston, Charles E ^e  

^a UNIVERSITY OF HUDDERSFIELD   (United Kingdom)

^b DE MONTFORT UNIVERSITY   (United Kingdom)

^c SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST   (United Kingdom)

^d MEDICAL UNIVERSITY OF VIENNA   (Austria)

^e MEDICAL COLLEGE OF WISCONSIN   (United States)

Author keywords

Care bundles; Compliance; Guidelines; Surgical site infection

Indexed keywords

ARTICLE; CARE BUNDLE; CHECKLIST; EVIDENCE BASED PRACTICE; HUMAN; PATIENT COMPLIANCE; PRACTICE GUIDELINE; PRIORITY JOURNAL; SURGICAL INFECTION; WORLD HEALTH ORGANIZATION; ANTIBIOTIC PROPHYLAXIS; PROCEDURES; RISK FACTOR; SURGICAL WOUND INFECTION; TOTAL QUALITY MANAGEMENT;

ANTIBIOTIC PROPHYLAXIS; GUIDELINE ADHERENCE; HUMANS; PATIENT CARE BUNDLES; QUALITY IMPROVEMENT; RISK FACTORS; SURGICAL WOUND INFECTION;

EID: 84929278424     PISSN: 17424801     EISSN: 1742481X     Source Type: Journal    
DOI: 10.1111/iwj.12243     Document Type: Article

References (77)

