Care Bundle Reduces Surgical Site Infections in Colorectal Cancer Surgery

Pictured: Martin Weiser, MD

Implementation of a multidisciplinary care bundle composed of 13 perioperative components has significantly decreased the rate of surgical site infections (SSIs) among patients undergoing colorectal cancer surgery at Memorial Sloan Kettering Cancer Center, according to our recent research.

Overall, SSI rates declined from 11.0 to 4.1 percent following implementation of the intervention bundle (p = 0.001) and remained low for almost 2.5 years (the duration of the study’s follow-up). (1)

The findings indicate that SSIs can be reduced effectively over the long term with a hospital-wide implementation of multidisciplinary best practices.

Surgical Site Infections

Surgical site infections are the most common type of healthcare-associated infection, with more than 150,000 cases per year. (2), (3) They are a major cause of morbidity and lengthened hospital stays for patients and place an additional financial strain on the healthcare system. (4), (5), (6)

Two intensive programs developed in the United States, the Surgical Infection Prevention Project (7) and the Surgical Care Improvement Project (SCIP), (8) were implemented initially for reducing infections associated with high-risk procedures, like colorectal surgery. (9) The goal of the SCIP was to improve care procedures through the appropriate administration of antibiotics, the use of optimal hair removal techniques, and the maintenance of normothermia. However, adoption of the SCIP guidelines did not uniformly lead to improved SSI rates. (10), (11), (12), (13)

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A Comprehensive Care Bundle to Reduce SSIs

In 2013 at MSK, 55 collaborating experts from the Departments of Surgery, Medicine, Anesthesia, Nursing, Administration, Infection Control, and Quality and Safety developed a care bundle for SSI reduction. The care bundle consists of 13 components: five established measures from the SCIP, plus eight new components that we added following a review of current literature, which identified optimal preoperative, intraoperative, and postoperative care practices with high levels of supporting evidence for infection reduction. Seven of the new components are as follows: consultation for elevated hemoglobin A1C, mechanical bowel preparation with oral antibiotics the night before surgery, preoperative chlorhexidine showers the night and morning before surgery, timely intraoperative readministration of antibiotics, a closing tray for open procedures, and a shower on postoperative day two. (1), (14)

The SSI rate in the implementation phase group was 4.1 percent, significantly lower than the 11.0 percent seen in the baseline phase group.
Martin R. Weiser
Martin R. Weiser Vice Chair for Education and Faculty Development, Department of Surgery; Stuart H.Q. Quan Chair in Colorectal Surgery

We also created a novel SSI risk prediction tool for colorectal surgery, which includes five clinically relevant factors associated with SSI: concurrent liver surgery, history of smoking, duration of the operation, Charlson co-morbidity index, and body mass index. Surgeons receive their patients’ SSI risk scores the day before surgery to guide decision-making on the method for wound closure and postoperative wound care. For example, partial skin closure, subcutaneous drains, and negative-pressure surface vacuum dressings on closed incisions may reduce superficial SSIs. (15)

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Study Results

To examine the changes in SSI rates associated with the implementation of the care bundle, we divided patients undergoing colorectal surgery at MSK into three groups: a baseline group of 454 patients who were treated before the bundle was put into practice, between January 1 and October 31, 2013; an implementation group of 616 patients who were treated between November 1, 2013, and December 31, 2014; and a sustainability phase of 758 patients who had surgery between January 1, 2015, and March 31, 2016. (1)

The SSI rate in the implementation phase group was 4.1 percent, significantly lower than the 11.0 percent seen in the baseline phase group (p = 0.001). Our analysis of interrupted time series did not reveal any significant time trends in the baseline or implementation phases, supporting the conclusion that the reduced SSI rates were attributed to the care bundle intervention. (1)

We used our MSK SSI prediction tool for colorectal surgery to group patients by low, intermediate, and high risk. Results for the intermediate-risk group showed a significantly lower SSI rate of 4.7 percent in the implementation phase compared to 10.3 percent in the baseline phase (p = 0.006). Similarly, the high-risk group had a significantly lower SSI rate of 2 percent in the implementation phase compared to 19 percent in the baseline phase (p < 0.001). (1)

In an analysis by infection type, the rates of superficial/deep SSIs for the implementation phase were statistically significantly lower than in the baseline phase for all three risk groups (p = 0.001, p = 0.034, and p = 0.004 for the low-, intermediate-, and high-risk groups, respectively). The rates of superficial/deep SSIs, which involve the skin or fascia, saw the most significant reductions. As expected, organ-space SSIs were not affected, given that they most often result from wound rupture or a leak and are not influenced by the interventions included in the care bundle.

