Cesarean
section is the most commonly performed surgery in reproductive age women in US.
According to CDC the rate of cesarean surgical site infection(SSI) varies
between 3% to 5%, depending upon the population studied and antibiotic prophylaxis
used.
At the
annual meeting of the American College of Obstetricians and Gynecologists 2016,
Dr. Ashley Pritchard of the Yale New Haven, Connecticut Hospital described care
bundle with protocols covering preoperative, intraoperative, and postoperative
care.
Across 3 months
sampling period, which included data from before and after implementation of
the care bundle, the SSI rate fell from 3.4% to 2.2%.
“Infection
is the most common complication following cesarean delivery … 2.5%-16% of all
cesarean deliveries will result in a surgical site infection, and there is
significant underestimation as between 15% to 80% of infections are diagnosed
after patients leave the hospital,” she said.
A SSI task
force was created by the hospitals obstetric patient safety program. In putting
together the bundle, the task force reviewed the best practices, guidelines,
and evidence-based reviews.
The preoperative
protocols for elective cesarean section consisted of a preoperative appointment
with the patient to instruct her about showering the night before surgery, not
shaving for more than 24 hours prior to surgery and using 2% chlorhexidine
wipes both the night prior to surgery and the day of surgery, and other hygiene
processes. Any active skin infection was treated as well as any respiratory infection
was taken care of.
Dr.
Pritchard said “We know from numerous studies that chlorhexidine is superior to
iodine, but we also have found that with these wipes you get a level of
antibiosis on the skin surface that decreases surgical site infections at the
time of incisions.”
For the
operative leg of the bundle the OT staff was reeducated about the scrubbing
technique, changing into proper attire and limiting the unnecessary presence of
staff in OT. The OT staff was also shown a video of proper scrubbing technique.
A
cephalosporin was administered within 30 minutes of incision.
Attention
was paid to maintaining normothermia, with the use of warming blankets before
surgery, maintaining proper temperature in OT and recovery room.
“We’ve
learned from colorectal and trauma surgery that normothermia and patient
warming lead to reduced SSI,” Dr. Pritchard said. “This hasn’t been proven with
cesarean delivery, but we know there’s improved maternal and fetal well-being
with preoperative warming.”
For the
postoperative care, the use of supplemental oxygen was discontinued, sterile
dressing applied in OT maintained for at-least 24 hours, but not more than 48
hours. Clear discharge instruction, with a follow up appointment to check the
incision.
Prior to the
implementations of the protocols, there were 382 cesarean deliveries, of which 8.6%
were diagnosed with an SSI. While, after the protocols were strictly followed
out of 361 cesarean deliveries only 2.9% were diagnosed with an SSI. This was
statistically significant showing a dramatic decrease in SSI.
After the
protocols, the postoperative follow up attendance also increased significantly.
All aspects
of the bundle were put in practice simultaneously.
Dr.
Pritchard reported no financial disclosures.
References:
http://www.acogdailynews.com/daily-news/
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