Departments of Obstetrics and Gynecology, MedStar Washington Hospital Center and MedStar Georgetown University Hospital, Washington, DC; the Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, Maryland; and Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC.
Obstet Gynecol. 2019 Feb;133(2):282-288. doi: 10.1097/AOG.0000000000003091.
To examine the association of a resident-driven quality initiative with cesarean delivery surgical site infections.
This was a quasi-experimental, preintervention and postintervention study of women undergoing cesarean delivery at 23 weeks of gestation or greater between January 2015 and June 2018 at a single tertiary care center. We implemented a resident-driven, evidence-based surgical bundle, excluding women who underwent emergency cesarean or had chorioamnionitis. The bundle included routine prophylactic antibiotics (both cefazolin and azithromycin), chlorhexidine alcohol skin preparation, use of clippers instead of a razor, vaginal cleansing with povidone iodine, placental removal by umbilical cord traction, subcutaneous tissue closure if wound thickness greater than 2 cm, suture skin closure, dressing removal between 24 and 48 hours, and use of postoperative chlorhexidine soap. Our primary outcome was surgical site infections (superficial incisional, deep incisional, and organ or space surgical site infections) occurring up to 6 weeks postpartum. Outcomes were compared between the preimplementation period (January 2015-August 2016) and postimplementation period (December 2016-June 2018). Coarsened Exact Matching with k-to-k solution was performed using age, race-ethnicity, body mass index, rupture of membranes, and labor.
In total, 1,624 underwent cesarean delivery in the preimplementation and 1,523 postimplementation periods, respectively; 1,100 women in the postimplementation period were matched to 1,100 women in the preimplementation period. The rate of surgical site infections in the unmatched cohort was significantly lower in the postimplementation period compared to those in the preimplementation period (2.2% [33/1,523] vs 4.5% [73/1,624]; odds ratio [OR] 0.47 [95% CI 0.31-0.71]; P<.001). This decrease in the rate of surgical site infections remained statistically significant after matching (1.9% [21/1,100] vs 4.1% [45/1,100]; OR 0.46 [0.27-0.77]; P<.001).
After implementation of a resident-driven quality initiative using a surgical bundle, we observed a significant decrease in cesarean surgical site infections.
探讨以住院医师为驱动的质量改进措施与剖宫产术部位感染的关系。
这是一项单中心回顾性队列研究，纳入 2015 年 1 月至 2018 年 6 月期间在 23 周或以上妊娠行剖宫产术的产妇。我们实施了以住院医师为驱动的、基于证据的手术包，不包括行急诊剖宫产或有绒毛膜羊膜炎的产妇。该手术包包括常规预防性抗生素（头孢唑林和阿奇霉素）、氯己定酒精皮肤准备、使用理发剪而非剃须刀、聚维酮碘阴道冲洗、通过脐带牵引取出胎盘、如果切口厚度大于 2 厘米，则行皮下组织缝合、皮内缝合、术后 24-48 小时去除敷料、术后使用氯己定肥皂。主要结局是产后 6 周内发生的手术部位感染（切口浅层感染、切口深层感染、器官或腔隙手术部位感染）。比较实施前（2015 年 1 月-2016 年 8 月）和实施后（2016 年 12 月-2018 年 6 月）两个阶段的结局。使用年龄、种族、体质指数、胎膜早破和产程进行粗化精确匹配（k-to-k 解）。
实施前和实施后分别有 1624 例和 1523 例行剖宫产术，实施后有 1100 例匹配到实施前的 1100 例。未匹配队列中，实施后手术部位感染率明显低于实施前（2.2%[33/1523] vs 4.5%[73/1624]；比值比[OR]0.47[95%CI 0.31-0.71]；P<.001）。匹配后，手术部位感染率仍有统计学意义（1.9%[21/1100] vs 4.1%[45/1100]；OR 0.46[0.27-0.77]；P<.001）。
实施以住院医师为驱动的质量改进措施，使用手术包后，剖宫产术部位感染率显著下降。
