Intra-institutional use of positive deviancy in surgical infections in isolated coronary bypass

Abstract Objective: To identify modifiable surgical practices associated with reduced sternal wound infection rates following isolated coronary artery bypass grafting (CABG) using positive deviancy methodology. Design: Retrospective cohort study with prospectively collected data (January 2021–June 2025). Setting: Single tertiary referral cardiac surgery center. Patients: 3,087 consecutive patients undergoing isolated CABG. Methods: Primary outcome was total sternal wound infection (deep and superficial combined) within 30 days. Risk-adjusted surgeon performance was evaluated using mixed-effects logistic regression with observed-to-expected (O/E) ratios. Positive deviants were defined as surgeons with O/E ratios <1.0 with 95% confidence intervals excluding unity. Surgical techniques were systematically reviewed through anonymized surveys, and volume-weighted analysis compared techniques of better and worse performers. Results: Total sternal wound infection occurred in 175 patients (5.7%). Nine surgeons were stratified: better performers (O/E <1.0, n = 5), worse performers (O/E ≥1.2, n = 3), and average performers (O/E 1.0–1.19, n = 1). One surgeon achieved statistically significant superior performance (O/E = 0.590, 95% CI: 0.39–0.91), representing 41% fewer infections than expected across 543 cases. Four protective techniques were identified: wound irrigation at closure (100% vs 0%), double skin preparation with chlorhexidine and povidone (100% vs 0%), superior Ioban adherence quality (5/5 vs 3.7/5 vs 3.2/5, P < .001), and minimal cautery usage (1.0/5 vs 3.2/5 vs 3.5/5, P < .001). Conclusions: Positive deviancy methodology successfully identified four modifiable surgical practices associated with reduced total sternal wound infections. These techniques represent immediately implementable interventions for infection prevention in cardiac surgery. Further study is needed to validate these findings across multiple institutions and evaluate implementation outcomes.