EP358 - Novel Surgical Skin Preparation Quality Improvement Program to Reduce Surgical Site Infection

Image or Table (Do Not add text here):

Purpose/Background: Over 2022, surgical site infection (SSI) rates at one academic medical center increased to the National Surgical Quality Improvement Program (NSQIP) level of “Needs Improvement.” Skin preparation (SP) is critical to prevention of SSI. We therefore implemented a quality improvement (QI) program to improve the primary outcome of compliance with combined chlorhexidine gluconate and isopropyl alcohol (CHG/IPA) applicator manufacturer instructions for use (IFU) overall and for colorectal surgery (CRS). The secondary outcome of interest was colorectal surgery SSI incidence as determined with existing NSQIP surveillance reports.

Methods/Interventions: The QI program included one hands-on in-person training session for all residents and operating room (OR) nurses and placement of posters in ORs. Over 15 months, SP was directly observed in the ORs of several surgical specialties, including CRS, and recorded using a structured observation tool. Observations were stratified into three groups – before in-person training, a period where either nurse or resident was trained, and after in-person training. Compliance with IFU was compared using chi-squared tests. We then performed multivariable logistic regression to determine the impact of in-person training on odds of compliance. Variables included in the multivariable logistic regression for all cases were selected a priori and included surgical service and staff member performing SP. For logistic regression in colorectal surgery, only the staff member performing SP was included in the model with in-person training status. SSI rates for colorectal surgery were tracked using existing NSQIP surveillance reports.

Results/Outcomes: Overall, 1032 SPs were observed – 233 (22.6%) prior to training, 238 (23.1%) where either resident or nurse was trained, and 561 (54.4%) after training completion. Of these observations, 199 (19% were for CRS – 41 (20.6%) prior to training, 33 (16.6%) where either resident or nurse was trained, and 125 (62.8%) after training completion. For all operations, complete compliance was higher in the post-training period and when either resident or nurse were trained when compared with the pre-training period – 39.4% (p < 0.0001) and 31.5% (p < 0.0001) respectively when compared with baseline of 13.3%. For CRS specifically, complete compliance was also higher in the post-training period and when either resident or nurse were trained – 48.0% (p < 0.0001) and 27.3% (p=0.0206) when compared with baseline of 7.3%. Adjusted odds of complete compliance were 3.4 (95%CI 2.29-4.97) fold higher overall and 9.8 (95%CI 3.93-24.70) for CRS if the staff member performing skin preparation had been trained. Over the QI study implementation period, colorectal SSI reduced by 46% to a level of ‘As Expected” when comparing the first quarter of 2022 with the fourth quarter of 2023.

Conclusion/Discussion: Skin preparation compliance improved after implementation of the QI program. One-time in-person training sessions improved odds of compliance with (CHG/IPA) applicator IFU. Increased compliance is also likely associated with reduced SSI as evidenced by reduction in colorectal SSI captured by CRS NSQIP reports over the implementation period. Future research should determine how often these training sessions should be held to maintain and improve SP skills.