Surgical site infection: poor compliance with guidelines and care bundles

Surgical site infections (SSIs) are probably the most preventable of the health care-associated infections. Despite the widespread international introduction of level I evidence-based guidelines for the prevention of SSIs, such as that of the National Institute for Clinical Excellence (NICE) in the UK and the surgical care improvement project (SCIP) of the USA, SSI rates have not measurably fallen. The care bundle approach is an accepted method of packaging best, evidence-based measures into routine care for all patients and, common to many guidelines for the prevention of SSI, includes methods for preoperative removal of hair (where appropriate), rational antibiotic prophylaxis, avoidance of perioperative hypothermia, management of perioperative blood glucose and effective skin preparation. Reasons for poor compliance with care bundles are not clear and have not matched the wide uptake and perceived benefit of the WHO 'Safe Surgery Saves Lives' checklist. Recommendations include the need for further research and continuous updating of guidelines; comprehensive surveillance, using validated definitions that facilitate benchmarking of anonymised surgeon-specific SSI rates; assurance that incorporation of checklists and care bundles has taken place; the development of effective communication strategies for all health care providers and those who commission services and comprehensive information for patients.