1. Health Protection Agency. English National Point Prevalence Survey on healthcare-associated infections and antimicrobial use, 2011. London: Health Protection Agency, 2012.
2. Health Protection Agency. Surveillance of surgical site infections in NHS hospitals in England, 2010/2011. London: Health Protection Agency, 2011.
3. Health Protection Agency. Fifth report of the mandatory surveillance of surgical site infection in orthopaedic surgery, April 2004 to March 2009. London: Health Protection Agency, 2011.
4. European Centre for Disease Control. Annual epidemiological report 2011. Stockholm: ECDC, 2011.
5. Makary MA, Aswani MS, Ibrahim AM, Reagan J, Wick EC, Pronovost PJ. Variation in surgical site infection monitoring and reporting by state. J Healthc Qual 2013;35:41-6. DOI: 10.1111/j.1945-1474.2011.00176.x.
6. Gastmeier P, Sohr D, Schwab F, Behnke M, Zuschneid I, Brandt C, Dettenkoffer M, Chaberny IF, Rüden H, Geffers C. Ten years of KISS: the most important requirements for success. J Hosp Infect 2008;70(Suppl. 1):11-6.
7. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992;20:271-4.
8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97-132.
9. Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Bannerjee SN, Edwards JR, Tolson JS, Henderson TS. National Nosocomial Infections Surveillance System. Surgical wound infection rates by wound class, operative procedure, and patient risk index. Am J Med 1991;91(3B):152S-7S.
10. Haley RW, Culver DH, Morgan WM, White JW, Emori TG, Hooton TM. Identifying patients at high risk of surgical wound infection: a simple multivariate index of patient susceptibility and wound contamination. Am J Epidemiol 1985;121:206-15.
11. Leaper D, Tanner J, Kiernan K. Surveillance of surgical site infection: more accurate definitions and intensive recording needed. J Hosp Infect 2013;83:83-6.
12. Tanner J, Padley W, Kiernan MA, Leaper DJ, Norrie P, Baggott R. A benchmark too far: findings from a national survey of surgical site infection surveillance. J Hosp Infect 2013;83:87-91.
13. Tanner J, Khan D, Aplin C, Ball J, Thomas M, Bankart J. Post discharge surveillance to identify colorectal surgical site infection rates and related costs. J Hosp Infect 2009;72:243-50.
14. Yokoe DS, Khan Y, Olsen MA, Hooper DC, Greenbaum M, Vostok J, Lankiewicz J, Fraser VJ, Stevenson KB. Enhanced surgical site infection surveillance following hysterectomy, vascular, and colorectal surgery. Infect Control Hosp Epidemiol 2012;33:768-73.
15. Lyytikäinen O, Kanerva M, Agthe N, Möttönen T, Ruutu P. Healthcare-associated infections in Finnish acute care hospitals: a national prevalence survey. J Hosp Infect 2008;69:288-94.
16. Murphy D, Carrico R, Wayne K. Building the infection prevention system of tomorrow: proceedings of the 2007 APIC Futures Summit. Am J Infect Control 2008;36:232-40.
17. Kurtz SM, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg 2007;89:780-5.
18. Bode LGM, Kluytmans AJW, Wertheim HFL, Bogaers D, Vandenbroucke-Grauls CNJE, Roosendaal R, Troelstra A, Box ATA, Voss A, van der Tweel I, van Belkum A, Verbrugh HA, Vos MC. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362:9-17.
19. Wenzel PR. Minimizing surgical-site infections. N Engl J Med 2010;362:75-7.
20. Fry DE. Fifty ways to cause surgical site infections. Surg Infect (Larchmt) 2011;12:497-500.
21. National Institute for Health and Clinical Excellence. Surgical site infection: prevention and treatment of surgical site infection. Clinical guideline 74. London: National Institute for Health and Clinical Excellence, 2008.
22. Department of Health. HCAI. Reducing healthcare associated infections. High impact intervention. Care bundle to prevent surgical site infection for prevention of SSI. London: Department of Health, 2010.
23. Fry DE. The surgical infection prevention project: processes, outcomes, and future impact. Surg Infect (Larchmt) 2006;7(Suppl. 3):S17-26.
24. Dellinger EP, Hausmann SM, Bratzler DW, Johnson RM, Daniel DM, Bunt KM, Baumgartner GA, Sugarman JR. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005;190:9-15.
25. Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect (Larchmt) 2008;9:579-84.
26. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010;303:2479-85.
27. Rasouli MR, Jaberi MM, Hozack WJ, Parvizi, Rothman RH. Surgical care improvement project (SCIP); has its mission succeeded? J Arthroplasty 2013;28:1072-5. DOI: 10.1016/j.arth.2012.03.004.
28. Weston A, Caldera K, Doron S. Surgical care improvement project in the value-based purchasing era: more harm than good? Clin Infect Dis 2013;56:424-7.
