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Hygienic interventions to decrease deep sternal wound infections following coronary artery bypass grafting
B Lytsy1, R P F Lindblom2, U Ransjö1
1Department of Medical Sciences, Unit for Clinical Microbiology and Infectious Medicine, Uppsala University, Uppsala, Sweden.
Insights
Root cause analysis and quality improvement interventions significantly reduced deep sternal wound infections (DSWIs) after coronary artery bypass grafting (CABG) surgery. This approach is effective for preventing healthcare-associated infections following cardiac procedures.
Area of Science:
- Cardiothoracic Surgery
- Infectious Disease Control
- Quality Improvement Science
Background:
- Uppsala University Hospital's Cardiothoracic Surgery department performs approximately 700 open-heart surgeries annually, including 250 isolated coronary artery bypass grafting (CABG) procedures.
- In 2009, an unacceptable rise in deep sternal wound infections (DSWIs) was observed despite adherence to existing hygienic guidelines.
Purpose of the Study:
- To investigate the impact of root cause analysis (RCA) combined with targeted quality improvement interventions on reducing DSWI rates in CABG patients.
- To demonstrate the effectiveness of a systematic approach in mitigating healthcare-associated infections within a surgical setting.
Main Methods:
- A prospective analysis of isolated CABG patients who developed DSWI and required surgical revision.
- Infection etiology was investigated using standard microbiological analysis of wound swabs and tissue biopsies.
- Root cause analysis (RCA) was conducted from September 2009 to April 2010, followed by the implementation of interventions based on findings and national recommendations.
- Environmental air sampling was performed to assess microbial contamination levels near the sternal incision.
Main Results:
- The incidence of DSWI after CABG surgery decreased from 5.1% pre-intervention to 0.9% post-intervention.
- Pre-intervention wound cultures showed high rates of Staphylococcus aureus (27.1%) and coagulase-negative staphylococcus (CoNS) (47.1%).
- Post-intervention, the rates of S. aureus decreased to 23.1% and CoNS to 30.8%, with air counts remaining below 5cfu/m³.
Conclusions:
- Root cause analysis (RCA), involving both medical professionals and infection control teams, is a valuable tool for identifying multifactorial causes of adverse events like healthcare-associated infections.
- Systematic quality improvement interventions, informed by RCA, can effectively reduce the incidence of deep sternal wound infections following coronary artery bypass grafting surgery.
Background:
The department of Cardiothoracic Surgery at Uppsala University Hospital has 25 beds in one to four patient rooms and an operating suite consisting of five operating rooms with ultraclean air. Around 700 open heart (250 isolated coronary artery bypass grafting, CABG) operations are performed annually. In 2009, the numbers of deep sternal wound infections (DSWIs) increased to unacceptable rates despite existing hygienic guidelines.
Aim:
To show how root cause analysis (RCA) followed by quality improvement interventions reduced the rate of DSWI after CABG surgery.
Methods:
Only isolated CABG patients requiring surgical revision due to DSWI were included. Swabs and tissue biopsies were taken during surgical revision and analysed with standard methods. DSWIs were registered prospectively according to US Centers for Disease Control and Prevention definitions. RCA for infection was performed between September 2009 and April 2010. Interventions based on results of the RCA and on nationally recommended practices were concluded in April 2010, and thought to have taken full effect by July 1st, 2010. Air was actively sampled at ≤0.5m from the sternal incision.
Findings:
DSWI incidence rates per CABG operations decreased from 5.1% pre intervention to 0.9% post intervention. Wound cultures pre intervention grew Staphylococcus aureus 27.1% and coagulase negative staphylococcus (CoNS) 47.1%, post intervention S. aureus 23.1% and CoNS 30.8%. Air counts did not exceed 5cfu/m(3).
Conclusion:
When the aetiology of an error is multifactorial, RCA engaging both the medical professions and the infection control team is a potential tool to map causes leading to adverse events such as healthcare-associated infections. A systematic quality improvement intervention based on the RCA may reduce the number of deep sternal wound infections after CABG surgery.
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