Pediatric hospital uses postoperative care bundle to reduce SSIs in cardiac patients

Surgical site infections (SSIs) are a serious concern for pediatric patients who undergo cardiac surgery. SSIs can range from superficial skin infections to more serious organ tissue infections, which can lead to morbidity or death.* A study published in the March issue of The Joint Commission Journal on Quality and Patient Safety details how Lucile Packard Children’s Hospital Stanford, Palo Alto, CA, reduced its rate of cardiac SSIs in pediatric patients by 74 percent by implementing a postoperative care bundle.

The study, “A postoperative care bundle reduces surgical site infections in pediatric patients undergoing cardiac surgeries,” by Caruso and colleagues determined the incidence of SSI was 3.4 percent in January 2013 to May 2015 among pediatric patients undergoing cardiac surgery. SSIs appeared to be related to a variety of factors, such as prolonged cardiopulmonary bypasses and delayed sternal closures, and most of their cardiac patients developed SSIs 10 to 30 days after the operation.

Keys to avoiding SSI

With the intent to decrease this rate of infection at Lucile Packard—a 311-bed pediatric academic center with a 20-bed cardiovascular intensive care unit (CVICU)—the authors created a multidisciplinary team (including surgeons, hospital quality management team members, cardiovascular intensivists, infectious disease physicians, pharmacists, anesthesiologists, and nurses) tasked with addressing the following five key drivers for reducing SSIs postoperatively:

  • Maintenance of clean postoperative site
  • Optimization of clinician electronic medical record interface
  • Maintenance of clean intensive care unit environment
  • Minimization of patient exposure to fomites
  • Consistent adherence to antimicrobial best practices

The study authors also developed a bundle of the following 11 postoperative elements to reduce the risk of SSIs:

  • Use postoperative chlorhexidine gluconate wipes daily
  • Change postoperative linen and gown daily
  • Remove dressing within 48 hours of procedure using the aseptic technique
  • Cover the incision site when at risk for contamination
  • Adhere to sterile environment standards during procedures performed in the CVICU, including appropriate attire
  • Perform echocardiograms in a sterile fashion
  • Minimize sternotomy exposure to home blankets
  • Appropriately document the state of the wound
  • Appropriately swab wounds to test for infections
  • Give the first postoperative antibiotic at appropriate time and dose
  • Continue the postoperative antibiotic at appropriate time and dose for 24 hours

Successful outcomes

The investigators sought to reduce the hospital’s cardiac SSIs by 50 percent in one year, from 3.4 to 1.7 per 100 procedures. They implemented the care bundle in June 2015 and recorded data through March 2017.

During that time, SSIs decreased at Lucile Packard—from 27 SSIs in 799 pediatric cardiac operations to 5 in 570 procedures (0.9 percent)—a decrease in SSI incidence of 74 percent. Given the results, the authors concluded that the care bundle effectively and sustainably reduced the risk of SSIs during prolonged CVICU recoveries from pediatric cardiac surgery.

The article by Caruso and colleagues will be open access on The Joint Commission Journal on Quality and Patient Safety’s website until July 31.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Centers for Disease Control and Prevention. Surgical site infection (SSI). Available at: Accessed May 16, 2019.

Caruso TJ, Wang EY, Schwenk H, et al. A postoperative care bundle reduces surgical site infections in pediatric patients undergoing cardiac surgeries. Jt Comm J Qual Pat Saf. 2019;45(3):156-163. Available at: Accessed May 16, 2019.

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