Implementation of an Evidence-Based Quality Improvement Protocol to Reduce Surgical Site Infections after Lower...

Surgical site infections (SSIs) are among the most common complications after lower extremity bypass (LEB) surgery, despite being considered a preventable event. In this Quality Improvement project, we report the development and implementation of an SSI reduction bundle at a tertiary academic medical center.

The Vascular Quality Initiative (VQI) infrainguinal bypass registry for our hospital was retrospectively reviewed to determine overall postoperative SSI rates from 2018-2022. Institutional medical records were then manually reviewed to verify these results, and collect further data on patient demographics, comorbidities, operative details, and postoperative complication rates. Logistic regression analysis was used to define risk factors for postoperative SSI, and along with internal audit, aid in the development of an SSI reduction bundle. After bundle implementation, SSI rates were prospectively tracked via the VQI registry.

From 2018-2022, our SSI incidence after LEB surgery was 23.2% (120/517; 85 superficial, 35 deep). Internal audit was conducted and revealed suboptimal compliance with skin preparation and clipping standards. Our final "SSI bundle" comprised of (1) appropriate perioperative antibiotics, (2) skin preparation training, (3) hair removal training, (4) glycemic control, (5) intraoperative normothermia, and (6) chlorhexidine prescrubbing. Perioperative antibiotic regimen was developed in collaboration with infectious diseases, tailored with our local antibiogram, and transitioned into an "order set" within the electronic medical record system. Skin preparation and hair removal training sessions were conducted with circulators and scrub nursing staff, with refresher courses planned. Vascular anesthesia colleagues were engaged regarding the importance of glycemic control and intraoperative normothermia. Chlorhexidine prescrubbing was included in the perioperative antibiotic order set for inpatient operations. Since the implementation of an SSI reduction bundle, our SSI incidence has been 3.5% (2/57; 1 superficial, 1 deep) to date (P < 0.001).

The VQI registry is useful for signal detection that can lead to programmatic changes in care delivery. At our institution, VQI aided in the development and implementation of an SSI reduction bundle after LEB surgery, ultimately leading to a reduction in overall complication rates.