Evidence-Based Bundled Quality Improvement Intervention for Reducing Surgical Site Infection in Lower Extremity Vascular Bypass Procedures

Background: Surgical site infection (SSI) poses a significant burden to patients and healthcare resources. Vascular Quality Initiative (VQI) data identify a higher rate of SSIs for lower extremity bypass than other vascular procedures. Bundled interventions have successfully reduced SSIs in other surgical procedures. Study Design: We evaluated our institution-specific VQI data for modifiable risk factors associated with index hospitalization SSI from January 2012 through October 2015. We implemented an evidence-based lower extremity bypass operation SSI reduction bundle (ie perioperative chlorhexidine showers and transverse groin incisions) and prospectively enrolled all patients who had lower extremity bypass procedures, with a target adherence rate of 50% per bundle component. Bundle adherence and SSI events were measured from March 2016 through August 2017. We carried out a pre-post evaluation of bundle effectiveness in reducing index hospitalization SSI. Results: In the pre-intervention period, 43 of 234 (18%) patients had SSI events. The only risk factors associated with SSI (ie female sex, diabetes, overweight BMI) were not readily modifiable. In an 18-month period after introduction of our intervention, adherence rates to preoperative chlorhexidine showers, a transverse incision, and a postoperative chlorhexidine shower were 71% (52 of 73), 48% (24 of 50), and 88% (64 of 73), respectively. Compliance with all applicable bundle components was 36% (26 of 73). The SSI rate post-intervention decreased from 18% to 4% (3 of 73). Intention-to-treat multivariable analysis showed a 97% SSI risk reduction with the bundle (p = 0.002). As-treated analysis identified 85% (p = 0.02) and 62% (p = 0.047) SSI risk reductions from the preoperative and postoperative chlorhexidine showers, respectively. Conclusions: In this evaluation study of the effectiveness of a quality improvement intervention, SSIs were markedly decreased after implementation of our evidence-based bundle for lower extremity vascular bypass procedures.