Reducing surgical site infections in paediatric cardiac surgery in a resource-constrained setting: a quality improvement initiative

Problem A newly established congenital cardiac surgery programme in a low-resource setting identified a high early surgical site infection (SSI) rate of 23% during the first 3 months, reflecting variation associated with small case volumes and evolving systems. Background Global paediatric cardiac SSI rates range from 0.25% to 6%, but can exceed 20% in low and middle-income countries due to workflow variability, resource constraints and patient-related risk factors. Most SSI prevention bundles originate from high-income settings and require contextual adaptation. Quality improvement (QI) methods can strengthen reliability when tailored to local systems. Methods A learning health system approach was used, combining process mapping, root cause analysis, a key driver diagram and four sequential Plan Do Study Act cycles. Interventions targeted reliability across the perioperative pathway. The primary outcome was SSI rate per 100 surgeries. Process measures included training completion, preoperative risk screening, wound documentation and structured review of moderate and severe infections. Balancing measures included length of stay, mortality rate, case cancellation rate and readmissions. Interventions included strengthened sterilisation and risk screening practices, a nurse-led wound clinic with 30-day follow-up and training in aseptic technique and hand hygiene. Results Among 500 surgeries, 31 SSIs occurred. SSI rates decreased from 12 to 6 per 100 surgeries and reached 2 per 100 surgeries, before increasing to 6 then 5 per 100 surgeries in later phases. Process reliability improved across all measures, while balancing measures remained stable. Following sustainability actions, environmental cleaning compliance improved from 20% to 85% and hand hygiene from 45% to 90%. Conclusion QI interventions were associated with reduced SSI rates, although sustained benchmark performance was not achieved. Continued monitoring and behaviour-focused strategies will guide further improvement.