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Reducing Surgical Site Infections in Colorectal Surgery Patients Carly Morgan, Zane Muthamia, Noelle Navarro, Chau Ngo, Alexandra O Neil, Michelle Otani, Amy Payares, Cherelene Pereira, !earelly Pinedo, " #simona Ze$die

%C&A School of Nursing M'CN ()*+ ,ecem-er, ()*.

Reducing Surgical Site Infections in Colorectal Surgery Patients /ac0ground and Significance

#he Centers for ,isease Control and Prevention 1C,C2 state that surgical site infections 1SSIs2 are the second most common ty3e of hos3ital4ac5uired infection 1Centers for ,isease Control and Prevention, ()*.26 An estimated .)),))) SSIs develo3 annually, 3rolonging hos3itali7ation -y 84*) days and incur additional costs from 9.,))) to 9(:,))) 3er SSI 1A$ad, ()*(26 #his translates to an estimated annual total of 9* -illion in the %nited States 1A$ad, ()*(26 In efforts to reduce 3reventa-le SSIs -y increasing com3liance to evidence4-ased 3ractice, the Centers for Medicare and Medicaid Services 1CMS2 and the C,C introduced infection 3revention measures in ())(6 #hese efforts evolved into the Surgical Care Im3rovement Pro;ect 1SCIP2, $hich standardi7ed 5uality im3rovement core measures $ith the aim to reduce 3reventa-le surgical com3lications -y (<= -y year ()*) 1A$ad, ()*(26 #he C,C defines a surgical site infection as any infection that occurs $ithin .) days after an o3erative 3rocedure, and can -e classified as su3erficial, dee3, or organ s3ace6 Surgical 3rocedures of the gastrointestinal tract are among the most commonly 3erformed surgeries every year 1O$ens " Stoessel, ())>26 Infections of the gastrointestinal tract occur fre5uently -ecause there are more -acteria that can -e ex3osed during surgery6 More s3ecifically, colon and rectal surgery have -een associated $ith higher SSI rates 1Cima et al6, ()*.26 SCIP consists of nine core measures, $hich include the follo$ing? *2 3ro3hylactic anti-iotic received $ithin one hour 3rior to surgical incision, (2 3ro3hylactic anti-iotic selection for surgical 3atients, .2 3ro3hylactic anti-iotic discontinued $ithin (+ hours after surgery and time, +2 cardiac surgery 3atients $ith controlled -lood glucose, <2 hair removal $ith cli33ers only, no ra7ors, @2 urinary catheter removed on 3ost4o3erative day one or t$o, 82 3erio3erative tem3erature management, >2 uninterru3ted -eta4-loc0er thera3y for 3atients on -eta4-loc0ers, and :2 venous throm-oem-olism 3ro3hylaxis 1C,C, ()*.26 Nurses $or0ing $ithin this

3articular ty3e of surgery 3lay a 3ivotal role in increasing com3liance among the surgical team and 3atients ali0e6 #he s3here of influence on affecting 3atient outcome is great6 Several of the core measures are indeed nursing interventions6 #he nation has made 3rogress in reducing SSIs since the im3lementation of SCIP measures6 #he goal of SSI reduction -y (<=, ho$ever, has not yet -een attained 1%6S6 ,e3artment of Aealth " Auman Services, ()*.26 In this 3a3er, $e $ill evaluate the effectiveness and shortfalls of SCIP 3rotocols, as $ell as additional interventions that are $idely used in current 3ractice and found in the existing -ody of 0no$ledge for SSI 3revention6 Binally $e $ill loo0 at the strategies that Clinical Nurse &eaders can use to translate evidence4-ased 3ractice recommendations into clinical 3ractice6 Synthesis of 'vidence? Summaries Cima et al6 1()*.2 conducted a study to evaluate current 3ractices for colorectal surgery at the Mayo Clinic Rochester cam3us6 A multidisci3linary team utili7ed a &ean Six Sigma a33roach to eliminate $aste, im3rove 5uality of the surgical 3rocess, and essentially develo3 a -undle to su-stantially and sustaina-ly reduce SSIs 1Cima et al6, ()*.26 #he -undle, consisting of 3reventative interventions covering all stages of surgical care from 3re4o3erative through discharge, in addition to SCIP core measures, $as im3lemented on !anuary *, ()** for an entire year6 ,ata $as collected from <.* 3atients during the 3re4intervention 3eriod 1()):4()*)2 and *:> 3atients during 3ost4intervention 1()**2 utili7ing American College of Surgeons National Surgical Cuality Im3rovement Program 1ACS NSCIP2 dataset6 After im3lementation of the care -undle, total colorectal SSI rates declined significantly from :6>= -efore intervention to +6)= 1Cima et al6, ()*.26 Daiser Sunnyside Medical Center 1DSMC2, a .)) -ed4hos3ital in Clac0amas, OR, $as a significantly high outlier for SSI incidence during fiscal year ())@4()): according to NSCIP

