Implementation of an SSI care bundle for patients undergoing emergency laparotomy

Structured Summary Background 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 rates. Most studies have focused on elective surgery where the surgical environment can be easily standardised. Methods This prospective quality improvement study, with continuous SSI surveillance over four years, aimed to establish a reliable method of measuring post-EL SSI and to evaluate the impact of a care bundle (2% chlorhexidine skin preparation, second antibiotic dose after 4 hours, use of a wound protector, antibacterial sutures, glove change and povidone iodine wound wash) to reduce SSI. Results There were 176 patients pre-intervention and 501 patients post-intervention. Baseline SSI rate was 32.1%; 23.1% for clean wounds, 24.5% for clean-contaminated, 45.0% for dirty. Post-intervention, overall SSI rate decreased to 18.1% (p=0.002); 11.8% for clean wounds (p=0.275), 15.1% for clean-contaminated (p=0.121), and 25.6% for dirty (p=0.021). Discussion Patients undergoing EL are complex. Measuring SSI after EL is challenging due to high mortality, use of laparostomy, and longer length of stay (LOS) meaning in-hospital surveillance for patients staying >30 days is also required. Implementing behaviour change in a diverse group of surgeons in the emergency setting, during a pandemic in an NHS hospital, was difficult. Conclusion We have 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 emergency laparotomy is challenging but feasible.