Piloting bundle of care for colorectal surgery in an Australian hospital – the challenge of achieving normothermia

Background:

Surgical site infection (SSI) rates following colorectal surgery are amongst the highest of any surgery, with rates of over 30% reported. Use of appropriate antibiotic prophylaxis has been shown to reduce the incidence of SSI following colorectal surgery. More recently, there is evidence that avoiding hypothermia, glycaemic control, avoiding hypotension and providing adequate oxygenation are important factors in reducing infections. The US Surgical Care Improvement Project (SCIP) promotes correct use of antibiotics, normothermia for colorectal patients and glucose control for cardiac patients. No similar projects operate in Australia. A hospital participating in the Victorian State surveillance program (the VICNISS Healthcare Associated Infection Surveillance System) with high colorectal SSI rates expressed interest in working with the VICNISS centre to implement a similar program.

Objective: To introduce a “bundle of care” program including evidence-based prevention processes with an intensive education and support program for staff involved in the peri-operative care of colorectal patients.

Methods:

Focus group meetings with key stakeholders were established, including surgeons, anaesthetists and peri-operative staff. Formal and informal education was introduced and maintained throughout the project. A patient checklist, including brief explanatory notes, was developed to monitor processes. Process measures were implemented and compliance recorded over a 6 month period for 133 colorectal procedures.

Results: 12 infections were observed during the study period, corresponding to a crude infection rate of 9.0%. Varied compliance with processes was noted, with general improvement over the project duration. Resistance to certain measures was evident, particularly provision of 80% inspired oxygen during surgery by some clinicians. Avoiding hypothermia proved the most difficult challenge. Routine use of commercial warming units was reported, however actual use was documented in only 64% of instances. Fluid warming was used for 52% of patients. On arrival to the operating suite only 54% of patients had their temperature taken and of these only 58% had a temperature of ≥ 36 degrees Celsius. Post-operatively, 83% of patients had a temperature recorded and only 55% were ≥ 36 degrees Celsius. Adequate antibiotic prophylaxis was used for 90% of patients and timing was consistent with recommendations in 76% of cases. However, repeat dosing was administered in only 30% of prolonged procedures.

Conclusions: Conclusions:

Introduction of the bundle was partially successful during the six month trial. Avoiding hypothermia proved particularly problematic. Sustainability at the study centre will address the problems identified. Project outcomes will facilitate the systematic introduction of bundle components to colorectal units in other VICNISS hospitals.