Decreasing Sternal Wound Infections After Cardiac Surgery: A Nurse-Driven Bundle Approach

Approximately 400 000 cardiac surgeries are performed annually in the United States.1 Patient outcomes after surgery depend on multiple factors, including existing comorbidities, perioperative education, glycemic control, surgical incision management, and socioeconomic status.2 In addition to the intraoperative risks, the postoperative period is critical in determining long-term outcomes. Sternal wound infections (SWIs) are complications associated with cardiac surgery that are multifactorial but preventable. The most significant consequence of SWI is delayed patient recovery with associated increased costs.Patients who undergo cardiac surgery with sternotomy are at risk of experiencing SWI. It is estimated that about 4% of patients develop such infections, which have major adverse consequences for patient outcomes and long-term prognosis.3 Sternal wounds are categorized as superficial or deep, depending on the infection source.3 Superficial SWIs involve the skin and subcutaneous tissue, whereas deep SWIs are beneath the fascial plane. Deep SWI involving the mediastinal space is also known as mediastinitis. Mediastinitis can be classified into distinct categories based on the extent of tissue involvement. In more severe cases, both bone and retrosternal tissues may be affected. When the infection spreads to the bone, it can lead to osteomyelitis or frank osteitis. Each classification reflects increasing severity, progressing from soft tissue infection to more complex cases involving bone and retrosternal structures. Data show that the presence of SWIs can increase the rates of morbidity and mortality, depending on classification.4Four nurses—2 from the cardiothoracic intensive care unit (CTICU) and 2 from the cardiothoracic surgical step-down unit—were presented with an opportunity from the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigator (CSI) Academy. With a dedicated team coach and mentorship from AACN, the Sternal Wound Action Team (SWAT) was created. Reducing SWI was selected as the project focus because of an increased prevalence of SWIs within both units. The SWAT members believed that superficial SWIs were preventable complications that frontline nurses were well positioned to manage. A bundled approach ensures that nurses, as primary caregivers, follow standardized, evidence-based practices to minimize the likelihood of infection. By taking a proactive role, registered nurses can prevent superficial infections and enhance overall patient safety and quality of care within their sphere of influence.At a large academic medical center in New York City, the cardiothoracic team performs more than 1600 cardiac surgeries annually. The incidence of SWI has been consistently above the national benchmark (Figure 1).The estimated cost of an SWI ranges from $7900 to $111 000, depending on the depth of infection.6 Sternal wound infection is state-reportable, and the Centers for Medicare & Medicaid Services will not reimburse the cost of care related to these infections.3 Although SWIs following cardiac surgery are potentially deadly and costly, they are preventable complications. Critical care nurses are at the helm of patient-centered care and thus are perfectly positioned to champion SWI prevention.Data from August 2022 to August 2023 indicated that our institution had 11 cases of SWI, of which 5 were deep and 6 were superficial. These data, which were obtained from our hospital database, were cross-referenced against data from the National Healthcare Safety Network (NSHN) database. Because of the large number of cardiothoracic surgeries we encountered on our unit, the change was implemented for all cardiac surgery patients with midsternal incisions for consistency in the care provided. Root-cause analysis revealed many inconsistencies across the disciplines and units. Even though a policy existed on surgical site care, clinical practice varied from unit to unit, primarily based on surgeon and other health care provider preference. Evidence has shown that providing standardized care can improve patient outcomes.7The aim of this CSI project was to decrease SWI rates in cardiac surgery patients by creating a nursing-driven bundled approach to standardize care. The specific goals of this initiative were as follows: We conducted a literature review to find research and analyze evidence on treating sternal wounds. We performed a comprehensive search using the Academic Search Complete, Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Columbia University Library, PubMed, Google Scholar, and MEDLINE databases to identify research related to SWIs and prevention strategies. Key search terms used were cardiac surgery complications, sternal wound infection, midsternal infection prevention, bundled approach, nurse-driven initiatives, multidisciplinary approach to reducing sternal wound infections, and effectiveness of a bundled approach. The focus was on the bundle approach and its implementation in acute care settings. The search was restricted to studies reported between 2018 and 2023, and only articles published in English were included. The search generated 20 references, with 8 articles selected to develop the SWAT preoperative and postoperative nursing bundle (Figure 2). One study reported in 2023 focused on a multidisciplinary team approach to eliminating deep SWI by identifying known risk factors and implementing evidence-based interventions across each phase of care. The results demonstrated that using a bundled infection-prevention approach reduced the incidence of deep SWI to zero during the first 12 months after implementation.8The SWAT developed an evidence-based nurse-driven bundle focused on preoperative and postoperative care to prevent SWIs. Preoperatively, the bundle focuses on 2 components: skin preparation and