All right. My name is Rachel Smith and this project was done underneath my mentor Dr. Elizabeth Mack who could not be here today. I'm from the Medical University of South Carolina. I'm a fourth year medical student slated to graduate this upcoming May. There's no disclosures. So for this project we wanted to look at four main prevention bundle factors that historically through evidence-based medicine have shown to reduce surgical site infections in colorectal surgeries. And so we wanted to look specifically in pediatric colorectal surgeries and look at the compliance to these bundle factors. And then based on our rates of compliance we wanted to identify any barriers to compliance and trying to maximize compliance and therefore minimize surgical site infections. So for our objectives, just a brief review of the history and impact of surgical site infections and then looking specifically into the pediatric colorectal SSI bundle. We will discuss the compliance rates that we found at our center and the possible causes that we identified for non-compliance. And then moving forward how we can use this data to make interventions to improve the outcomes. So as we all know SSIs are a major contributor of both morbidity and mortality in our surgical patients in both adults and pediatrics. They have an estimated mortality rate of about 3%. And then annually in the U.S. alone they cause an increased hospital cost of over $3 billion. They also cause an increased length of stay in the hospital, increased need for the ICU and stay in the ICU, and readmission rates to the hospital. And then for the reasons, you know, the environment of the surgery and the contamination risk, the colorectal surgeries have a much higher rate of SSIs which can be upwards of 25%. So the Solutions for Patient Safety is a collaborative that has formed a cohort of children's hospitals across the country, our institution being one of them, where they are trying to make work streams in order to eliminate preventable harm in multiple areas. And one of those is through pediatric colorectal surgery bundle prevention. And so it includes the four main bundles. The first is a perioperative chlorhexidine bath. So this involves the night before or morning of surgery to be scrubbed with a chlorhexidine bath or soap and water if there is an exception for an allergy. And this is in addition to the scrub that is done in the OR prior to incision. Next is antibiotic selection and dose timing for prophylaxis. So in our colorectal surgeries we recommend IV metronidazole and Cefazolin or appropriate equivalents with similar coverage. And based on the data in the past, it's recommended that these doses are given prior to incision. For bowel preparation, it's recommended to give either antibiotic bowel prep or a combination of mechanical and antibiotic bowel prep. And in this case we were using oral metronidazole and oral neomycin. And then lastly for a surgical closing protocol, it involves three separate portions which is when the surgeon is preparing to close, all scrubbed members change their gloves to new clean gloves. There are sterile towels placed around the surgical site. And then all of the instruments are exchanged out that were used during the case for new sterile instruments in order to close. So at our institution we looked at about 16 months' worth of data from January 2021 to April 2022. It included 52 pediatric colorectal surgeries that were performed at this time. 47 of them were strictly colon surgeries and 5 of them were rectal by 7 different operating surgeons. And in order to collect the data in the EMR we used pre- and post-operative notes. And that was mainly to look at if there were certain preferences or contraindications stated by the surgeon for one of the bundle factors. And then also if the closing protocol was documented in the post-op note. Those sheets were used mainly for the pre-operative bath to make sure that that was done prior to the surgery. And then the medication administration record for the bowel preparation and for the antibiotic prophylaxis. And then this was all compiled in order to find the compliance rates. So of the 52 colorectal surgeries we had three documented surgical site infections for an overall rate of 5.8%. However all three of these SSIs occurred in the colon group. So specifically looking at those 47 procedures there was a rate of 6.4%. We also looked at the individual bundle elements for compliance across the surgeries. So the pre-operative chlorhexidine bathing had the highest compliance and was performed 90% of the time. Next was the bowel preparation where using antibiotics alone was 56%. And using a combination of mechanical and antibiotic was 44%. Third was antibiotic selection and dose timing which was 44%. And then the lowest was the use of a surgical closing protocol at 2%. We also looked at the all or none compliance for all four bundle elements for each surgery. And we did have no surgeries that were performed that had all four bundle factors included. So this graph has a combination of all the results that we looked at. So the four