ris04ad;usted re3ortsE overall colorectal SSI rates stood at ((= com3ared to *+= at other NSCIP 3artici3ating hos3itals 1&utfiyya et al6, ()*(26 #o address this, the authors conducted a 3ros3ective study on a colorectal care -undle6 #he -undle $as develo3ed -ased on current evidence in the literature, consensus on feasi-ility, and surgeon s recommendations, and included SCIP com3onents and various ad;unct interventions 1see A33endix /26 Current and ne$ staff mem-ers $ere educated on the colorectal care -undle, and after its im3lementation in ()*), the rate of infection dro33ed to @68= $ithin one year 1&utfiyya et al6, ()*(26 ,eierhoi et al6 1()*.2 sought to determine $hether there $as a correlation -et$een the ty3e and route of anti-iotic 3ro3hylaxis for elective colorectal surgery and SSI rates6 A study of <,8<) cases collected from **( Feterans Administration hos3itals from ())< to ()): revealed that the addition of an oral anti-iotic to intravenous 1IF2 anti-iotic 3ro3hylaxis resulted in significantly lo$er rates of SSI 1@6.=2 than use of IF anti-iotics alone 1*@68=26 #hough the choice of the IF anti-iotic agent com-ined $ith oral anti-iotic $as not significantly associated $ith SSI, this $as not the case in the a-sence of oral anti-iotics6 Second4generation ce3halos3orin agents are the most commonly used and recommended IF anti-iotic -y SCIP, yet results indicated these to -e the least effective $hen com3ared to non4SCIP a33roved agents 1,eierhoi et al6, ()*.26 Our study also investigated the current evidence on mechanical -o$el 3re3aration 3rior to elective colorectal surgeries6 A retros3ective cohort study -y Dim et al6 1()*.2 examined the rate of 3osto3erative infections in (,+8< 3atients $ho received 3reo3erative full mechanical -o$el 3re3aration and oral anti-iotics com3ared to those $ho received no 3re3aration 3rior to elective colectomy6 #he results indicated that 3atients given full -o$el 3re3aration had reduced infection rates6 A Cochrane revie$ conducted -y GHenaga, Matos, and Iille4!Jrgensen 1()**2,