education. Skin preparation includes 2 chlorhexidine gluconate (CHG) wipe treatments the evening before surgery and immediately before the patient is transferred to the preoperative area. The patient must also shower or bathe using a bottled CHG solution between the 2 CHG wipes. Additionally, emphasis is placed on removing any adhesive from the patient’s skin to reduce bacterial burden. Evidence shows that involving patients in their care can lead to favorable outcomes.3 Therefore, patient education is a crucial component of the nursing bundle. The primary nurse educates patients on SWI prevention and glycemic management before and after surgery.Postoperatively, the SWAT initiative was piloted on the CTICU and cardiothoracic step-down unit at a large academic medical center in the Washington Heights neighborhood of New York City. The CTICU is a 31-bed unit and the cardiothoracic step-down unit is a 36-bed unit with a combined staffing of 200 registered nurses and additional health care professionals. U.S. News & World Report ranked our cardiac program number 5 nationwide for 2024 to 2025.9 These 2 units primarily care for patients who have undergone cardiothoracic surgery, including heart transplants, coronary artery bypasses, aortic surgeries, and valvular surgeries.Before the rollout of the bundle, the CSI team met frequently with key stakeholders including cardiac surgeons, medical directors, and nursing leaders to address concerns and ensure support for implementing the bundle. Feedback from all disciplines was well received, and the bundle was updated several times. The most important suggestion for improvement came from the frontline nursing staff members, who recommended specifying the timing of the CHG skin treatments.Specific practice changes besides staff education included documentation of the bundle’s components. Our institution’s electronic medical record (EMR) system lacked areas for certain parts of the bundle documentation, initially making auditing and adherence challenging. Staff members were educated on where to document specific elements, such as securement devices (surgical bras or abdominal binders), under the free-text comment section of the flow-sheet. Also, the CHG section of the flowsheet lacked specific dropdown options for timing CHG baths. A goal is to update the EMR once the bundle is adapted systemwide. In collaboration with the pharmacist assigned to the CTICU, the health care providers’ order set was modified to include triple antibiotic ointment as an option for treatment. This change made ordering more accessible, increasing compliance with the bundle.Subsequently, at the request of key stakeholders, the bundle was implemented in 6 additional cardiac units and perioperative areas, including the operating room and preoperative areas. As a result, 700 nurses and other health care workers were educated. A health care provider checklist was created and distributed to the cardiac division teams, with the SWAT providing education and answering questions regarding the bundle.A collaborative partnership was quickly established from the project’s inception. There was tremendous support from both medical and nursing leadership teams. More importantly, the CSI fellows met frequently with the medical and surgical teams to monitor patient outcomes and be part of case discussions. Even after completing the CSI Academy, the SWAT presents monthly at our cardiac outcomes meeting, which occurs on the second Tuesday of every month.The AACN CSI Academy 12-month framework provided the team with guidance and implementation structure. The project plan was divided into sections to ensure seamless throughput. Months 1 to 3 focused on activities that included finalizing the project plan, gathering data, performing root-cause analysis, and creating education materials, logos, slogans, and flyers for the project kickoff event. The “SWAT” name was fitting because it captured the team’s vision. A fellow CTICU colleague designed the logo. Champions were recruited from all the cardiac units. They function as unit-designated resource personnel, providing ongoing education and monitoring bundle compliance. Recruitment initially began on the 2 units but quickly spread to all cardiac units. The CSI team also made T-shirts for all the SWAT champions and key stakeholders. The vast success of the apparel program was an unintended positive outcome. Everyone from support staff to physicians wanted to be a SWAT champion. Ordering apparel was made possible through an Edwards Life Sciences grant accompanying the CSI opportunity.The focus of months 4 to 6 was the bundle’s finalization, the official kickoff, and record audits to monitor compliance. The team made “badge buddies” of the bundle and distributed them to nursing staff members and other health care providers. Additionally, the badge reels were posted by workstations for easy access. The team checked in and disseminated materials during unit huddles, unit and divisional skills days, new-hire orientations, and hospital-wide meetings. Approximately 1500 badge buddies were printed in assorted colors and laminated by hand. To track bundle compliance, the team created an audit tool to examine the EMR documentation (Figure 3). The audit tool helped the team identify gaps in practice, implementation successes, and target areas for reeducation. The team provided every staff member with a badge buddy to reinforce compliance. Finally, this period was concluded with regular follow-up meetings with champions to solicit feedback and identify barriers and a midpoint presentation to other CSI cohorts (Figure 4).Months 7 to 9 concentrated primarily on preventing project stagnation, data transparency, and sharing results from record audits. The team presented at many meetings, giving updates on the project goals and record audits. The chief cardiothoracic surgeon sponsored a “redosing” breakfast, where