Following Cesarean section (C-section) delivery, SSI infections affect a mother physically, mentally and emotionally and critical infant bonding is disrupted. The incidence of surgical site infection (SSI) following a Cesarean section is 3-15%, a rate 3-5x that of SSI rates with vaginal delivery.1,2 Patients that develop an SSI have a 6-fold risk of being readmitted to the hospital within 30 days.3 Unreimbursed treatment costs, increased length of stay and readmissions, increase healthcare costs. Sixty percent of SSIs are preventable.3
Numerous best practice guidelines recommend many different interventions to reduce SSI rates. We began to implement best practice interventions in 2012 when we started to see our rates increase. See Table 1.
CentraCare St. Cloud Hospital is a regional level 3 obstetric hospital. In Q1 of fiscal year (FY) 2014, the Cesarean SSI rate reached 2.84%, a full percentage point above the national benchmark (1.84%). Administration began to consider ending Cesarean deliveries on our unit. See Figure 1.
PREPARATION AND PLANNING:
To reduce SSI incidence, facilities must assess and implement current infection prevention best practices. Our review of best practice revealed that use of antimicrobial post-op dressings* resulted in SSI rate reductions.4,5 Following literature review to cull evidence-based practice principles, we evaluated whether the use of self-adherent antimicrobial soft silicone foam dressing applied aseptically in the OR following Cesarean delivery would reduce SSI rates. Additionally, using new surgical closing trays including a complete change of surgical attire, instruments and drapes after closure of the uterus or peritoneum/muscle, were also found to reduce SSI rates.6 Following adoption of the incision management intervention, we implemented use of surgical closing trays to examine whether C-section rates could be further reduced at our hospital.
Prior to initiating the new dressing, staff were trained on aseptic incision care and a protocol eliminating the routine incision check under the dressing before discharge.
Post Operative Dressing Intervention
An evidence-based self-adherent soft silicone antimicrobial bordered foam dressing (intervention group) was compared to an all-in-one transparent dressing (control group) over 3 quarters. Patients assessed as high-risk (See Table 2.) received the intervention dressing while low risk patients received the control dressing. In the 501 high risk patients (85%) that received the intervention dressing, the SSI rate was 1.0%. In the 88 patients (15%) that were assessed as low risk and received the control dressing, the SSI rate was 2.2%. See Figure 2 and Table 2. Based on these results, the antimicrobial soft silicone bordered foam dressing was implemented on all C-section patients as of June of 2015.
Standardizing a protocol utilizing self-adherent antimicrobial soft silicone bordered foam dressings and surgical closing tray procedures post-Cesarean delivery led to a reduction in SSI rates, from 2.15% in FY 2014, a rate which threatened to stop Cesarean deliveries on our unit, to 1.01% in 2017. At a $22,239 cost to the hospital per SSI, these initiatives to reduce SSI rates may have possibly saved the facility $266,868 since its implementation.7See Figure 3.
Post Operative Dressing
The downward trend in SSI rate reduction post implementation of the antimicrobial soft silicone bordered foam postop dressing and closing tray suggest that these interventions may have contributed to reducing SSI rates at our facility.
In this evaluation, the antimicrobial post-op dressing performance was at the crux of the quality improvement project so a detailed analysis as to why it performed so well was critical to the outcome. A key influential factor for postsurgical outcomes is healing of the incision site. The presence of bacteria in a wound can negatively impact healing.7 Postoperative dressings serve as a barrier to bacteria and contaminants.7
Silver has broad spectrum activity against microbes, which is sustained for 7 days in this product. Unlike antibiotics, resistance to silver is rare.5 When patients are discharged to home, we have no control over the potential threats from the environment. Extending antimicrobial protection several days longer and into the home may have influenced SSI rate reduction.