ho$ever, came to a different conclusion6 #he authors researched eighteen randomi7ed control trials $ith a total of <,>)< 3artici3ants to com3are the efficacy of mechanical -o$el 3re3aration versus no mechanical -o$el 3re3aration6 #he authors concluded that mechanical -o$el 3re3aration did not 3roduce any statistical significance in 3reventing or im3roving infection rate or 3atient outcomes 1GHenaga et al6, ()**26 Chlorhexidine and iodine are antise3tic solutions used to reduce the rate of SSI -y decreasing the amount of -acteria coloni7ing the s0in6 &ee et al6 1()*)2 3erformed a meta4 analysis of nine randomi7ed control trials $ith a total of .,@*+ 3atients to examine the effectiveness of chlorhexidine versus iodine6 #he result of the revie$ yielded a .@= reduction in the num-er of SSIs among 3atients $ho received 3reo3erative s0in antise3sis $ith chlorhexidine 1&ee et al6, ()*)26 #hese findings $ere consistent regardless of the ty3e of chlorhexidine 3re3aration used6 #hree of the trials re3orted fe$er SSIs $ith the use of chlorhexidine com3ared to iodine6 In addition, chlorhexidine 3roved to -e more effective in decreasing the ris0 of 3ositive s0in cultures -y <@= 1&ee et al6, ()*)26 A cost4analysis revealed that s$itching from iodine to chlorhexidine resulted in net cost savings of 9*@K9(@ 3er surgical case and 9.+:,:)+K9<@>,<:+ 3er year for the institution 1&ee et al6, ()*)26 Synthesis of 'vidence? Identifying Ga3s in the Research Although SCIP consists of nine core measures to reduce SSIs, there still remain several ga3s in the research6 Birst, $hether com3liance to SCIP 3rotocols actually reduce SSIs among 3atients undergoing colorectal surgery or not, is de-ata-le 1Cima et al6, ()*.26 #here have -een contradictory results K some studies demonstrated SSI reduction $hile others sho$ed no significant association of SSI rate $ith increased SCIP com3liance 1&utfiyya et al6, ()*(26 Several hos3itals have ta0en initiative to ex3and on SCIP measures -y incor3orating additional

3rocedures such as chlorhexidine s0in 3re3aration, mechanical -o$el 3re3aration, and oral anti-iotics in tailored colorectal Lcare -undlesM 1&utfiyya et al6, ()*(26 Since im3lementation of these -undles, studies -y Cima et al6 and &utifyya et al6 revealed significantly reduced SSI rates6 #hese care -undles are more 3romising com3ared to SCIP measures aloneE ho$ever, to isolate $hich s3ecific strategies of the -undle are most effective in SSI reduction re5uires further investigation6 &astly, among our articles only t$o touched u3on other ma;or SSI ris0 factors such as -ody mass index, dia-etes, and cancer diagnosis6 In efforts to continually reduce SSI and im3rove 3atient safety, further research focused on ho$ to 3revent SSI in these vulnera-le 3o3ulations is $arranted6 #here is little standardi7ed clinical 3ractice of SSI reduction measures in the hos3ital setting6 As 3reviously mentioned, various institutions have gone -eyond SCIP 3rotocols and im3lemented their o$n care -undles, $hich differ in content across institutions6 One exam3le is anti-iotic use6 Iithin the SCIP guidelines, several different IF anti-iotic agents are a33roved and oral anti-iotic use remains o3tional6 #his is des3ite studies sho$ing a com-ination of oral and IF anti-iotics having an inde3endent 3rotective effect, and ironically, the SCIP4a33roved second4generation ce3halos3orin -eing least effective among a33roved agents in colorectal surgery 1,eierhoi et al6, ()*.26 &ac0 of consensus also exists in $hether to 3ractice full mechanical -o$el 3re3aration or not 1Dim et al6, ()*.26 Mechanical -o$el 3re3aration is a standard measure in many hos3italsE ho$ever, its efficacy has -een controversial6 GHenaga et al6 1()**2 $ent further to suggest that 3racticing mechanical -o$el 3re3aration in colorectal surgery can -e left to the surgeon s discretion, thus illustrating the com3lexity of SSI 3reventative measures and need for more rigorous and consistent research6 Current standards of SSI 3reventative care are clearly outlined in the SCIP core measures6