the team went to each unit, providing breakfast and a redose of SWAT education (SWAT Goes to the People). During the redosing education, the team used a mannequin, “Sternella,” to demonstrate proper wound care and surgical bra application. Actively engaging frontline staff members provided real-time education, allowed questions to be answered, and elicited feedback. In addition, SWAT tote bags and gift cards were given to staff members with excellent practice and thorough documentation. These incentives were well received by staff members.The final months were spent finalizing data collection, calculating the fiscal impact, and sharing lessons learned. Throughout the 12 months, the team was invited to present at many hospital-wide meetings. Participation was measured by having attendees scan a QR code and complete a brief form. The results confirmed that more than 700 nurses received in-servicing across our institution. More importantly, the SWAT has a standing slot to present monthly at divisional cardiothoracic outcomes meetings to report back on progress and foster collaborative input from surgical, operating room, and postanesthesia care unit teams. The cardiothoracic outcomes meeting involves discussing the incidence of possible SWI, readmission rates, and current benchmark standing. Input from the CSI fellows is well received. The team was recently invited to give a 10-minute presentation on preventing SWIs during grand rounds. Other notable activities included being selected to present the project to Magnet appraisers and collaborating with 2 of our other campuses.The CSI project was concluded in July 2024. Postintervention data were collected over the 12 months following the project’s initiation. Our hospital data indicated 5 SWIs, of which 3 were deep and 2 were superficial. The rate of SWIs decreased by 55%, based on data from our institution and the National Healthcare Safety Network (NHSN). Of those reported cases, 40% met NHSN definitions for SWI but were not treated clinically because the cultures were negative for growth. Thus, the infection rate was lower than reported. At the time, the Society of Thoracic Surgeons reported the infection rate at 0% for our institution. Based on the literature and NHSN data, the potential fiscal savings can be estimated at $254 184 (see Table).6The audit tool developed by the team tracked the patient’s date of birth, date of service, type of surgery, hemoglobin A1c level upon admission, triple antibiotic ointment application (postoperative day 2), CHG application, and securement devices, such as surgical bras and abdominal binders (Figure 3). Education monitoring on glycemic control and incisional care was also audited. Additionally, the cardiothoracic step-down unit patients were provided with a perioperative education package. Compliance was tracked manually via paper documentation. The auditing was conducted at random biweekly in both units. The CSI team met biweekly with all stakeholders including the surgeons, nurses, physician assistants, and patient care technicians to discuss audit outcomes and barriers, along with plans to address gaps.Early buy-in from key stakeholders, nursing leadership support, and cross-campus collaboration were unintended positive outcomes throughout the project. However, many challenges were encountered during the CSI fellowship, such as dealing with scope creep and maintaining realistic goals, using data and evidence-based research to define the project, collaborating with many disciplines, and acknowledging that change can be difficult. The project expanded beyond our initial expectations, leading to potential burnout. However, the support from our coach and the monthly CSI meetings helped us stay focused and on track.The CSI team successfully reduced the incidence of SWI by 55%. The project demonstrates the impact of nursing on patient care, as nurses took a leading role in reducing complications and improving patient outcomes. As mentioned previously, the project’s fiscal savings are estimated at $254 184. More importantly, our institution’s SWI rate has fallen below the state average for the first time in more than a decade (Figure 1). The CSI team leveraged evidence-based initiatives and proved that nurses are essential contributors to positive patient outcomes. Consequently, many opportunities ensued.The CSI project was selected as a Magnet story, with the team recognized as innovative change agents. As previously mentioned, the CSI team is expected to attend and present monthly at the cardiac outcomes meeting. Additionally, the team conducts random record audits each month. The SWAT bundle has already been integrated into new-hire orientations and unit-specific skills days. An EMR optimization request will follow once the bundle is adopted system wide.Because of the project’s major impact, nursing leaders have asked the CSI team to develop a hospital-wide program based on the CSI framework to support other nurses aiming to influence clinical practice. Furthermore, the CSI team is collaborating with the surgical site infection team at the affiliated children’s hospital to enhance infection prevention efforts in the pediatric population and with an affiliated academic medical center to promote cross-institutional learning for adult cardiac surgical patients. The goal is to incorporate the SWAT bundle into hospital policy once other campuses adopt it.The support from the CSI Academy, our coach, nursing leaders, and champions and collaboration with the cardiothoracic surgery team empowers us to drive meaningful change. Implementing a nurse-driven bundle at a large academic center would not have been possible without the assistance of key stakeholders. In addition, the tools and resources provided by AACN through the Edwards Life Science grant were instrumental in achieving our goal of reducing SWIs and developing the nurse-driven bundle.