The Combination of Accurate Documentation and Clean Closure Protocol Decreases the Rate of Deep-SSI in Colon Surgery

Author(s):
Ricardo Fonseca; Deirdre Epstein; Melissa Canas; Leonardo Diaz; Hussain Afzal; Michael Alchaer; Douglas J Schuerer; Grant Bochicchio; Obeid Ilahi

Background:

Colorectal Surgery has a substantial risk of surgical site infection (SSI), from 3% to 40%. Bacterial inoculum within the intra-abdominal space can lead to peritonitis, with contamination of the incision. This results in morbidity, mortality, and increased healthcare costs. Current risk models, shaped by the analysis of SSIs, highlight the importance of proper documentation of infection present at the time of surgery (PATOS). However, the specific impact of PATOS on outcomes in colon surgery patients is unresolved.

Hypothesis:

We hypothesize that the use of proper PATOS documentation can reduce the reported incidence of deep-SSI in patients undergoing colonic surgery.

Methods:

Prospective data were collected on all patients undergoing colon surgery on Acute and Critical Care Surgery service during 2023. Analysis of this data was performed on cases with a CDC Class IV dirty-infected surgical wound to compare the incidence of reported deep-SSI. Faculty were educated on terminology that is required by NHSN (National Healthcare Safety Network) to demonstrate PATOS. Cohorts were divided into Pre-PATOS (Jan-Jun 2023) and Post-PATOS (Aug-Dec 2023). July 2023 cases were excluded due to PATOS implementation rollout education. Data included demographics, clinical management, microbiology results, and outcomes. The incidence of SSI was calculated as # of SSI cases (confirmed by infectious diseases) ÷ # of colonic surgical interventions. Documentation of Clean Closure protocol and PATOS from operative notes was analyzed.

Results:

In 2023, a total of 165 colonic surgical interventions were performed. The overall deep-SSI rate for colonic procedures was 2.8% (n=5). Pre-PATOS, 92 colonic procedures were performed (15.3 cases/month) with a deep-SSI rate of 4.3% (n=4). Post-PATOS, 65 colonic procedures were performed (13 cases/month), without any deep-SSI reported during this period (n=0). Appropriate documentation of infection was found in 73.8% of post-PATOS cases.

Conclusions:

Implementation of PATOS documentation and initiation of clean closure protocol during colonic surgical interventions significantly reduced the rate of reported deep-SSI. A proactive faculty education on documentation requirements based on NHSN updates on SSI reporting is warranted. An accurate diagnosis of SSI is essential.