Com3liance has increased since its im3lementation6 #here is a heightened a$areness for enhancing 3atient safety and outcomes, yet SSIs still occur at alarming rates6 Burther research and evidence4-ased 3ractice, therefore, is im3erative in sustaining continual efforts to reduce unnecessary and 3reventa-le SSIs6 Summary of Recommendations &utfiyya et al6 1()*(2 and Cima et al6 1()*.2 concluded that SSI reduction occurs -y im3lementing 3revention techni5ues in addition to SCIP core measures in a colorectal care -undle6 'valuation of the efficacy of single measures and com3liance $ith all elements of the -undle $ere not $ithin the sco3e of the studiesE therefore, it is not 3ossi-le to determine exactly $hich elements of the -undle $ere associated $ith a decrease in SSI rates6 Cima et al6 1()*.2 demonstrated that standardi7ation of care techni5ues from all 3roviders utili7ing a single -undle could greatly im3act the incidence of SSIs in colorectal surgery 3atients6 /oth studies demonstrated that SSI reduction does not result from a single ste3 or 3recaution ta0en, and must -e vie$ed as a holistic, multidisci3linary effort across all stages of surgery from inta0e and throughout the critical 3ost4surgery 3eriod6 Oral anti-iotics should -e used in con;unction $ith IF anti-iotics for 3ro3hylaxis 3reo3eratively 1,eierhoi et al6 ()*(26 #he authors noted that there is an increased rate of -acteroid resistance among various anti-iotics such as cefoxitin, cefotetan, and am3icillin6 #he use of -road4s3ectrum anti-iotics $ith a lo$er rate of resistance to common -o$el organisms is recommended to hel3 reduce SSI rates6 Ihen an infection does occur, culturing $ounds $ould also -e -eneficial for the 3ur3oses of hel3ing institutions decide on the -est 3ro3hylactic IF anti-iotic course6 Overall, there is no consensus across 3ractitioners regarding the effect of full mechanical

-o$el 3re3aration on the ris0 of SSIs follo$ing colectomy6 #he study conducted -y Dim et al6 1()*.2 concluded that -o$el 3re3aration $ith non4a-sor-a-le oral anti-iotics 3rior to elective colectomy did indeed decrease the ris0 of SSIs6 In this study, the grou3 that received full -o$el 3re3aration sho$ed significantly lo$er rates in all ty3es of SSI6 Also, the 3artici3ants $ho received full mechanical -o$el 3re3aration had a lo$er ris0 for C difficile colitis6 Another significant finding in this study $ere the intrao3erative -enefits resulting from mechanical -o$el 3re3aration, $hich included im3roved handling of the -o$el, facilitation of lesion 3al3ation and reduced o3erative time, all of $hich may 3otentially have a 3ositive effect on SSIs6 Given these favora-le findings, Dim et al6 1()*.2 recommends administering full mechanical -o$el 3re3aration $ith oral anti-iotics -efore elective colectomy in all 3atients, unless any contraindications exist6 ,es3ite this, ho$ever, the eighteen trials summari7ed -y GHenaga et al6 1()**2, concluded no such favora-le findings6 Analysis of these trials, in $hich 3atients receiving mechanical -o$el 3re3aration $ere com3ared $ith those receiving no 3re3aration, revealed no statistically significant results in regards to having any im3act on the ris0 for infection6 #herefore, GHenaga et al6 1()**2 concluded that 3ro3hylactic mechanical -o$el 3re3aration has not -een 3roven valua-le for 3atients6 Mechanical -o$el 3re3arations continue to -e routinely used -efore colorectal surgery in the a-sence of ade5uate -ody of 0no$ledgeE GHenaga et al6 1()**2 urged for further 5uality research to -e conducted6 &astly, chlorhexidine use is not a com3onent of the SCIP core measures, yet it $as 3reviously mentioned that there $as a significant reduction in the rate of SSIs $ith chlorhexidine use com3ared to iodine6 #his resulted in greater overall cost savings 1&ee et al6, ()*)26 #herefore, the recommendation is to use 3reo3erative chlorhexidine s0in antise3tics instead of

