Checklist Utilization May Improve Surgical Site Infection (SSI) Bundle Effectiveness and Improve Patient Outcomes

Background: Surgical site infections (SSI) are the second most common nosocomial infection, accounting for up to 14-16% of all hospitalization-related complications, leading to increased length of stay, complications and overall hospitalization costs.

Objective: Our goal was to improve the effectiveness of a SSI bundle that would lower infection rates to less than 4% for all patients undergoing congenital heart surgery within a period of twelve months, utilizing an operative checklist.  

Methods: 422 consecutive pediatric cardiac surgery operations were performed between August 2007 and August 2010.  A SSI bundle was gradually put in place, consisting of 1) preoperative antiseptic bathing (September 2008); 2) tailored preoperative organism-specific antimicrobials (January 2010); 3) checklist-driven timed prophylactic antibiotics (March 2010); and 4) routinely discontinued postoperative antibiotics (April 2009).  Compliance with preoperative baths and discontinuing postoperative antibiotics was determined by random audit.  Both retrospective and prospective data collection were used to determine prophylactic antibiotic choice and timing of administration.  SSI’s were ascertained through routine surveillance, using the National Nosocomial Surveillance system methodology.

Results: Checklist utilization increased average time between antibiotic administration and skin incision from 28 ± 27 minutes to 59 ± 28 minutes.  Overall SSI rates steadily decreased from 7% to 3.8% as each intervention was put in place, with the largest improvement occurring after checklist implementation.  

Conclusions: Checklist utilization may enhance SSI bundle compliance, prevent SSI’s, and should be generalizable to any operative cohort.