sections are broken down for the four bundle factors across the top. And then across the bottom for each one are the seven different performing surgeons. You can see off the bat that the surgeon number 3 performed the most surgeries at 18 compared to surgeon number 7 who only performed one. Along the left are the total prevention factors that we looked at across all the surgeries. So unless there was an exemption for something, each surgery had four opportunities for compliance. So it shows on the left that the green is the compliance and the red is non-compliance. And then along the right is what we already discussed, that the CHG bath on the yellow line had 90% compliance. And then down for the closing protocol only had 2% compliance. So for our observed SSI rate of 6%, this is lower than the national average. And I do think it's because we are one of the hospitals that have employed these four bundle factors. So it is lower and that is beneficial. But we obviously would like our goal to be zero surgical site infections. And then we did have no surgeries that were compliant with all four bundle factors every time. If you exclude the surgical closing protocol because of the low compliance to that, if you just do the other three, it does increase to 29% compliance. And then there is possible underestimating of compliance. And the best two examples of this are for the preoperative CHG bath and the closing protocol. So it's very possible that these were completed but were simply not checked off on the checklist or put in the postoperative note. And especially for the closing protocol, the only place in our system that we can look for it is at the bottom of the surgeon's dictated post-op note. So it's very understandable while they're outlining the procedure that they do not include that. Barriers to compliance, one of the biggest ones we saw was that for antibiotic prophylaxis, many times the correct antibiotic was given, but they were given after first incision. So incision was at 7 a.m., but the antibiotics were given at 7.15 a.m. And while it's very likely that the patients are getting the benefit from these medications and this prophylaxis, based on the pharmacokinetics and all of the previous data, it should be given prior to incision for full effect. And then also proper patient and family education. Again these are pediatric patients. It relies a lot on the family in order to do things such as the antibiotic and mechanical bowel prep. For the surgeries where it was a planned admission, it requires the patient and their family to go pick up these bowel preparations beforehand. And a lot of times maybe they just weren't simply picked up. And then we do point out that there were exceptions for emergent cases. These did not factor into non-compliance because it's not feasible in order to do a preoperative bath or a bowel preparation in an emergent case. So one step that we wanted to take in order to improve compliance and improve our surgical site infection rate was to make surgeon-specific dashboards to anonymously relay this information to each surgeon. So this is an example of one of our surgeon dashboards. And this was for surgeon number 3 who performed the most cases. So on the left it's our department data which included the total surgeries and the number of SSIs for this time period. It also shows that the mean bundle compliance of all of the opportunities to be compliant was 45%, with a range of 34% to 64%. And then the pie chart which shows the distribution of cases with surgeon number 3 in the green performing a large number of the cases. On the right shows the surgeon's specific compliance. So this surgeon had 18 colorectal surgeries and 2 surgical site infections documented. And then underneath for the four bundle factors, the green triangle is obviously our goal at 100% compliance. The yellow was the average for the department and the blue was for this specific surgeon. So this surgeon was slightly below average on the CHG bath, was at average for the surgical closing protocol, but above average for antibiotics and bowel prep. So moving forward, a lot of this has to do with continuing education with staff and not just the surgeons. It involves the surgeons, the nurses that are taking care of the patients, the anesthesia staff, anyone who has an opportunity to educate the families themselves and to work towards meeting these bundle factors in order to reduce our infection rate. We also want to continue communication with the staff to figure out any other barriers to compliance and how we can combat these. And beyond the dashboards for education, we also want to try and improve our user-friendly checklist to make sure that we're documenting it correctly. And also the possibility of adding reminders within the ENMR that can pop up intraoperatively in order to remind people to make sure that everything is given properly at the same time and that closing protocols are in fact done. And that's all. Thank you.

surgical site infections

pediatric colorectal surgeries

compliance rates

preoperative chlorhexidine bath

surgical closing protocol