This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us, and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.
Learn more about the other initiatives by viewing the introduction to this series and previous topics.
What is the problem
A cesarean delivery is the most common major surgical procedure performed in the United States, with well over one million procedures performed each year. Unfortunately, postoperative surgical site infections (SSIs) and wound complications affect approximately 10% of these deliveries across the nation. A number of risk factors for these SSIs have been identified, some of which are inherent characteristics of that particular pregnancy and cannot be changed. However, there are evidence-based strategies that have been shown to reduce the risk of post-cesarean infections and wound complications, including processes such as administering appropriate antibiotic prophylaxis within 60 minutes of the surgical skin incision and using chlorhexidine-alcohol solutions for skin antisepsis.
What is a surgical site infection after cesarean section
According to the Centers for Disease Control and Prevention, cesarean SSIs are defined as superficial or deep incisional infections—or infections involving organs/spaces—that occur within 30 days of surgery. In general superficial SSIs involve only the skin and subcutaneous tissue of the incision, while deep incisional SSIs involve the deeper soft tissues of the incision such as the fascial or muscle layers. Organ space SSIs involve any other part of the patient’s anatomy that was entered at the time of surgery. At UI Hospitals & Clinics, the Program of Hospital Epidemiology monitors and tracks surgical site infections.
In fall 2020, a multidisciplinary core team consisting of representatives from the Departments of Nursing, Obstetrics and Gynecology, Anesthesia, Pharmacy, Hospital Epidemiology and the Quality Improvement Program came together to begin reviewing the current performance data and identifying opportunities for improvement.
Metrics being tracked
In addition to comprehensively reviewing each reported cesarean delivery SSI, we conduct periodic observations in the operating room (OR) to ensure recommended best practices—such as having a surgical debrief after each case that includes discussing the wound classification, urgency of the delivery, and quantified blood loss—are being completed. We monitor compliance with a variety of evidenced-based process metrics, including the following:
- Administration of appropriate antibiotic prophylaxis within 60 minutes before skin incision
- Maintenance of maternal normothermia
- Hair removal using clippers instead of razors before entering the OR prior to surgery
- The use of chlorhexidine-alcohol solutions for skin antisepsis, except in emergency cesarean deliveries where povidone-iodine is recommended
- The use of chlorhexidine vaginal preparation
- Redosing of antibiotics if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss during the procedure (>/= 1500 mL)
What is the team doing to improve metrics
Upon review of UI Health Care’s cesarean section SSI trends, a significant number were found to be superficial SSIs, for which expanded efforts on skin antisepsis and antibiotic prophylaxis were identified as improvement opportunities. The core team facilitated an adjustment to the antibiotic prophylaxis regimen to expand the indications for azithromycin use and implemented an expanded use of daily chlorhexidine gluconate (CHG) bathing for select patient populations. The pre-operative abdominal skin preparation process prior to a cesarean delivery has been adjusted based on recommended best practices to enhance skin antisepsis. A review of the literature concerning cesarean delivery incisional wound care was conducted, and there is now a standard preferred dressing that is recommended for use. A standard script for post-operative wound care education instructions was created and each patient who undergoes a cesarean section delivery receives a follow-up phone call after discharge.
Recommendations for prophylactic antibiotics for patients with chorioamnionitis during labor who deliver by cesarean were reviewed and order sets were updated. These changes are all intended to help mitigate the likelihood that superficial SSI occurs.
There have been multiple other improvement steps taken as a result of this project, including the purchasing of new surgical instruments, expanded staffing of Environmental Services personnel to assist with routine cleaning of the labor and delivery ORs and creation of a best practice alert to help identify pregnant women with a self-reported penicillin or cephalosporin allergy who may benefit from referral to the Allergy Clinic for further allergy testing so that appropriate antibiotics can be used when indicated at the time of delivery.
The multidisciplinary core team that has been focused on this work has been integrated into the Obstetrics Quality & Safety Committee who will continue to oversee this important work for the organization moving forward.
-Noelle Bowdler, MD, Clinical Professor of Obstetrics and Gynecology, Physician Value Officer
-Derek Zhorne MD, Clinical Associate Professor of Pediatrics, Associate Chief Medical Officer