J. Jackson1, R. Griffith1 1St. Joseph’s Hospital, General Surgery, Denver, CO, USA
Introduction:
Surgical site infections (SSIs) are associated with significant morbidity and mortality. The associated costs of treating these complications are significant, prompting investigation into associated risks and strategies for prevention. Costs to the US healthcare system are estimated to be $24,000 to $100,000 per hospitalization for these complications, with a total cost estimated to be $3.5-$10 Billion per year.1–3 The incidence of SSIs has been found to be higher in colorectal and emergency general surgery laparotomy.3,4 The CDC, WHO, and other organizations have published evidence-based recommendations for the prevention of surgical site infections.5,6 We developed and implemented an evidence-based SSI prevention bundle for emergency general surgery laparotomy cases and report our results.
Methods:
We developed a SSI prevention bundle using recommendations from the CDC, WHO, and other organizations.2,3,7–13 A general surgery emergency laparotomy was defined as an urgent or emergent case with abdominal incisions 2 cm or larger, excluding any minimally invasive port sites. Surgical site infections were classified using NSQIP classification criteria. Patient demographics and known SSI risk factors were collected including sex, history of diabetes mellitus, BMI, ASA, tobacco use, use of immunosuppressive medications, operative time, perioperative blood transfusions, and stoma formation.
Results:
117 emergency general surgery laparotomies were performed over the course of 1 year, performed by 23 general surgeons. The bundle was used and documented in 70 of these cases, with a compliance rate of 59.8%. 5.71% of patients developed superficial SSIs and 11.42% organ space SSIs. Of the superficial SSIs, half of those cases had a wound classification of dirty. Wound classifications were as follows: 18.57% clean, 32.86% clean-contaminated, 24.29% contaminated, and 24.29% dirty. Our demographic breakdown was as follows: 63% female, 20% diabetes mellitus, 28% obese, and 31% with an ASA classification greater than 3.
Conclusion:
Prior estimates of SSIs following emergency general surgery range between 6 and 15% with a reported incidence of 10-30% in dirty cases. 1,8,9,14 Notably, compliance with documentation of the bundle is lower than we anticipated. Additional challenges included consistent availability of all components of the bundle, reminders for use of all components of the bundle, failure to document use of the bundle over the course of a year, and lack of enthusiasm for a proposed new practice standard during overnight cases. One limitation of our study is that we lacked prior data regarding the specific rate of SSIs at our institution to compare these results to. A future randomized trial using this bundle would allow us to identify the efficacy of this bundle in emergency general surgery. Additionally, a cost analysis would be useful to understand the exact cost savings the use of the bundle would confer at our institution.