29. Seabrook G. Does rigorous process reporting guarantee superior-quality healthcare? JAMA 2013;310:316-7.
30. Cohen ME, Ko KY, Bilimoria KY, Zhou L, Huffman K, Wang X, Liu Y, Kraemer K, Meng X, Mercow R, Chow W, Matel B, Richards K, Hart AJ, Dimick JB, Hall BL. Optimizing ACS NSQIP modelling for evaluation of surgical quality and risk; patient risk adjustment, procedure mix adjustment, shrinkage adjustment and surgical focus. J Am Coll Surg 2013;217:336-46.e1.
31. Darouiche RO, Wall MJ, Itani KM, Otterson MF, Webb AL, Carrick MM, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH. Chlorhexidine-alcohol versus povidone-iodine for surgical site antisepsis. N Engl J Med 2010;362:18-26.
32. National Institute of Health and Clinical Excellence. Intraoperative hypothermia (Inadvertent). Clinical guideline 65. London: National Institute of Health and Clinical Excellence, 2008.
33. Acklin YP, Widmer AF, Renner RM, Frei R, Gross T. Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach. Injury 2011;42:209-16.
34. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden. Patient Saf Surg 2012;6(3-8):11.
35. Crolla RMPH, van der Laan L, Veen EJ, Hendriks Y, van Schendel C, Kluytmans J. Reduction of surgical site infections after implementation of a bundle of care. PLoS One 2012;7:e44599. DOI: 10.1371/journal.pone.0044599.
36. Liau KH, Aung KT, Chua N, Ho CK, Chan CY, Kow A, Earnest A, Chia SJ. Outcome of a strategy to reduce surgical site infection in a tertiary-care hospital. Surg Infect (Larchmt) 2010;11:151-9.
37. McCahill LE, Ahern JW, Gruppi LA, Limanek J, Dion GA, Sussman JA, McCaffrey CB, Leary DB, Lesage MB, Single RM. Enhancing compliance with medicare guidelines for surgical infection prevention: experience with a cross-disciplinary quality improvement team. Arch Surg 2007;142:355-61.
38. Trussell J, Gerkin R, Coates B, Brandenberger J, Tibi P, Keuth J, Montefour K, Salisbury H, Ferrara J. Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients. Am J Surg 2008;196:883-9.
39. Anthony T, Murray BW, Sum-Ping JT, Lenkovsky F, Vornik VD, Parker BJ, McFarlin JE, Hartless K, Huerta S. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg 2011;146:263-9.
40. World Health Organisation. WHO Guidelines for Safe Surgery 2009: safe surgery saves lives. Geneva: World Health Organisation, 2009.
41. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
42. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA, Safe Surgery Saves Lives Investigators and Study Group. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010;251:976-80.
43. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dreikan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF, Reznick RK, Taylor B, Vats A, Gawande AA, Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. Br Med J Qual Saf 2011;20:102-7.
44. Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, Gawande AA. Perspectives in quality: designing the WHO surgical safety checklist. Int J Qual Health Care 2010;22:356-70.
45. Sparkes D, Rylah B. The World Health Organization surgical safety checklist. Br J Hosp Med 2010;71:276-80.
46. Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy K. Practical challenges of introducing WHO surgical checklist: UK pilot experience. Br Med J 2010;340:b5433. DOI: 10.1136/bmj.b5433.
47. Messahel FM, Al-Qahtani AS. Benchmarking of World Health Organization surgical safety checklist. Saudi Med J 2009;30:422-5.
48. Schlack WS, Boermeester MA. Patient safety during anaesthesia: incorporation of the WHO safe surgery guideline into clinical practice. Curr Opin Anaesthesiol 2010;23:754-8.
49. Cabarrot P, Bataillon R, Le Moign R. One year implementation of the safe surgery checklist in France, what has been achieved so far, what could be improved? Ann Fr Anesth Reanim 2011;30:469-74.
50. Takala RS, Pauniaho SL, Kotkansalo A, Helmio P, Blomgren K, Helmimem M, Takala A, Aaltonen R, Katila AJ, Peltomaa K, Ikonen TS. A pilot study of the implementation of WHO surgical checklist in Finland: improvements in activities and communication. Acta Anesthesiol Scand 2011;55:1206-14.
51. Soria-Aledo V, Da Silva ZA, Saturno PJ, Grau-Polan M, Carrillo-Alcaraz A. Difficulties in implementing a surgical check list in operating theatres. Cir Esp 2012;90:180-5.
52. Delgado Hurtado JJ, Jimenez X, Penalonzo MA, Villatoro C, de Izquierdo S, Cifuentes M. Acceptance of the WHO surgical safety checklist among surgical personnel in Guatemala city. BMC Health Serv Res 2012;12:169.
53. Yuan CT, Walsh D, Tomarken JL, Alpern R, Shakpeh J, Bradley EH. Incorporating the World Health Organisation surgical safety checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf 2012;38:254-60.
