Development of Interventions for Reducing Surgical Site Infection in Pediatric Cardiac Surgery: A Case Study of Michigan Medicine Open Access

Abstract

Background: Hospital acquired infections (HAI) contribute to significant morbidity, mortality, and healthcare-associated costs. Among HAI, surgical site infections (SSI) are the most difficult to manage, especially in children. Children’s immune systems are still developing and pediatric patients undergoing cardiac surgery are a particularly vulnerable subpopulation. There is a need to develop SSI prevention recommendations targeted for pediatric patient populations that are adaptable for individual patient and surgical contexts. Purpose: This case study, aimed to: 1) document the process of developing a bundle of interventions for SSI prevention for pediatric surgery patients and 2) evaluate the impact of this intervention bundle on SSI rates among pediatric surgery patients at C.S. Mott Children’s Hospital. Method: The development of interventions involved  5 steps: 1) forming an expert panel, 2) developing a process map outlining the current state of care and  identify gaps leading to SSI, 3) developing an impact-effort matrix and prioritizing areas for intervention, 4) developing a root cause analysis that identifies the underlying causes of SSI and 5) developing and implementing a bundle of interventions to reduce SSI. A process evaluation was conducted to evaluate if process measure targets were met and measure the overall change in SSI rates. An evaluation of adherence to the bundle of interventions was conducted at 1 month and 6 months post-implementation, to determine the efficacy of the developed intervention bundle. Results: This case study documents the process of developing and implementing a bundle of 17 interventions.  High fidelity to the interventions was shown with 100% of process measure targets with 86% adherence measures met. For SSI rates, a 47% decrease was observed relative to pre-intervention baseline SSI rates. Discussion: This case study demonstrates the feasibility of the process of intervention development for other clinical areas of hospitals or target populations (pediatric, adult, underserved etc.). Aspects of the development process can also be used to manage resource allocation and prioritization of interventions, which is important with increasing healthcare costs. Conclusion: This study documents the successful development and implementation of a bundle of interventions targeted at attenuating SSI rates in pediatric cardiology patients at CS Mott Children’s Hospital. Future work should be done to further evaluate the efficacy of interventions as well as applying the intervention development process to other clinical settings.

Table of Contents

Table of Contents

Table of Contents…………………………………..………………...………………………........…7

List of Figures……………….…………………………………………………….......…………..…...8

List of Acronyms…………………………………………………...…………….......…………….….8

1.    Background…………..………………………………………………………......…………….....9

2.  Current Recommendations to Prevent SSI………………………………......……………...11

           2.1  Preoperative Period…………………………………..…………..…......……………..12

           2.2  Intraoperative Period…………………………………………………........…………..12

           2.3  Postoperative Period……………………………………………………......…………..13

3.  Case Study Site: Michigan Medicine………………………………….…………......……..…14

4.  Statement of Purpose……………………………………….………………………......…...…..15

5.  Documentation of Intervention Development Process………………...……......……….15

           5.1  Step I: Creating an Expert Panel………………………………......…………..……..16

           5.2  Step II: Developing a Process Map…………………………………………….......….16

           5.3  Step III: Ranking Critical Areas for Intervention via Impact-Effort Matrix.....20

           5.4  Step IV: Root Cause Analysis………………………………………………….....…....21

           5.5  Step V: Development of Interventions………………………………………..……...23

           5.6  Implementation of Interventions………………………………………….……...…..24

           5.7  Assessing Efficacy of Interventions…………………………………………….….....25

           5.8  Evaluation of Intervention Bundle………………....…………………………………25

6.  Discussion………………………………………………………….........…………………..……..27

7.  Conclusion…………………………………………………………………..........…..…………….34

References……………………………………………………………………………….........………..35

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Sustainability Health Sciences, Surgery
Keyword	Intervention Development Cardiology Pediatrics Surgical Site Infection Sustainability
Committee Chair / Thesis Advisor	Monique Hennink, Emory University
Committee Members	Scott Fridkin, Emory University

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