Johnson Megan P, Kim Sharon J, Langstraat Carrie L, Jain Sneha, Habermann Elizabeth B, Wentink Jean E, Grubbs Pamela L, Nehring Sharon A, Weaver Amy L, McGree Michaela E, Cima Robert R, Dowdy Sean C, Bakkum-Gamez Jamie N
Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, the Division of Healthcare Policy and Research, Infection Prevention and Control, the Department of Nursing, the Surgery Research Office, the Division of Biomedical Statistics and Informatics, and the Department of General Surgery, Division of Colorectal Surgery, Mayo Clinic, and Mayo Medical School, Mayo Clinic, Minnesota.
Obstet Gynecol. 2016 Jun;127(6):1135-1144. doi: 10.1097/AOG.0000000000001449.
To investigate whether implementing a bundle, defined as a set of evidence-based practices performed collectively, can reduce 30-day surgical site infections.
Baseline surgical site infection rates were determined retrospectively for cases of open uterine cancer, ovarian cancer without bowel resection, and ovarian cancer with bowel resection between January 1, 2010, and December 31, 2012, at an academic center. A perioperative bundle was prospectively implemented during the intervention period (August 1, 2013, to September 30, 2014). Prior established elements were: patient education, 4% chlorhexidine gluconate shower before surgery, antibiotic administration, 2% chlorhexidine gluconate and 70% isopropyl alcohol coverage of incisional area, and cefazolin redosing 3-4 hours after incision. New elements initiated were: sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24-48 hours, dismissal with 4% chlorhexidine gluconate, and follow-up nursing phone call. Surgical site infection rates were examined using control charts, compared between periods using χ or Fisher exact test, and validated against the American College of Surgeons National Surgical Quality Improvement Program decile ranking.
The overall 30-day surgical site infection rate was 38 of 635 (6.0%) among all cases in the preintervention period, with 11 superficial (1.7%), two deep (0.3%), and 25 organ or space infections (3.9%). In the intervention period, the overall rate was 2 of 190 (1.1%), with two organ or space infections (1.1%). Overall, the relative risk reduction in surgical site infection was 82.4% (P=.01). The surgical site infection relative risk reduction was 77.6% among ovarian cancer with bowel resection, 79.3% among ovarian cancer without bowel resection, and 100% among uterine cancer. The American College of Surgeons National Surgical Quality Improvement Program decile ranking improved from the 10th decile to first decile; risk-adjusted odds ratio for surgical site infection decreased from 1.6 (95% confidence interval 1.0-2.6) to 0.6 (0.3-1.1).
Implementation of an evidence-based surgical site infection reduction bundle was associated with substantial reductions in surgical site infection in high-risk cancer procedures.
探讨实施一套综合的循证实践措施（即捆绑式干预措施）是否能够降低术后30天手术部位感染率。
回顾性确定某学术中心2010年1月1日至2012年12月31日期间开放性子宫癌、未行肠道切除的卵巢癌以及行肠道切除的卵巢癌病例的手术部位感染基线率。在干预期间（2013年8月1日至2014年9月30日）前瞻性实施围手术期捆绑式干预措施。既往已确定的要素包括：患者教育、术前用4%葡萄糖酸氯己定沐浴、抗生素给药、用2%葡萄糖酸氯己定和70%异丙醇覆盖手术切口区域以及在切开后3 - 4小时重新给予头孢唑林。新启动的要素包括：无菌缝合托盘以及在缝合筋膜和皮肤时更换工作人员手套、在24 - 48小时拆除敷料、用4%葡萄糖酸氯己定进行出院指导以及术后随访护理电话。使用控制图检查手术部位感染率，采用χ²检验或Fisher精确检验比较不同时期的感染率，并与美国外科医师学会国家外科质量改进计划十分位数排名进行验证。
在干预前期，所有病例中30天手术部位感染总发生率为635例中的38例（6.0%），其中11例表浅感染（1.7%），2例深部感染（0.3%），25例器官或腔隙感染（3.9%）。在干预期间，总发生率为190例中的2例（1.1%），均为器官或腔隙感染（1.1%）。总体而言，手术部位感染的相对风险降低了82.4%（P = 0.01）。在肠道切除的卵巢癌中，手术部位感染的相对风险降低了77.6%；在未行肠道切除的卵巢癌中降低了79.3%；在子宫癌中降低了100%。美国外科医师学会国家外科质量改进计划十分位数排名从第十位提升至第一位；手术部位感染的风险调整优势比从1.6（95%置信区间1.0 - 2.6）降至0.6（0.3 - 1.1）。
实施循证手术部位感染降低捆绑式干预措施与高危癌症手术中手术部位感染的大幅降低相关。
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