Standard adhesives on a dressing may cause significant stripping of the top layer of skin leading to disruption of skin integrity, increased susceptibility to infection, increased pain with mobilization or with dressing removal, and considerable patient dissatisfaction despite positive surgical outcomes. Use of soft silicone across the entire dressing has been shown to reduce dressing complications in several studies.7
The dressing used in this study continuation underwent innovation and was made available in 2017 with clear adhesive borders, increased conformability and stay-on-ability, and could remain intact during showering. None of our patients whose incisions were protected by the new dressing experienced skin irritation. An informal phone interview/survey was done post discharge. Results showed that patients were very satisfied with the healing of their incision and the comfort of the dressing. Surgeons reported that at one and six week observations, the incisions were well healed and that they felt there was a reduction in scarring with the new dressing.
Surgical Closing Tray Intervention
In July of 2015, opening and losing trays were implemented for Cesarean cases that were Wound Class 2 and higher. In this process, both trays are opened and counted at the beginning of the case. The closing tray set up and owns/gloves for the changeover are aseptically covered and set aside. The case proceeds as usual until the uterus and or peritoneum is closed. Then, the closing tray is utilized. Full instrument, lap and sharp counts for both trays are done on the opening tray instruments and set up, and after the case ends.
Following uterine/peritoneal closure, everyone at the OR table steps away as the light handles are removed, cautery tip and suction tips removed and unplugged. Gowns and gloves are aseptically removed, with new sterile gowns and gloves are aseptically donned. A new drape is applied to the surgical field, with new light handles, cautery, and suction are placed if needed. New sterile, pre-counted closing instruments are then moved to the field and the
case proceeds from this point as usual. See Images 1-5.
This change in practice to use of a surgical closing tray was controversial because our OB surgeons feared that pausing to change gowns and instruments would prolong surgery times and disrupt the OR schedule. Resistance was overcome upon demonstration that the actual change time added only 60 seconds to the procedure. This amount of time was acceptable to the OB surgeons when balanced with the potential to improve patient safety.
Standardizing a protocol utilizing self-adherent antimicrobial soft silicone bordered foam dressings for 7 days post-op and extending incision protection into the home environment, coupled with implementation of closing surgical tray procedures post Cesarean delivery led to a 53% reduction in SSI rates and has potentially saved the facility $266,868 in avoided SSI treatment costs over the period between 2014 to 2017.
Implications for perioperative nursing: This nurse-driven approach to reducing SSI rates in our Cesarean population demonstrated that the perioperative nurse can impact patient outcomes, safety and satisfaction with intra- and postoperative interventions while reducing the cost of care. Additionally, this study highlights the increasing importance of nursing consideration for patient safety post discharge as we move toward CMS bundled payment reimbursement, where optimal outcomes positively impact the bottom line.
- Zuarez Easton S. Zafran N, Garmi G, et al. Post cesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Women Heal. 2017:9 81–88.
- Keets E. Reducing infection rates aber C-section deliveries. Contagion Live. Oct. 13, 2016. Available at: http://www.contagionlive.com/news/reducing-infec/on-rates-aber-c-sec/on…
- SHEA/IDSA Practice Recommendations. Anderson DJ, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S66-88.
- Kles C, Murrah P, Smith K, et al. Achieving and sustaining zero: reduction of deep sternal wound infections following CABG with saphenous vein donor site. Dimen Crit Care. 2015;24(5):265-272.
- Abboud E, SeLle J, Legare T, et al. Silver-based dressings for the reduction of surgical site infection: review of current experience and recommendation for future studies. Burns. 2014;40S:S30-39.
- Robbins R, Bakkum-Gamez J. The MN slashing SSSI bundle: Raising the bar to lower the rate. [PowerPoint Presentation] Available at: hLp://www.mnhospitals.com
- Shepherd J, Ward W, Milstone A, et al. Financial impact of surgical site infections on hospitals the hospital management perspective. JAMA Surg. 2013:148(10):907-914.
- Doughty D, McNichol L. General Principles of Topical Therapy. Core Curriculum Wound Management. Philadelphia, PA: Wound, Ostomy and Continence Nurses Society™; 2016:181-195.