Improving Implementation of Evidence-based Approaches and Surveillance to Prevent Bacterial Transmission and Infection
Improving Implementation of Evidence-based Approaches and Surveillance to Prevent Bacterial Transmission and Infection
Surgical site infections (SSIs) are associated with increased patient morbidity, mortality,
 and healthcare costs. ESKAPE (Enterococcus, S. aureus, Klebsiella, Acinetobacter,
 Pseudomonas, and Enterobacter spp.) pathogens are particularly pathogenic because they have
 increased capacity to acquire resistance and virulence traits. We have proven that a
 multifaceted program involving improved basic perioperative preventive measures can generate
 substantial reductions in S. aureus transmission and significant reductions in SSIs (88%
 reduction as compared to usual care). In this study, we aim to examine the relative
 effectiveness of each component of this program in controlling ESKAPE transmission and
 reducing SSIs and to identify an optimal implementation strategy for national dissemination.
 This work will improve perioperative patient safety for the 51 million patients who undergo
 surgery each year.
We propose to test the implementation of a multifaceted, evidence-based, peri-operative
 surgical site infection (SSI) preventive program that leverages basic preventive measures
 optimized by pathogen cluster detection software (surveillance) to reduce ESKAPE
 (Enterococcus, S. aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp.)
 transmission and SSIs. SSIs increase patient morbidity, prolong hospitalization, and increase
 the risk of death. ESKAPE pathogens are particularly problematic because they have increased
 capacity to acquire resistance and virulence traits. For example, S. aureus explains a
 significant proportion of SSIs. S. aureus transmission can be detected in 39% of surgical
 cases, has been directly linked to up to 50% of S. aureus SSIs by single nucleotide variant
 analysis, and is tightly associated with SSI development across a variety of surgical
 specialties. The isolation of ≥ 1 KAPE isolate from ≥ 1 intraoperative reservoir is
 associated with increased risk of infection development. We have proven that improvements in
 basic perioperative preventive measures can generate substantial and sustained reductions in
 perioperative S. aureus transmission and SSIs, with the magnitude of the effect exceeding
 that of SSI preventive efforts focused on host optimization and inhibition of bacterial
 virulence strategies, the status quo. However, perioperative application of these basic
 preventive measures has been inconsistent, and some evidence suggests that S. aureus explains
 20% of SSIs. Thus, there remains room for further advancement in perioperative infection
 control by addressing other ESKAPE organisms and by delineating an implementation approach
 that will yield effective, national dissemination of these proven measures. Our planned
 approach to address these pathogens mirrors our approach for perioperative S. aureus control,
 integrating evidence-based provider hand hygiene, intravascular catheter design/handling,
 environmental cleaning/organization, and patient decolonization improvement strategies with
 surveillance. Our surveillance approach maps the epidemiology of transmission of each
 pathogen, identifying for example, reservoirs of origin that become improvement targets for
 sustainability. While this approach is proven effective in preventing perioperative S. aureus
 transmission and SSIs, the relative effectiveness of the various components of the
 multi-faceted approach in reducing ESKAPE transmission and associated SSIs, as well as an
 effective national dissemination strategy, remain unknown. Therefore, our overall objectives
 for this study are to examine the relative effectiveness of each programmatic component in
 controlling ESKAPE spread and associated SSIs and to identify the best approach for national
 dissemination of this technology. We will use a cluster-randomized design to evaluate the
 implementation and sustainability of each approach guided by PHARIS framework. More broadly,
 these findings will be relevant to supporting hospital's implementation of a wide array of
 preventive interventions and has potential for vastly improving patient care and outcomes.
Site Inclusion and Exclusion Criteria. Five-hundred patients at each participating site
 will be enrolled into the trial with a series of inclusion and exclusion criteria across
 nine service lines including two surgeons per service line. Site Inclusion Criteria: All
 medical centers with an operating room are eligible. Surgeons performing orthopedic total
 joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open
 vascular, plastic, and/or open urological procedures with uniform, baseline infection
 control practices will be recruited (i.e. similar decolonization and dressing change
 practices for orthopedic spine surgeons between sites) as done previously. Exclusion
 Criteria: medical centers actively enrolling patients in a bacterial transmission or
 infection prevention trial will be excluded. We currently have 12 sites enrolled that have
 met the inclusion and exclusion criteria with engaged surgeons. Patient Inclusion Criteria:
 all elective patients undergoing surgery with the surgeons and procedures and uniform basic
 practices as described above, at least one incision (including laparotomy), placement of a
 peripheral intravenous catheter, and acquiring informed, written consent. Exclusion
 Criteria: no requirement for anesthesia and/or placement of a peripheral intravenous
 catheter, lack of incision or informed, written consent, an allergy to chlorhexidine,
 povidone iodine or isopropyl alcohol, and ASA health classification status>5.