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      Implementation of an evidence-based practice to decrease surgical site infection after coronary artery bypass grafting

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          Abstract

          Objective

          Surgical site infection (SSI) is a serious complication after coronary artery bypass grafting (CABG). This study was performed to evaluate evidence-based practice and structured problem-solving to reduce SSI after CABG.

          Methods

          An infection control strategy including supervised chlorhexidine gluconate (CHG) showers was implemented from January 2017 to March 2018 for 119 patients undergoing CABG. The controls comprised 244 patients who underwent CABG from 2014 to 2016. Risk factors for SSI were identified, and a problem-focused strategy was used to control SSI. Propensity score matching was used to study the effect of CHG showers on SSI.

          Results

          SSI occurred in 25 patients (10.25%) in the control group, and the significant risk factors were the postoperative blood glucose level, transfer from an outside hospital, emergency operation, redo sternotomy, a higher American Society of Anesthesiologists score, and the duration of surgery. After implementation of the program, the SSI rate significantly decreased to 3.36%. Patients who had undergone preoperative CHG showers had a significantly lower SSI rate (1.69%) than the matched controls (13.56%).

          Conclusion

          SSI after CABG can be reduced using evidence-based practice and structured problem-solving to identify risk factors. A preoperative CHG shower is associated with a lower SSI rate after CABG.

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          Most cited references17

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          Estimating health care-associated infections and deaths in U.S. hospitals, 2002.

          R. Monina Klevens, Jonathan Edwards, Chesley Richards … (2007)
          The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals. No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990-2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths. In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.
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            Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida.

            Jessica Guzmán-Morales, Mobeen H. Rathore, Anne Starling … (2012)
            To determine healthcare-associated infection (HAI) prevalence in 9 hospitals in Jacksonville, Florida; to evaluate the performance of proxy indicators for HAIs; and to refine methodology in preparation for a multistate survey. Point prevalence survey. Acute care inpatients of any age. HAIs were defined using National Healthcare Safety Network criteria. In each facility a trained primary team (PT) of infection prevention (IP) staff performed the survey on 1 day, reviewing records and collecting data on a random sample of inpatients. PTs assessed patients with one or more proxy indicators (abnormal white blood cell count, abnormal temperature, or antimicrobial therapy) for the presence of HAIs. An external IP expert team collected data from a subset of patient records reviewed by PTs to assess proxy indicator performance and PT data collection. Of 851 patients surveyed by PTs, 51 had one or more HAIs (6.0%; 95% confidence interval, 4.5%-7.7%). Surgical site infections ([Formula: see text]), urinary tract infections ([Formula: see text]), pneumonia ([Formula: see text]), and bloodstream infections ([Formula: see text]) accounted for 75.8% of 58 HAIs detected by PTs. Staphylococcus aureus was the most common pathogen, causing 9 HAIs (15.5%). Antimicrobial therapy was the most sensitive proxy indicator, identifying 95.5% of patients with HAIs. HAI prevalence in this pilot was similar to that reported in the 1970s by the Centers for Disease Control and Prevention's Study on the Efficacy of Nosocomial Infection Control. Antimicrobial therapy was a sensitive screening variable with which to identify those patients at higher risk for infection and reduce data collection burden. Additional work is needed on validation and feasibility to extend this methodology to a national scale.
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              Superficial and deep sternal wound complications: incidence, risk factors and mortality.

              H Ahlfeldt, H Gill, L Ridderstolpe … (2001)
              Sternal wound complications often have a late onset and are detected after patients are discharged from the hospital. In an effort to catch all sternal wound complications, different postdischarge surveillance methods have to be used. Together with this long-term follow-up an analysis of risk factors may help to identify patients at risk and can lead to more effective preventive and control measures. This retrospective study of 3008 adult patients who underwent consecutive cardiac surgery from January 1996 through September 1999 at Linköping University Hospital, Sweden, evaluated 42 potential risk factors by univariate analysis followed by backward stepwise multivariate logistic regression analysis. Two-thirds of the 291 (9.7%) sternal wound complications that occurred were identified after discharge. Of the 291 patients, 47 (1.6%) had deep sternal infections, 50 (1.7%) had postoperative mediastinitis, and 194 (6.4%) had superficial sternal wound complications. Twenty-three variables were selected by univariate analysis (P<0.15) and included in a multivariate analysis where eight variables emerged as significant (P<0.05). Preoperative risk factors for deep sternal infections/mediastinitis were obesity, insulin-dependent diabetes, smoking, peripheral vascular disease, and high New York Heart Association score. An intraoperative risk factor was bilateral use of internal mammary arteries, and a postoperative risk factor was prolonged ventilator support. Risk factors for superficial sternal wound complications were obesity, and an age of <75 years. The 30 day mortality was 2.7% for patients without sternal wound complications and 2/291 (0.7%) for all patients with sternal wound complications, 0.5% for superficial sternal wound complications, and 1.0% for deep sternal infections/mediastinitis. The 1 year mortality rate was 4.8% for patients without sternal wound complications and 11/291 (3.8%) for patients with sternal wound complications, 2.1% for superficial sternal wound complications, and 7.2% for deep sternal infections/mediastinitis. The risk factors found in this study have been detected and reported in previous studies. The predictive ability was stronger though for deep sternal infections/mediastinitis (those needing surgical revisions) than for superficial sternal wound complications. Earlier recognition of sternal wound complications and aggressive treatment have probably contributed to the relatively low mortality rate seen in this study.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Int Med Res
                Journal ID (iso-abbrev): J. Int. Med. Res
                Journal ID (publisher-id): IMR
                Journal ID (hwp): spimr
                Title: The Journal of International Medical Research
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Print): 0300-0605
                ISSN (Electronic): 1473-2300
                Publication date (Electronic): 21 March 2019
                Publication date (Print): August 2019
                Volume: 47
                Issue: 8
                Pages: 3491-3501
                Affiliations
                [1 ]Infection Control and Epidemiology Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                [2 ]Department of Cardiovascular Diseases, Cardiothoracic Surgery Section, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                [3 ]Cardiothoracic Surgery Department, Faculty of Medicine, Tanta University, Tanta, Egypt
                [4 ]Department of Internal Medicine, Infectious Diseases Section, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                [5 ]Department of Anesthesia, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                [6 ]Department of Cardiovascular Diseases, Cardiology Section, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
                Author notes
                [*]Ahmed Elmahrouk, Department of Cardiovascular Diseases, Cardiothoracic Surgery Section, King Faisal Specialist Hospital and Research Center, MBC J-16, PO Box 40047, Jeddah 21499, Saudi Arabia. Email: Ael-Mahrouk@ 123456KFSHRC.edu.sa
                Author information
                https://orcid.org/0000-0003-0951-7287
                Article
                Publisher ID: 10.1177_0300060519836511
                DOI: 10.1177/0300060519836511
                PMC ID: 6726785
                PubMed ID: 30897994
                SO-VID: 230b23ae-a8bb-4548-8102-921499c08961
                Copyright © © The Author(s) 2019
                License:

                Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Date received : 3 January 2019
                Date accepted : 18 February 2019
                Categories
                Subject: Special Issue: Cardiothoracic Critical Care

                Keywords: surgical site infection,coronary artery bypass grafting,infection control,chlorhexidine gluconate,evidence-based practice,propensity score matching
                Data availability:
                Keywords: surgical site infection, coronary artery bypass grafting, infection control, chlorhexidine gluconate, evidence-based practice, propensity score matching

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