iodine as the -est evidence4-ased 3ractice6 Role of the Clinical Nurse &eader Clinical Nurse &eaders have a res3onsi-ility to their 3atients to 3rovide care according to the latest evidence4-ased 3ractice recommendations6 Net ho$ are -est 3ractices esta-lished in the first 3laceO Nurses must -e a-le to im3lement, develo3 and criti5ue evidence4-ased 3ractice6 Since its introduction in the mid4nineties, the Io$a Model has -een used to guide nursing research as $ell as hel3 unit managers 3ut evidence4-ased 3ractice to the test in clinical settings 1#itler et al6, ())*26 #he frame$or0 focuses on existing 0no$ledge and 3ro-lem4focused triggers and may -e used as a tool for staff to 5uestion and im3rove u3on current unit 3rotocolsE as such, it is a -efitting strategy to utili7e for our current 5uality of care 3ro-lem6 Indeed, $ith a little -it of imagination, the 3rocess of $riting this very 3a3er can -e seen as an exercise in using the Io$a Model? a to3ic $as selected 1viz6, investigating nursing interventions and current evidence4-ased 3ractice regarding SSIs in colorectal 3atients2 and a team $as formed 1our $riting grou326 'vidence $as retrieved, graded and evaluated6 No$ $e set forth our evidence4-ased 3ractice standard for im3lementation on our nursing unitE for the 3ur3oses of continuity, our unit is the Pre4o3erative %nit at Galins0i Memorial Aos3ital6 Ie recommend -undling the -est research4su33orted interventions $ith the SCIP core measures, e6g6, 3re4surgery chlorhexidine s0in 3re3aration and 3ro3hylactic use of oral anti-iotics6 ,ue to the advances in the 5uality of care movement, the CN& and other decision ma0ers at the unit level may im3lement any of numerous strategies to institute the use of care -undles and evaluate their efficacy6 In the role of information manager, the CN& may choose to trac0 nurse and other 3rovider -undle com3liance -y im-edding chec0lists as 3art of the mandatory

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$or0list in the electronic medical record6 As outcomes managers, the CN& $ould then synthesi7e the data, revie$ outcomes $ith other sta0eholders, and modify the care -undle6 #he $hole 3rocess $ould -e re3eated, and the care -undle fine4tuned $ith every cycle6 After a 3articular care -undle $as vetted, it could -e shared $ith other units6 #he ultimate mar0er of a successful care -undle 1or any intervention2 is that it becomes 3art of the -ody of evidence4-ased 3ractice6 Conclusion CMS no$ re5uires hos3itals to re3ort SCIP com3liance and 3erformance measures to receive full Medicare 3ayment 1A$ad, ()*(26 ,ue to this mandatory re3orting, SCIP com3liance has dramatically im3roved6 #his is, ho$ever, only the -eginning of SSI 3revention efforts K continued em3hasis on -uilding a culture of safety u3on evidence4-ased 3ractice that tailors to 3atient 3o3ulations at ris0 for SSI is im3erative6 Again, further research on cost4 effective care -undles 3romoting a culture of safety is 0ey to increasing com3liance and standardi7ation of care6

References A$ad, S6 S6 1()*(26 Adherence to surgical care im3rovement 3ro;ect measures and 3ost4 o3erative surgical site infections6 Surgical Infections (Larchmt), 131+2, (.+4(.86 doi?*)6*)>:Psur6()*(6*.*

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Centers for ,isease Control 1C,C2PNASN Protocol Clarifications6 1()*.26 Retrieved from? C,C6govPNASNP3dfP3scmanualP:3scssicurrent63df Center for ,isease Control and Prevention6 1*:::26 Guideline for 3revention of surgical site infection6 Infection Control and Hospital pidemiolog!, "#1+26 Retrieved from htt3?PP$$$6cdc6govPhic3acP3dfPguidelinesPSSIQ*:::63df Cima, R6, ,an0-ar, '6, &ovely, !6, Pendlimari, R6, Aronhalt, D6, Nehring, S6, 6 6 6 Cuast, &6 1()*.26 Colorectal surgery surgical site infection reduction 3rogram? a national surgical 5uality im3rovement 3rograme driven multidisci3linary single4institution ex3erience6 $ournal of the %merican College of Surgeons, "1& 1*26 Retrieved from htt3?PPdx6doi6orgP*)6*)*@P;6;amcollsurg6()*(6):6)): ,eierhoi, R6!6, ,a$es, &6 G6, Fic0, C6, Itani, D6M6, " Aa$n, M6#6 1()*.26 Choice of intravenous anti-iotic 3ro3hylaxis colorectal surgery does matter6 $ournal of %merican College of Surgeons, "1'1<2, 8@.48@:6 Retrieved from htt3?PPdx6doi6orgP*)6*)*@P;6;amcollsurg6()*.6)86)). GHenaga, D6 B6, Matos, ,6, " Iille4!Jrgensen, P6 1()**26 Mechanical -o$el 3re3aration for elective colorectal surgery6 Cochrane (atabase of S!stematic )evie*s (+)C,))*<++6 doi?*)6*))(P*+@<*><>6C,))*<++63u-+