Wound closure modifications were used in 43.2 percent of patients in the implementation phase, a much larger proportion compared to 24.9 percent of patients in the baseline phase. In the implementation phase, incisions were closed with a wider range of approaches: primarily with a dry dressing (57 percent), closed over a drain (12.6 percent), closed with an overlying surface vacuum dressing (17.2 percent), and left partially open (13.2 percent). By contrast in the baseline phase, a larger proportion of incisions were closed with a dry dressing (75.1 percent) and the other methods were employed as follows: over a drain (16.8 percent), closed with an overlying surface vacuum dressing (1.4 percent), and left partially open (6.7 percent). (1)

The care bundle significantly reduced the median length of hospital stay (LOS) to six days in the implementation phase compared to seven days in the baseline phase (p = 0.002). For the intermediate-risk group, LOS was significantly lower in the implementation phase compared to the baseline phase, six versus seven days (p = 0.006), and likewise for the high-risk group, with a median LOS of six versus eight days (p = <0.001). Implementation of the care bundle did not reduce the 30-day readmission rate, likely because superficial and deep wound infections can be treated on an outpatient basis whereas significant SSIs require rehospitalization. (1)

This present prospective study adds significant weight to a previously published retrospective study that analyzed SSI rates before and after the implementation of the new care bundle in 424 patients who underwent synchronous colorectal and liver resection at MSK from 2011 to 2016. In that study, the care bundle was associated with a reduced rate of SSI of 61 percent (p < 0.001) for the intervention group compared to the pre intervention group, including an 81 percent reduction in superficial/deep SSIs (p < 0.001) and a 48 percent reduction in organ-space SSI (p = 0.008). (14)

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Advancing Colorectal Surgical Cancer Care

Learn about how we care for our patients with colorectal cancer.

At MSK, we are dedicated to improving oncologic outcomes, minimizing the burden of treatment for patients, and pioneering ways to reduce healthcare costs. Optimizing surgical cancer care takes place across the whole continuum of the patient journey, including the preoperative, intraoperative, and postoperative surgical phases and longer-term surveillance.

The SSI risk tool has now been implemented at MSK for use with pancreatic, gynecologic, and urologic surgical procedures.

Our cancer care team of multidisciplinary experts consult on each case to determine the optimal treatment plan for each patient. We continue to advance clinical research to find new ways to improve patient outcomes. Currently, we are conducting 32 clinical trials, investigating new surgical, chemotherapy, chemoradiation, and combination approaches for treating colorectal cancer.

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  1. Weiser MR, Gonen M, Usiak S, et al. Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections. Br J Surg. 2018;105(12):1680–1687.

  2. Magill SS, Hellinger W, Cohen J, et al. Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. Infect Control Hosp Epidemiol. 2012;33:283–291.

  3. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370:1198–1208.

  4. Anderson DJ, Kaye KS. Staphylococcal surgical site infections. Infect Dis Clin North Am. 2009; 23: 53–72.

  5. Artinyan A, Orcutt ST, Anaya DA, et al. Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients. Ann Surg. 2015;261:497–505.

  6. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015;313:483–495.

  7. Bratzler DW, Houck PM, Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. 2005;189:395–404.

  8. Surgical Care Improvement Project. Specifications manual for Joint Commission National Quality Core Measures. 2010. Accessed December 7, 2018 at https://manual.jointcommission.org/releases/archive/TJC2010B/SurgicalCareImprovementProject.html

  9. Merkow RP, Ju MH, Chung JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015;313:483–495.

  10. Ingraham AM, Cohen ME, Bilimoria KY, et al. Association of Surgical Care Improvement Project infection-related process measure compliance with risk-adjusted outcomes: implications for quality measurement. J Am Coll Surg. 2010;211:705–714.

  11. Larochelle M, Hyman N, Gruppi L, Osler T. Diminishing surgical site infections after colorectal surgery with Surgical Care Improvement Project: is it time to move on? Dis Colon Rectum. 2011;54:394–400.

  12. Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. JAMA. 2010;303:2479–2485.

  13. Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: time to move beyond the Surgical Care Improvement Program. Ann Surg. 2011;254:494–501.

  14. Tufts LS, Jarnagin ED, Flynn JR, et al. A perioperative multidisciplinary care bundle reduces surgical site infections in patients undergoing synchronous colorectal and liver resection. HPB (Oxford). 2018 August. [Epub ahead of print]

  15. Blackham AU, Farrah JP, McCoy TP, et al. Prevention of surgical site infections in high-risk patients with laparotomy incisions using negative-pressure therapy. Am J Surg. 2013;205:647–654.