Bundled Care Program Cuts Colorectal Surgical Site Infection Rates in Half

Innovative approach successful in addressing issue

The Challenge

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) identified Cleveland Clinic as a “high outlier” for surgical site infections (SSIs). Further analysis identified the primary cause: A high proportion of colorectal patients, a high-risk subset. SSIs are the most common hospital-acquired infections following colorectal surgery, resulting in increased morbidity, mortality and hospital costs.

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Given the inherent high-risk procedures performed by the Department of Colorectal Surgery, leaders knew that an innovative approach would be needed to address this issue. Part of the challenge was that while the surgical team had identified unique SSI risk factors in colorectal surgery, many were not amenable to modification. As a result, the focus shifted from individual risk factors to a big-picture approach.

“We realized that achieving sustained SSI reduction would hinge on collaborative efforts among multiple providers, with an emphasis on continuity of care,” says colorectal surgeon I. Emre Gorgun, MD.

The Solution: In February 2014, the department initiated the “SSI Prevention Bundle Project,” a coordinated program targeting SSI reduction through evidence-based pre-, intra- and postoperative elements [see “Bundle Elements” below].

The bundle project worked.

“Observed infection rates were reduced by nearly one half,” Dr. Gorgun says. That finding is based on the results of the department’s recent study that compared the one-year outcomes of the prevention bundle to the pre-bundle period.

Study Highlights

The study looked at SSI rates among 2,279 abdominal colorectal surgical procedures performed between February 2013 and February 2015. Ileostomy closure, anorectal and enterocutaneous fistula repair procedures were excluded. SSIs were classified according to NSQIP definitions — superficial, deep and organ space.

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Researchers analyzed SSI outcomes for one year following the implementation of the Prevention Bundle Project, and compared them with SSI rates during the prior year. Comorbidities, perioperative characteristics and procedure types were similar in both periods.

The initiative resulted in significant declines in both overall SSIs (decreased by nearly half) and organ space SSIs (slashed by two-thirds). Decreases in superficial SSIs and deep SSIs were not statistically significant.

The evidence-based SSI Prevention Bundle Project consisted of:


                Bundle Elements
Preoperative Mechanical bowel prep ± oral antibiotics
Shower at home with Hibiclens®
Usage of chlorhexidine wipes
Intraoperative Antibiotic prophylaxis with ceftriaxone 2 g IV + metronidazole 500 mg IV
Wound edge protection, glove change after each intraoperative DRE
Sleeve placement and glove change after anastomosis established
  Glove change for wound closure with separate instruments
  Suction tip change and wound washout with saline before closure
Postoperative Dressing removal after 48 hours
Wound check
Close monitoring of surgical sites and timely management of any issues

DRE: digital rectal examination

Team Effort

The success of the project hinged on surgeons, physicians and the entire care team buying into it and seamlessly implementing each element of the patients’ perioperative care.

“We accomplished the desired culture change to achieve a significant improvement in SSI outcomes,” Dr. Gorgun says.

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The bundle project was implemented for two reasons: “First and foremost, to provide optimal healthcare for our patients with the best possible outcomes,” Dr. Gorgun says.

In addition, it was critically important to ensure that the high volume of colorectal surgeries performed at Cleveland Clinic did not adversely impact its standardized infection ratio (SIR), he explains. The SIR, which tracks healthcare-associated infections (HAIs), including SSIs, has been widely adapted as a quality parameter by government entities such as the Centers for Medicare & Medicaid Services (CMS). Therefore, SIRs increasingly are being tied to revenue for healthcare institutions.

The SIR, which is risk-adjusted based on the level of care that a hospital provides, compares its actual number of HAIs with the predicted number of HAIs (based on national baseline data). “There’s an SIR threshold that each hospital needs to meet,” Dr. Gorgun says. “Any rate above that is penalized financially by CMS.”

The good news? “Last year, due in large part to the SSI Prevention Bundle Project, we were able to successfully get our SIR below the threshold.”