!oint Commission Center for #ransforming Aealthcare 1()*.26 Retrieved from? $$$6centerfortransforminghealthcare6org Dim, '6, Sheet7, D6, /onn, !6, ,eRoo, S6, &ee, C6, Stein, I6, 6 6 6 'ngles-e, M6 1()*.26 A state$ide colectomy ex3erience? #he role of full -o$el 3re3aration in 3reventing surgical site infection6 Annals of Surgery, ##1))26 Retrieved from? doi?*)6*):8Psla6)-)*.e.*>(a@(@+.

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&ee, I6, Agar$al, R6 D6, &ee, /6 N6, Bishman, N6 O6, " %mscheid, C6 A6 1()*)26 Systematic revie$ and cost analysis com3aring use of chlorhexidine $ith use of iodine for 3reo3erative s0in antise3sis to 3revent surgical site infection6 Infection Control and Hospital pidemiolog!, 311*(2, *(*:4*((:6 doi?*)6*)>@P@<8*.+ &utfiyya, I6, Parsons, ,6, /reen, !6, 1()*(26 A colorectal Lcare -undleM to reduce surgical site infections in colorectal surgeries? A single4center ex3erience6 ,he -ermanente $ournal, 1& 1.26 Retrieved from htt3?PP$$$6nc-i6nlm6nih6govP3mcParticlesPPMC.++(8<<P O$ens, C6,6, " Stoessel, D6 1()*.26 Surgical site infections? e3idemiology, micro-iology and 3revention6 $ournal of Hospital Infection, '#1<(2, .4*)6 Retrieved from htt3?PP$$$6sciencedirect6com #itler, M6G6, Dlei-er, C6, Steelman, F6, Ra0el, /6A6, /udreau, G6, 'verett, &6C, 6 6 6 Goode, #6 1())*26 #he Io$a model of evidence4-ased 3ractice to 3romote 5uality care6 Critical Care .ursing Clinics of .orth %merica, 13, +:84<):6 %6S6 ,e3artment of Aealth " Auman Services6 1()*.26 Retrieved from htt3?PP$$$6hhs6govPashPinitiativesPhaiPnationaltargetsPRSCIP

A33endix A #a-le A* Summary of 'vidence

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Key Search Terms

Cochrane Central Register of Controlled Trials

CINAHL

JSTOR

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Selected Rele#ant Articles

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#a-le A( Grade of 'vidence Score *) : > 8 @ Grade &evel of Studies Meta4Analysis of Randomi7ed Controlled #rials &arge Sam3le Randomi7ed Controlled #rials Small Sam3le Randomi7ed Controlled #rials Non4random, Controlled Pros3ective Studies Non4random, Controlled Retros3ective Studies * . R@ R *, (, + Relevant Articles ( Article Num-er R ., <

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Cohort Studies Case4Controlled Studies Non4Controlled, Clinical, ,escri3tive Studies Case Studies 'x3ert Consensus, Manufacturers Recommendations, &iterature Revie$s Anecdotes #otal @ @

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A33endix / #a-le /* Synthesis of 'vidence

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Source

$uality Issues

%esign Ty&e

!easurements' (aria les) Outcome !easures

Study Setting and Study Inter#ention Study Po&ulation

Key *indings

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* Cima et al6, #his study used Non4 ()*. clinically randomi7ed a-stracted data to retros3ective assem-le a cohort study colorectal SSI reduction -undle and com3ared the effectiveness of the -undle in reducing SSIs in colorectal surgery6

