Major article
Educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections

https://doi.org/10.1016/j.ajic.2009.10.004Get rights and content

Background

In 2005, of the approximately 4 million births in the United States, 30% were by cesarean section (C-section) delivery, which translates to roughly over 1 million C-sections in 2005 alone. C-section is associated with higher morbidity than vaginal delivery. Women who undergo C-section are 5 times more likely to develop a postpartum infection after delivery than women who undergo vaginal delivery.

Objective

Estimates of surgical site infection (SSI) after C-section range from 1.50 to 2.64. A quality improvement initiative was implemented at the University of Minnesota Medical School to reduce rates of SSI using changes based on recommended care initiatives.

Methods

The multidisciplinary team developed a comprehensive staff education and training program, added a preoperative skin preparation protocol using chlorhexidine gluconate (CHG) no-rinse cloths, added CHG with alcohol for interoperative skin preparation, and modified instrument sterilization techniques.

Results

Data analysis revealed a statistically significant reduction in the overall SSI rate from 7.5% (33/441) in January-July 2006 to 1.2% (5/436) in January-July 2007 (χ2 test statistic, 21.2; P < .001; relative reduction of 84%).

Conclusion

Interventions, including staff education, use of CHG no-rinse cloths for preoperative skin prep, CHG with alcohol for intraoperative skin prep, and appropriate instrument sterilization management led to reductions in SSI rates in patients undergoing C-section at our institution. Rates of endometritis were also noted to be lower after implementation of the interventions.

Section snippets

Methods

The University of Minnesota Medical Center, Fairview, is a teaching hospital with 1868 licensed beds. At the time of the intervention in this facility, the historical rates of SSI after C-section were from 1% to 8%, which is higher than the benchmarks set by the National Nosocomial Infections Surveillance System index (NNIS index). Of note, at the time of this intervention, the NNIS provided our benchmarks; however, benchmarks are now provided by the National Health Safety Network. In response

Sample size

With data from over 400 procedures in each time period, there was adequate statistical power to detect an absolute difference of more than 4.5% as statistically significant with an α level of 5% and a β level of 20%.

Statistical analysis

The χ2 test was used to assess the change in the SSI rate from 2006 to 2007. Counts per procedures were presented as the SSI rates. In addition, the test statistics and P values were reported. A P value less than or equal to an α level of .05 was considered statistically significant.

Discussion

Interventions, including staff education, use of CHG no-rinse cloths for preoperative skin preparation, CHG with alcohol for intraoperative skin preparation, and appropriate instrument sterilization management, led to a significant reduction in SSI rates in patients undergoing C-section at our institution. Of note, the incisional infection rate fell to 0 immediately after initiating use of the 2% CHG no-rinse cloth skin preparation protocol in August of 2006. We also noted a rapid reduction in

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