54. Low DK, Reed MA, Geiduschek JM, Martin LD. Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. Paediatr Anesth 2013;23:571-8. DOI: 10.1111/pan.12121.
55. Abdel-Rehim S, Morritt A. Perks G. Vol. 2011. Plast Surg Int: WHO surgical checklist and its practical application in plastic surgery, 2011:579579. DOI: 10.1155/2011/579579.
56. Hancorn K, Blair S. Checklist culture. WHO needs changing. Br Med J 2010;340:c909. DOI: 10.1136/bmj.c909.
57. Young B, Ng TM, Teng C, Ang B, Tai HY, Lye DC. Nonconcordance with surgical site infection prevention guidelines and rates of surgical site infections for general surgical, neurological, and orthopedic procedures. Antimicrob Agents Chemother 2011;55:4659-63.
58. Jones S. Your life in WHOs hands: the World Health Organization surgical safety checklist: a critical review of the literature. J Perioper Pract 2011;21:271-4.
59. Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. AORN J 2010;91:722-9.
60. Allard J, Bleakley A, Hobbs A, Coombes L. Pre-surgery briefings and safety climate in the operating theatre. Br Med J Qual Saf 2011;20:711-7.
61. Editorial. Benchmarking study shines light on surgical malpractice causes. Healthcare Benchmarks Qual Improv 2010;17:85-8.
62. Edmiston CE, Spencer M, Lewis BD, Brown KR, Rossi PJ, Henen CR, Smith HW, Seabrook GR. Reducing the risk of surgical site infections: did we really think SCIP was going to lead us to the promised land? Surg Infect (Larchmt) 2011;12:1-9.
63. Nair BG, Newman SF, Peterson GN, Wu WY, Schwid HA. Feedback mechanisms including real-time electronic alerts to achieve near 100% timely prophylactic antibiotic administration in surgical cases. Anesth Analg 2010;111:1293-300.
64. Schwann NM, Bretz KA, Eid S, Burger T, Fry D, Ackler F, Evans P, Romancheck D, Beck M, Ardire AJ, Lukens H, McLoughlin TM. Point-of-care electronic prompts: an effective way of increasing compliance, demonstrating quality, and improving outcome. Anesth Analg 2011;113:869-76.
65. Mainthia R, Lockney T, Zotov A, France DJ, Bennett M, St Jacques PJ, Furman W, Randa S, Feistritzer N, Eavey R, Leming-Lee S, Anders S. Novel use of electronic white board in the operating room increases surgical team compliance with pre-incision safety practices. Surgery 2012;151:660-6.
66. Potenza B, Deligencia M, Estigoy B, Faraday E, Snyder A, Angle N, Schwartz A, Chang L, Hackett J, Minokadeh A, Madani M, MacCaulay K, Ramamoorthy S, Blaner L, James C, Bansal V, Torriani F, Coimbra R. Lessons learned from the institution of the surgical care improvement project at a reaching medical center. Am J Surg 2009;198:881-8.
67. Berenguer CM, Ochsner MG, Lord SA, Senkowski CK. Improving surgical site infections: using National Surgical Quality Improvement Program data to institute surgical care improvement project protocols in improving surgical outcomes. J Am Coll Surg 2010;210:737-41.
68. Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of post-operative infection, including surgical site infection. Surg Infect (Larchmt) 2011;12:163-8.
69. Hedrick TL, Heckman JA, Smith RL, Sawyer RG, Friel CM, Foley EF. Efficacy of protocol implementation on incidence of wound infection in colorectal operations. J Am Coll Surg 2007;205:432-8.
70. Forbes SS, Stephen WJ, Harper WL, Loeb M, Smith R, Christoffersen EP, McLean RF. Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and post intervention study. J Am Coll Surg 2008;207:336-41.
71. Hubner M, Diana M, Zanetti G, Eisenring MC, Demartines N, Troillet. Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon. Arch Surg 2011;146:1240-5.
72. Meeks DW, Lally KP, Carrick MM, Lew DF, Thomas EJ, Doyle PD, Kao LS. Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? Am J Surg 2010;201:76-84.
73. Barchitta M, Matranga D, Quattrocchi A, Bellochi P, Ruffino M, Basile G, Agodi A. Prevalence of surgical site infections before and after the implementation of a multimodal infection control programme. J Antimicrob Chemother 2012;67:749-55.
74. NHS National Patient Safety Agency. Five steps to safer surgery. "How to guide". London: NHS National Patient Safety Agency, 2010.
75. Fry DE. Surgical site infections. Chapter 4. In: Fry DE, editor. Surgical infections. London: JP Medical, 2013:49-62.
76. van Dishoek AM, Koek MBG, Seyerberg EW, vanBenthem BH, Vos MC, Lingsma HF. Use of surgical-site infection rates to rank hospital performance across several types of surgery. Br J Surg 2013;100:628-37.
77. Levy SM, Phatak UR, Tsao K, Wray CJ, Millas SG, Lally KP, Kao LS. What is the quality of reporting of studies of interventions to increase compliance with antibiotic prophylaxis? J Am Coll Surg 2013;217:770-9.