Outcomes set -y Setting? SSI reduction -undle? #here $ere 8(: American College #he Mayo Clinic *6 Preo3erative? 3artici3ants analy7ed of Surgeons Rochester cam3us, U Patient cleansing from ()):4()**, $ith National Surgical ,ivision of Colon $ith chlorhexidine <.* 3atients in the 3re4 Cuality and Rectal Surgery6 cloths6 intervention 1()):4 Im3rovement A multidisci3linary U Ai-iclens sho$er ()*)2 sam3le and *:> Program 1ACS team that $as a 3art night -efore and day of 3atients after the NSCIP2 $ere of a multi4institution surgery im3lementation of the measured monthly6 colla-orative of the U 'nsuring 3atient -undle 1()**26 #he SSI !oint CommissionTs understanding 3re4intervention rate (6 Intrao3erative for the ( years 1()):4 Faria-les? Patients Center for U Anti-iotics @) min ()*)2 -efore reduction $ho 3artici3ated #ransforming 3rior to incision and -undle im3lementation in the study during Aealthcare $as discontinued $ithin (+ $as :6>=6 ,uring 3re4intervention esta-lished to times 1()):4()*)2 evaluate colorectal hrs6 'nsuring re4dose im3lementation of SSI SSI outcomes6 of cefa7olin $ithin .4+ reduction -undle in and those $ho hours after incision6 ()**, su3erficial and 3artici3ated during 3ost4intervention Study 3o3ulation? U Chlora3re3 a33lied to organ s3ace infections com3lete coverage of declined6 Su3erficial 1()**26 A total of 8(: infection declined 3atients undergoing incision area6 significantly to *6<= colorectal surgery U Closing 3rotocol? Outcomes %se of closing tray for from +6:= 3re-undle $ere analy7ed in the measures? closure of fascia and 13 V)6)<26 Organ s3ace ACS NSCIP, $ith Su3erficial, dee3, s0in6 Glove change -y infection also declined <.* in the 3re4 and organ s3ace staff -efore closure of to (6<= -ut the reduction -undle surgical site reduction $as not infection rates .) grou3 1()):4()*)2 fascia6 clinically significant days after surgery6 and *:> 3atients in .6 Posto3erative U Patient and hand 113W )6*)26 ()** after the im3lementation of hygiene U Remove dressing the SSI reduction $ithin +> hours6 -undle6 +6 ,ischarge U Provide + o76 -ottle of Ai-iclens, U Patient education on $ound care and recogni7ing infection sym3toms U Bollo$4u3 3hone call from nurses6 Faria-les U Oral 3lus IF anti-iotics versus IF anti-iotics 3reo3eratively Outcomes Measures U Su3erficial and dee3 incisional surgical site infections $ithin .) days after surgery Setting U ,ata $as analy7ed from **( Feterans Administration hos3itals6 #he data came from t$o sources? *2 #he Feterans Affairs Surgical Cuality Im3rovement Program 1FASCIP2 (2 Feterans Administration ,ecision Su33ort Systems 3harmacy #he 3reo3erative ris0 Results and SSI outcomes U 8): total surgical site from the Feterans infections 1*(6.=2 Affairs Surgical develo3ed out of <,8<) Cuality Im3rovement colorectal 3rocedures Program 1FASCIP2 U Oral anti-iotics X IF $as lin0ed to the FA had a lo$er surgical ,ecision Su33ort site infection rate Systems 3harmacy 1@6.=2 than IF data from **( anti-iotics alone hos3itals6 Patients $ho 1*@68=26 under$ent colorectal U Oral anti-iotics $ere resections from ())< the most im3ortant to ()): $ere included factor in reducing in the study6 SSI s6 UAm3icillinPsul-actam 1**6.=2 had a higher surgical infection rate Po3ulation than first generation 15 U Patients Cefa7olinPmetronida7ol undergoing elective e 1@6(=26 colorectal resections UCefa7olinPmetronida7 -et$een ())< and

( ,eierhoi, ,a$es, Fic0, Itani, " Aa$n, ()*.

#his study Retros3ective com3ared the cohort study effectiveness of a33roved intravenous anti-iotics and oral anti-iotics on SSI ris0 for colorectal surgery6

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