Evaluation of the CDC
Guideline for Prevention of
Surgical Wound Infection
Presented by
Sujha Subramanian, PhD,
Lucy Savitz, PhD, Linda Pucci, MA,
Shulamit Bernard, PhD, and
Michele A. Pearson, MD, MPH
411 Waverley Oaks Road, Suite 330 · Waltham, MA 02452-8414
Phone: 781-788-8100 · Fax: 781-788-8101
Research Motivation

CDC has developed and disseminated
consensus guidelines in 1999 to prevent and
reduce surgical site infections (SSIs).

Despite these efforts, SSIs remain a significant
cause of patient morbidity and mortality.

The objective of this research is two-fold:
1) To assess adherence with guideline
recommendations
2) To evaluate practitioner/institutional barriers
to and facilitators of implementing
prevention strategies.
2
Methods: Objective 1

Quantitative assessment of adherence - data
collected via chart abstraction at three hospitals:
academic medical center, teaching community
hospital and a non-teaching community hospital
(Veteran’s administration hospital to be added).

Four target procedures were selected: CABG,
joint procedures, vascular procedures, general
surgery

Sample size: 50 patients per procedure were
randomly selected (200 per hospital)

Timeframe: Jan 1, 2002 through Dec 31, 2002
3
Objective 1: Measures

Perioperative Antimicrobial Prophylaxis




Perioperative Glucose Control



Antibiotics administered within 1 hour of surgical
incision
Antibiotic agent consistent with guidelines
Antibiotics discontinued within 24 hours of surgery
end time
Patients tested for serum glucose level
Serum glucose level maintained in normal range
during the perioperative and postoperative period.
Warming peri-op; Oxygen intra & post-op
4
Methods: Objective 2

Qualitative assessment of barriers/facilitators
through focus groups and key informant
interviews
 Focus group - 2 w/ surgeons; 2 w/ nurses
 Society of Thoracic Surgeons/AATS
 American Society of PeriAnesthesia Nurses
 Key informant interviews - same 3 sites
selected for quantitative data collection

Qualitative content analysis framework:
Awareness, Agreement, Adoption, Adherence
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Findings: Guideline Adherence
Procedure Type
CABG
General
Joint
Vascular
Start time
68% (42-98)
62% (51-69)
58% (20-84)
49% (45-56)
Agent
99% (96-100)
71% (29-96)
99% (88-98)
93% (88-96)
End time
33% (14-81)
62% (39-88)
76% (43-100)
20% (57-100)
43% (18-82)
21% (20-24)
21% (18-26)
29% (24-36)
Hyperglycemia 39% (14-82)
16% (12-18)
9% (0-14)
15% (14-16)
Warming
96% (96)
86% (68-94)
77% (62-100)
Antibiotics
Glucose level
Tested
100% (100)
6
Comparison with National
Estimates
(CMS/CDC National SSI Prevention: Medicare
Quality
Procedure
Type Improvement Project)
CABG
General
Joint
Vascular
Antibiotic administered with 1 hour
Current Study
68%
62%
58%
49%
CDC/CMS
45%
47%
52%
40%
Current Study
99%
71%
99%
93%
CDC/CMS
96%
84%
97%
92%
Correct Antibiotic
Antibiotic stopped within 24 hours
Current Study
33%
62%
76%
20%
CDC/CMS
34%
60%
36%
44%
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Barriers/Facilitators to SSI
Recommendation Adherence
Barriers
Facilitators:

Tradition/habit

Leadership buy-in

Absence of an
implemented protocol

Adequate resources

Training (with
refreshers)

Local reinforcing
activities (signs,
meetings, role
models)

Feedback data

Evidence to support

Lack of
awareness/exposure

Conflicting cultures

Facility layout

Inconsistent care
process reengineering
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Emergent Themes and
Challenges

Disconnect between cost and infections

Education on SSI should be for anyone who touches
the patient, hospital wide, including family members

Hospitals are not aware of superficial SSI after
discharge (unless patient is re-admitted)

There is some confusion and/or overlap of various
staff roles in task activity

Surgeons may practice at multiple facilities that
have differing SSI prevention practices/protocols

Compelling data drives quality improvement

Multidisciplinary teams/task forces for quality
improvement are key to successful implementation
of targeted initiatives
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Conclusions

Overall, adherence with SSI guidelines
recommendations is not high (except for
antibiotic agent).

Significant barriers exist to adoption but
approaches to improving adherence can
be identified.

Need to identify key facilitators to
increasing adherence with guideline
recommendation (objective of final focus
groups w/ experts).
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Implications for Monitoring
Hospital Quality

Antibiotic administration is influenced by patient’s
risk factors (renal failure, compromised immune
system)

Adherence with recommendations could differ by
type of surgery

Significant data collection challenges

Antibiotic end times are generally not available

Difficult to identify antibiotics given as prophylaxis
versus treatment

Assessing appropriate use of vancomycin requires
detailed information on choice of antibiotics
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