Can implementation strategies diminish infection prevention barriers and reduce cardiac surgical site infections

Background: Surgical site infections (SSI) can affect up to 26.8% of patients undergoing coronary artery bypass grafting (CABG). In New York State (NYS), hospitals are evaluated by comparing their risk-adjusted CABG SSI rates to the NYS average rate. In 2021, our facility’s rate was significantly higher than the NYS average at 3.40 and 1.51, respectively. We sought to reduce infection rates using a multidisciplinary Implementation Science (IS) approach across the continuum of care. Methods: Standardized definitions from the National Healthcare Safety Network were utilized in a 24-month before and after study at a 528-bed hospital that averages 468 CABG/year. In November 2021, a multidisciplinary team, with representation from ambulatory, inpatient, and post-discharge settings, was convened. Group evaluation of barriers to implementation of evidence-based practice was completed. Gemba walks, product review, staff interviews, observation of practices, and prospective audits were conducted. Focus areas included pre-operative Methicillin-resistant Staphylococcus aureus (MRSA) screening and Hemoglobin A1C testing, peri-operative glucose control, normothermia, and standardization of dressing-change protocols. Monthly evaluation of fidelity through process metrics allowed for ongoing analysis and real-time project modification to account for identified barriers. Pre- and post- implementation infection rates were compared utilizing Mid-P Exact Rate Ratio analysis. Results: CABG SSI rate of 3.40 in 2021, was significantly reduced, following the intervention, to a rate of 1.25, in 2022 (p=0.04), which was no longer significantly different than NYS rate of 1.04. SSI reduction has been sustained as of November 2023, with the continuation of the strategy. Conclusions: A significant reduction in infections was achieved using a multidisciplinary IS approach. This was replicated among other surgical service lines. Including all phases of care in the approach is critical to understanding gaps in implementation. Our IS-based approach allowed the workgroup to identify barriers, track metrics and adapt strategies to reduce their SSI rate by 65%.