Cesarean Section Infection Prevention Bundle
Vanderbilt University Medical Center
Jennifer Campbell, RN, MSN, Vicki Brinsko, RN, MSN, CIC, Tom Talbot, MD, MPH, Josh Kellett, DO
Results:
Background:
At Vanderbilt, Cesarean Section Surgical Site Infections (CSEC SSI) were increasing in frequency
from a standardized infection ratio of 0.753 in 3Q2012 to 1.97 in 3Q2014. As part of an overall
infection reduction initiative, evidence based strategies were researched and best practices
bundled together in an effort to reduce these infections and improve patient outcomes. The
aim of the study was to describe a bundled approach to reduce surgical site infections in
patients undergoing Cesarean section.
The integration of the bundle elements in 3Q2014 has resulted in a 90.64% reduction in infection
rates sustained by 88.4% overall
bundle compliance .
C-Section SSI Standardized Infection Ratio
(SIR)
2.5
C/S Bundle
Initiated
C-Section SIR
2
C-Section SSI Standardized Infection Ratio
(SIR)
1.5
1
2.5
C-Section SIR
2
0.5
1.977
0.185
0
1.5
1
SIRAll
0.5
CDC_Benchmark
Linear (SIRAll)
0
SIRAll
CDC_Benchmark
Number of Cesarean Section Surgical Site Infections
by month
FY2015
Linear (SIRAll)
Analysis: The overall rate is increasing since Q2 2013. The risk-adjusted
Standardized Infection Ratio (SIR) for 2014 Q3 is at 1.97. This represents
22 infections out of 459 procedures; ten infections occurred in July, five
in August, and seven in September.
12
C/S Bundle
Initiated
10
8
6
Methods:
4
A multi-disciplined task force was assembled in 8/2014 and baseline data from the past 24
months reviewed. An evidence based bundle of recommended interventions was developed.
The bundle was comprised of the following: Chlorhexidine gluconate (CHG) preoperative
bathing, administration of prophylactic antibiotics within one hour of incision time and adjusted
to patient BMI, traffic control in OR, CHG OR skin preparation, glove change between closing
fascia and skin, removing placenta by gentle traction, proper OR attire, skin closure with suture
(rather than staples), and pre-warming.
2
0
July
August
September
October
November
December
January
Cesarean Section
C/S Bundle
Initiated
Preadmission:
CHG wipes the night before surgery.
Intraoperative
Administer appropriate* IV
antibiotic within 1 hour prior to
incision. Do not wait to administer
until cord clamping.
Adjust antibiotic doses for increased
BMI. Use 2gm of cefazolin for
weight up to 120kg, 3gm for weight
≥ 120 kg.
Use chlorhexidine and alcohol-based prep
Wound care
(ChloraPrep) for skin cleansing in the OR unless teaching
contraindicated. Do not wipe off. Allow to dry.
(Replaces betadine scrub, wipe, betadine paint).
For emergency prep: Use Chloraprep and blot
dry with sterile towel. DO NOT wipe off.
Use povidone-iodine vaginal prep prior to Csection delivery to prevent endometritis.
CHG wipes the day of surgery.
Traffic control: limit the number of Glove change when moving from intrapersonnel in room and restrict
abdominal to fascia/skin closure.
If necessary, clip hair at the surgical site right
nonessential personnel.
Prewarm patient to achieve a core temperature
before surgery prior to entering the OR.
of at least 36.0°C; Monitor intraoperative
temperature and maintain ≥ 36.0°C.
Remove the placenta by traction on the
OR Cleaning:
placenta rather than manual extraction.
Thorough cleaning of OR rooms according to
Wear proper OR attire according to Consider sutures rather than staples for skin
AORN standards, including end of day cleaning AORN standards.
closure.
daily and cycle cleaning once/week.
Preop day of surgery:
Postoperative
Infeciton Rate per 100 Procedures
10.00%
Preoperative
February
9.00%
8.00%
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Discontinue
prophylactic
antibiotics within
24 hours after
surgery
*Approved
antibiotics:cefazo
lin + azithromycin
If β-lactam
Close the uterine incision in two layers rather allergy:clindamyci
than one. In patients whose subcutaneous n +
aminoglycoside
tissue is >2cm in thickness, close the layer with
(gentamicin or
a running suture.
tobramycin)
Infections
Procedures
Inf Rate * 100
0.40%
2012Q4
8
368
2.17%
2013Q1
8
348
2.30%
2013Q2
4
322
1.24%
2013Q3
6
382
1.57%
2013Q4
7
356
1.97%
2014Q1
9
379
2.37%
2014Q2
13
392
3.32%
2014Q3
22
459
4.79%
2014Q4
11
447
2.46%
2015Q1
1
253
0.40%
The current infection rate for 2015Q1 data is 0.40 infections per 100 procedures.
TEAM MEMBERS AND CONTACT INFORMATION
Jenny.Campbell@Vanderbilt.edu
615-322-5929
Vicki.Brinsko@Vanderbilt.edu
615-936-0724
Tom.Talbot@Vanderbilt.edu
615-322-2035
William.Kellett@Vanderbilt.edu
615-343-5700
www.mc.vanderbilt.edu/infectioncontrol 615-936-0725