Evaluation of a bundle of care to reduce incisional surgical site infection after gastrointestinal surgery.

BACKGROUND: Surgical site infection (SSI) is associated with morbidity, mortality and increased care costs; many SSIs are considered preventable. The aim of the present study was to test implementation of a pragmatic, evidence-based bundle designed to reduce incisional SSI after emergency laparotomy and elective major lower gastrointestinal surgery. METHOD: This was a prospective before-and-after study. Data were collected before the intervention and for two separate subsequent time periods. An evidence-based bundle of care (BOC) was implemented; the primary outcome measure was incisional SSI at 30 days. The secondary outcome measure was 30-day unplanned readmissions. The initial post-intervention group, Group 2, assessed a variable number of potential impacting factors; however, due to funding and staffing levels the second post-bundle group, Group 3, focused on the core aspects of the BOC and rates of incisional SSI and readmission. RESULTS: In total, 99 patients were included in the 'before' group; and 71 in Group 2 and 92 in Group 3, the post-intervention groups. The incisional SSI rate was 29.3% (29/99) before and 28.2% (20/71) in Group 2 (P=0.873) and 21.7% (20/92) in Group 3 (P=0.234) after the intervention. After adjustment for confounders, the care bundle was associated with a non-significant reduction in SSI (Group 2: odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.45-1.93, P=0.0843). However, it was associated with significantly reduced readmissions 18.1% (18/99) before versus 5.6% (4/71) in Group 2 (OR = 0.236, 95% CI = 0.077-0.72, P=0.012) and 8.7% (8/92) in Group 3 (OR = 0.38, 95% CI = 0.16-0.9, P=0.029). Comparing the pre-bundle group to the post-bundle groups, there was an overall significant reduction in readmissions (P=0.003). This implies a number needed to treat of 8-11 patients to prevent one readmission. Adherence to antibiotic prophylaxis with the Trust guidelines increased from 91% to 99% (1 vs. 2, P=0.047). CONCLUSION: Introduction of the bundle was associated with a reduction in the observed rate of incisional SSI from 29.3% to 21.7%; significantly fewer patients required unplanned readmission. Use of the bundle was associated with significantly improved compliance with appropriate antimicrobial prophylaxis.

Pneumoperitoneum without visceral trauma: an under-recognised phenomenon after blast injury?

OBJECTIVES: The management of patients who have sustained blast injuries poses an important challenge for military healthcare professionals. Current military operations are generating large numbers of casualties and modern military healthcare facilities are increasingly using CT scanning to facilitate their management. This small case series serves to draw attention to a rare (or possibly under-reported) phenomenon after blast injury. METHODS AND RESULTS: We report two patients exposed to blast who had pneumoperitoneum identified by CT scan but who did not have abdominal visceral injury or ballistic peritoneal violation. DISCUSSION: The use of cross-sectional imaging is leading to the recognition of otherwise occult injury. Military practitioners should be aware of this injury pattern when using CT to help select patients for conservative management after abdominal blast injury.