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Changing "outbreak-response" cycles to evidence-based bundles: Implementation of a surgical site infection (SSI) prevention bundle in the Veterans Health Administration

Reisinger HS, Goedken CL, Hockett Sherlock SM, Dukes K, Schweizer ML, Krein S, Perencevich EN. Changing "outbreak-response" cycles to evidence-based bundles: Implementation of a surgical site infection (SSI) prevention bundle in the Veterans Health Administration. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Dec 15; Washington, DC.


Background: Prior interventions to improve surgical outcomes have focused on checklists and culture change. However, few evidence-based bundles exist in the surgical literature. The objective of this study was to characterize orthopedic and cardiothoracic surgical practices prior to implementation of an evidence-based surgical site infection (SSI) prevention bundle. Methods: An ethnographic study was conducted with infection control teams and surgical staff at six geographically dispersed VA Medical Centers. Semi-structured interviews, observations, and documentation of orthopedic and cardiothoracic surgical policies and procedures were completed. Transcripts, field notes, and policy documents were analyzed for thematic content to assist in characterizing individual surgical programs. Findings: Fifty-four infection control and surgical staff participated in semi-structured interviews. Overall, participants described current SSI prevention protocols as based on the most recent "outbreak" of an infectious agent and specific to the surgery service directly impacted. Each of the six sites characterized their current SSI infection prevention protocol as a similar process. The process started with infection control teams and VA Surgical Quality Improvement Program administrators tracking infections among surgical patients. Then, when an increase in infections in a particular surgical service was observed, a team of surgical staff, infection preventionists, and hospital epidemiologists developed a protocol aimed at decreasing the infection rate. These protocols often included changes to patient preoperative preparation, operating room set-up and procedures, and administration of pre- and post-operative antimicrobials. After the protocol was developed and the number of infections decreases, the protocols remained in place until a new "outbreak" occurred and a new protocol was developed to respond to the particularities of the recent increase in infections. Implications for DandI Research: Evidence-based bundles reduce SSI; however, they may be difficult to implement in a culture that promotes constant vigilance and immediate response. Algorithms, which focus on proactive, long-term changes, may be viewed as counter to traditional "outbreak-response" cycles. Transitioning surgical services to a practice of evidence-based bundles will take careful understanding of the history and context of local practice to engage surgical services and infection control teams in long-term change and to enable them to take advantage of what evidence-based bundles promise the field.

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