Measured Wound Outcome Feedback Improves Surgical Site Infection Rates

Reference: Marche B, Neuwirth M, Kugler C, Bouillon B, Mattner F, Otchwemah R. Implementation methods of infection prevention measures in orthopedics and traumatology—a systematic review. Eur J Trauma Emerg Surg. 2021;47(4):1003–1013. doi:10.1007/s00068-020-01477-z

Rationale: Current guidelines on preventing hospital-acquired SSIs do not identify which practices in the SSI-prevention bundle work best.

Objective: This study systematically reviewed the literature on preventing SSIs after orthopedic and trauma surgery procedures to identify those most critical to implement.

Methods: Using Preferred Reporting Items for Systematic Reviews⁵ (PRISMA), the authors searched Cochrane Wounds Specialised and Central Registries, MEDLINE, and SCOPUS reference databases to identify studies reporting effective practices implemented to prevent SSI in patients undergoing orthopedic or trauma surgery. Eligible studies had to be published in English or German between January 1, 1950, and June 1, 2019. All study designs were included. Studies were excluded if they did not report a significant (P <.05) practice or SSI difference following orthopedic or trauma surgery.

Results: Among the 8414 unique references found in the literature search, 13 qualified for inclusion. Important, qualified practices that reduced the likelihood of SSIs were developing standardized, printed practice guides, multidisciplinary or interdisciplinary practice with regular meetings, audits and training, feedback to physicians and nurses, and online or electronic materials. Studies were of mixed quality (leaning toward low quality), prospective observational designs with high potential for bias, except for one high-quality, low-bias RCT. They differed in numbers and types of outcomes measured, with heterogeneity, which prevented pooled data analyses. Only 5 of the studies reported reduced SSI incidence in response to multidisciplinary interventions, including personal training (5 studies), regular audits and feedback to surgeons and/or nurses (3 studies), and using online or electronic materials (3 studies). Team communication and departmental culture were key factors for successful implementation of effective practices.

Authors’ Conclusions: Despite scarce evidence and mainly low-quality research, practice implementation methods focusing on interdisciplinary work and interactions, with regular audits and feedback, support improvement in professional adherence to practice guidelines and reduction of SSIs resulting from orthopedic or trauma surgery.

Reference: Tomsic I, Heinze NR, Chaberny IF, Krauth C, Schock B, von Lengerke T. Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review. BMC Health Serv Res. 2020;20(1):236. doi:10.1186/s12913-020-4995-z

Rationale: Surgical site infections after abdominal surgery often increase the clinical, patient, and economic burdens for health care systems. Those who implement bundles of at least 3 evidence-based SSI prevention practices reduce SSI incidence by up to 40%, despite barriers to implementation.

Objective: This systematic literature review explored the association between SSI guideline or bundle implementation, compliance levels, and reduced SSI rates.

Methods: Following PRISMA principles, authors searched MEDLINE/PubMed and Web of Science Core Collection databases for studies describing evidence-based guidelines or bundle practices to prevent SSI following abdominal surgery. Studies were included if they monitored implementation and reported compliance with the evidence-based practices, were written in English or German, and were published before January 1, 2018. Studies without abdominal surgery or guidelines or bundles to reduce SSI likelihood were excluded. Two reviewers extracted data identifying the study, its date and design, type of surgery, practices implemented, baseline and cohort sample sizes, cohort outcomes, SSI rates, and compliance rates reported. A qualitative analysis of all eligible studies described each study in terms of 20 implementation strategies listed in the taxonomy developed for health system interventions by the Cochrane Effective Practice and Organisation of Care⁶ (EPOC). Study implementation interventions, quality, and SSI outcomes were tabulated. Effectiveness analyses tested significance (P <.05) of absolute and percent reduction in SSI from before to after implementation of different numbers of evidence-based practice bundles.

Results: Among 1010 articles returned by the literature searches, 40 qualified for qualitative analyses. Of these, the earliest was published in 2004 and most were published after 2014. All studies were historically controlled or baseline-controlled cohort studies. No RCT evidence supporting SSI bundle or guideline implementation was found. Thirty-two qualifying studies included some measure of compliance with bundle implementation. Thirty-five studies reported baseline and cohort SSI rates specific to abdominal surgery during differing surveillance periods. Inadequate sample size and duration excluded 3 studies from analysis. Among the 40 studies reporting interventions implemented to reduce SSI rates, audit with feedback to care providers was the most commonly implemented intervention (used in 32 [80%] of the qualifying studies), followed closely by multidisciplinary practice and monitoring health care delivery. Among the 31 studies that monitored compliance with bundle implementation and measured cohort SSI rates, absolute risk of SSI reduced by 6.5% compared with baseline for those implementing 1 to 2 of the evidence-based interventions (P <.018). For those implementing 3 to 5 interventions absolute SSI risk reduced by 10.8% (P <.001). For those implementing 6 to 8 interventions, SSI risk reduced 6.5% (P <.004). Heterogeneous implementation practices and outcomes measures made it impossible to conduct a meta-analysis of the effects of using any specific intervention on SSI rates.

Authors’ Conclusions: The 5 most commonly used tactics for reducing SSI were audit/feedback, multidisciplinary organizational culture, performance monitoring, reminders, and educational meetings. The greatest reduction in SSI risk was achieved by institutions using all 5 interventions. Better research using more standard implementation practices and outcomes measures are needed to draw firmer conclusions.

The current literature reviews focusing on the effects of implementing practice interventions on reducing SSI rates highlight care provider feedback as a key element of the care bundle to prevent SSI following trauma, orthopedic, and abdominal surgery.^3,4 They also help health care professionals understand the importance of standardized surveillance and reporting of clinically important outcomes such as SSIs and healing. Lack of standardized SSI surveillance was recognized as an important barrier to analyzing effects of bundle or guideline implementation by both of these rigorous literature reviews. These studies concluded that there is a critical need to use consistent, validated measures to monitor SSIs, which was also found for other clinical and patient-centered wound outcomes such as healing.⁷ Implementation science is young,⁴ with few RCTs.³ Despite the need for more rigorous research, the 2 studies^3,4 summarized here lead to the next step following the adage—you can’t manage what you don’t measure. That vital next step is to continuously monitor for SSIs and regularly provide feedback about SSIs to all on the multidisciplinary care team. Each health care provider needs to critically consider the SSI (and healing, pressure injury, or other wound outcomes) resulting from the care delivered to determine the benefit being delivered to patients. Evidence-based guidelines such as those by the Association for the Advancement of Wound Care⁸ and the World Health Organization⁹ only benefit patients if they are implemented with consistent outcomes, surveillance, and feedback to the professionals providing care, so that health care providers may learn which outcomes need improvement as well as how to improve their evidence-based practices and related patient outcomes. Evidence-based practice benefits only those patients in whom it is consistently applied.

Laura Bolton, PhD
Mentor, Thomas Edison State University
Adjunct Associate Professor
Department of Surgery
Rutgers Robert Wood Johnson Medical School
New Brunswick, NJ