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Analysis

This Care Bundle Cut Pediatric Cardiac Surgical Site Infections by 74%

By Christopher Cheney  
   April 19, 2019

The postoperative care initiative at a California-based children's hospital has 11 elements.

A new approach to cardiac surgery postoperative care at Lucile Packard Children's Hospital Stanford slashed the surgical site infection rate.

SSIs have been linked to significant negative outcomes such as increased duration of mechanical ventilation, longer ICU and hospital lengths of stay, and higher mortality rates.

For pediatric cardiac surgery patients, a new postoperative care bundle at Lucile Packard Children's in Palo Alto, California, reduced SSIs from 3.4 incidences per 100 procedures to 0.9 per 100 procedures, recent research shows.

The lead author of the research, Thomas Caruso, MD, MEd, told HealthLeaders that other hospitals seeking to reduce SSIs should also assess postoperative care.

"The national guidelines focus on the preoperative, intraoperative, and immediate postoperative period, but SSIs can occur up to 30 days postoperatively," said Caruso, a clinical associate professor in the Division of Pediatric Anesthesiology at the Stanford University School of Medicine, Stanford, California.

The first step is examining instances of SSIs, he said.

"For an institution with high rates of SSIs, I would recommend starting with an analysis of when the majority of SSIs occur and whether they occur more commonly during a specific surgery. If the majority of SSIs are occurring in postoperative days 10 to 30, consider examining the extended recovery care, in addition to the typical perioperative guidelines."

Care bundle components
 

The new cardiac surgery postoperative care bundle at Lucile Packard Children's has 11 elements.

1. Antiseptic wipe: Once a day, patient skin is wiped with 2% chlorhexidine gluconate

2. Linen and gowns: Maintaining clean gowns and linens reduces patients' potential antibiotic burden

3. Dressing removal: With an aseptic technique, dressings are removed within 48 hours because they can provide a conducive environment for infection development

4. Covering incision site: In some circumstances such as placing ECG cables, the incision site is covered to avoid contamination

5. Sterile echocardiograms: Using a sterile sheath and gel on the probe lowers risk of infection

6. Sterile environment standards: When procedures are performed in the cardiovascular intensive care unit, appropriate attire is donned and the surgical bed is demarcated with physical barriers and draping

7. Home blankets: While home blankets are considered a comfort measure for children, they are a potential source of contamination, and a clean gown or linen is placed between the blanket and the surgical site

8. Wound documentation: EMR modification reduces variability in documentation of wound status

9. Wound monitoring: Swabbing of wounds for infection is only conducted if there are signs of erythema or purulence

10. Postoperative antibiotics: Rather than make nurses responsible for appropriate time and dose of first postoperative antibiotics, a pharmacist determines appropriate administration

11. Continuation of antibiotics: Administration of postoperative antibiotics is maintained for 24 hours or extended beyond a day if the chest remains open

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Surgical site infections have been linked to several negative outcomes such as longer hospital length of stay.

These infections can occur as many as 30 days after a surgical procedure.

The first step in addressing high SSI rates should be assessing occurrences of the infections and whether they occur commonly during a specific surgery.

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