Adhering to a national surgical care bundle reduces the risk of surgical site infections

Abstract

Background: In 2008, a bundle of care to prevent Surgical Site Infections (SSIs) was introduced in the Netherlands. The bundle consisted of four elements: antibiotic prophylaxis according to local guidelines, no hair removal, normothermia and 'hygiene discipline' in the operating room (i.e. number of door movements). Dutch hospitals were advised to implement the bundle and to measure the outcome. This study's goal was to assess how effective the bundle was in reducing SSI risk.

Methods: Hospitals assessed whether their staff complied with each of the bundle elements and voluntary reported compliance data to the national SSI surveillance network (PREZIES). From PREZIES data, we selected data from 2009 to 2014 relating to 13 types of surgical procedures. We excluded surgeries with missing (non)compliance data, and calculated for each remaining surgery with reported (non)compliance data the level of compliance with the bundle (that is, being compliant with 0, 1, 2, 3, or 4 of the elements). Subsequently, we used this level of compliance to assess the effect of bundle compliance on the SSI risk, using multilevel logistic regression techniques.

Results: 217 489 surgeries were included, of which 62 486 surgeries (29%) had complete bundle reporting. Within this group, the SSI risk was significantly lower for surgeries with complete bundle compliance compared to surgeries with lower compliance levels. Odds ratios ranged from 0.63 to 0.86 (risk reduction of 14% to 37%), while a 13% risk reduction was demonstrated for each point increase in compliance-level. Sensitivity analysis indicated that due to analysing reported bundles only, we probably underestimated the total effect of implementing the bundle.

Conclusions: This study demonstrated that adhering to a surgical care bundle significantly reduced the risk of SSIs. Reporting of and compliance with the bundle compliance can, however, still be improved. Therefore an even greater effect might be achieved.

Fig 1. Statistical analysis: Four analyses comparing the influence of bundle-compliance on the SSI-risk.

Comparisons made in Models 1 to 4 schematically represented. A stack of four boxes represents the entire bundle, a stack of three boxes represents the partial bundle. Compliance with a single bundle element is presented as a blue box with a Y (= Yes). Non-compliance with a bundle element is presented in a white box with an N (= No). Only bundles being completely reported were included (N = 62 486 for entire bundle, N = 99 371 for the partial bundle). Bundles with missing data concerning compliance were excluded. Key: * Model 4: The partial bundle does not include the bundle element hygiene discipline (‘minimising operating room door movements’), but is only composed of the bundle elements PAP-LG, hair removal and normothermia. † Model 2: Level of compliance entered as a categorical variable produces 4 Odds Ratios (ORs), comparing full compliance with the four other levels of compliance separately. ‡ Model 3: Level of compliance entered as a continuous variable produces 1 Odds ratio (OR), signifying the reduced risk for each single point increase in compliance-level.

Fig 2. Compliance over time.

Compliance with the bundle elements and with the bundle over time. Compliance with each bundle element was calculated using surgeries for which the element was reported, i.e. not missing (n = 72 457 for hygiene discipline, n = 112 215 for normothermia, n = 130 622 for hair removal, and n = 139 089 for PAP-LG). Bundle compliance was calculated within the group of surgeries for which (non-)compliance was reported for the entire bundle (n = 62 486). * Data from 2014 are incomplete because of the mandatory delay in follow-up of one year, which caused a delay in reporting the data. PAP-LG = Peri-operative Antibiotic Prophylaxis according to Local Guidelines.