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Surgery. 2014 Apr;155(4):602-6. doi: 10.1016/j.surg.2013.12.004. Epub 2013 Dec 14.

Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery.

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Department of Surgery, University of Michigan, Ann Arbor, MI.
Department of Surgery, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, Ann Arbor, MI.
Department of Surgery, University of Michigan, Ann Arbor, MI. Electronic address:



Surgical site infection (SSI) remains a costly and morbid complication after colectomy. The primary objective of this study was to investigate whether a group of perioperative care measures previously shown to be associated with reduced SSI would have an additive effect in SSI reduction. If so, this would support the use of an "SSI prevention bundle" as a quality improvement intervention.


Data from 24 hospitals participating in the Michigan Surgical Quality Collaborative were included in the study. The main outcome measure was SSI. Hierarchical logistic regression was used to account for clustering of patients within hospitals.


In total, 4,085 operations fulfilled inclusion criteria for the study (Current Procedural Terminology codes 44140, 44160, 44204, and 44205). A "bundle score" was assigned to each operation, based on the number of perioperative care measures followed (appropriate Surgical Care Improvement Project-2 antibiotics, postoperative normothermia, oral antibiotics with bowel preparation, perioperative glycemic control, minimally invasive surgery, and short operative duration). There was a strong stepwise inverse association between bundle score and incidence of SSI. Patients who received all 6 bundle elements had risk-adjusted SSI rates of 2.0% (95% confidence interval [CI], 7.9-0.5%), whereas patients who received only 1 bundle measure had SSI rates of 17.5% (95% CI, 27.1-10.8%).


This multi-institutional study shows that patients who received all 6 perioperative care measures attained a very low, risk-adjusted SSI rate of 2.0%. These results suggest the promise of an SSI reduction intervention for quality improvement; however, prospective research are required to confirm this finding.

[Indexed for MEDLINE]

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