Implementation of an SSI care bundle for patients undergoing emergency laparotomy

Surgical site infection (SSI) is common after emergency laparotomy (EL) due to contamination of the surgical field, yet most hospitals are unaware of their SSI rate. Most studies have focused on elective surgery where the surgical environment can be standardized easily.

This prospective quality improvement study, with continuous SSI surveillance over 4 years, aimed to establish a reliable method for measuring post-EL SSI and to evaluate the impact of a care bundle (2% chlorhexidine skin preparation, second antibiotic dose after 4 h, use of a wound protector, antibacterial sutures, glove change and povidone iodine wound wash) to reduce SSI.

There were 176 patients pre intervention and 501 patients post intervention. The baseline SSI rate was 32.1%: 23.1% for clean wounds, 24.5% for clean-contaminated wounds, and 45.0% for dirty wounds. Post intervention, the overall SSI rate decreased to 18.1% (P=0.002): 11.8% for clean wounds (P=0.275), 15.1% for clean-contaminated wounds (P=0.121), and 25.6% for dirty wounds (P=0.021).

Patients undergoing EL are complex. Measuring SSI after EL is challenging due to high mortality, use of laparostomy, and longer length of stay, meaning in-hospital surveillance for patients staying >30 days is also required. Implementing behavioural change in a diverse group of surgeons in the emergency setting, during a pandemic in a National Health service hospital, was difficult.

This study demonstrated a 44% reduction in post-EL SSI following introduction of a care bundle, highlighting the value of structured quality improvement in emergency surgery. SSI measurement following EL is challenging but feasible.