Surgical Site Infection


This topic is intended to help anyone who is interested in quality improvement surrounding Surgical Site Infection and surgical infection.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

Ostomy Closures

Nationwide Children’s Hospital

Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients resulting in significant morbidity. We previously demonstrated that a GI bundle (e.g. bowel prep, preoperative warming, preoperative cleansing, skin prep and a closing protocol) decreases SSI rates, length of stay (LOS) and hospital charges. Following this success we hypothesized that by targeting the preoperative antibiotics for stoma closure based on organisms found in infected wounds we could further decrease surgical site infection rates.

The recommended strategy for roll out is

  1. Present at faculty meeting; establish consensus around goals to improve compliance
  2. Send out education/announcement emails to current residents (and obtain a schedule of future resident rotations so they can be sent the emails when they begin). This should be part of their orientation day agenda.
  3. Send out templated reminder email to faculty about the current guidelines.
  4. Monthly auditing of targeted cases using templates to ensure adherence to guidelines.
  5. Send out templated emails to faculty and residents for non-compliant cases as a reminder and to assess reasons for non-compliance



List tools, ordersets, what steps you did to accomplish this project. (Index of items
contained in folder)
1. Quarterly quality improvement (QI) meetings
2. Monthly nursing education
3. Faculty education at monthly faculty meetings
5. New resident education sessions
6. Handouts for easy reference

Stakeholders: surgery, QI team, nursing, operating room team

Challenges and solutions: Implementation of the change in preoperative antibiotics led to fewer rates of surgical site infections. We found that our colleagues in anesthesia were amenable to using the antibiotics per colorectal surgery guidelines. We also found that extensive teaching with the nursing staff resulted in accurate order placements preoperatively so that antibiotics were always available for the cases. Since multiple residents from different hospitals rotate through the pediatric surgery service each month, our biggest challenge was resident education. This was accomplished by holding multiple educational sessions every month. We also facilitated this by creating a pocket size handout for easy reference.

Submitted by Hira Ahmad

Skin Preparation

University of Texas Houston

This was a project in attempt to standardize skin prep for all surgical cases. We had significant variation between and within services. This was very confusing for operating room teams as well as not meeting the highest level of evidence. The main hurdle was the ability to use chlorhexidine and cases that was thought to be contraindicated such as infants and the perineum.



Stakeholders: surgical subspecialists, infectious disease/control and operating room personnel including circulating nurses who prepped the patient.

Challenges and solutions: There are a couple of major hurdles to overcome. First, it was difficult to identify the best evidence and practices for our patient population. Although, neonatology had been using chlorhexidine for their procedures, many believed that this product was contraindicated for infants, perineum, and head and neck cases. We did extensive literature review to demonstrate that chlorhexidine was the superior product compared to iodine. Several children’s hospitals were surveyed around the country to identify their best practices. Many of these were consistent. There are no national guidelines or consensus that we could find the literature.

Second, surgeons had to change the way they prepped their patients. There were significant biases. We utilized the evidence as well as imploring the need for standardization. This was overcome through open dialogue and education. Ultimately, we did achieve buy in. Before we implemented any new policy, service lines signed off on the final protocols and policies. We did leverage the surgeon’s desire for a smoother process and better standardization. We identified several significant challenges that were due to cases in the gray zone such as heavy prep and abdomen with an ostomy. We agreed on a set of absolute contraindications which included exposed mucosa, exposed neural elements, open wounds, the face and intravaginal preps.

Finally, we also standardize the logistics of different preps including small babies, head and neck cases and open dirty traumatic wounds. This seemed to help surgeons appreciate and except standardization of preps.

Submitted by KuoJen Tsao


  1. Breckler FD, Rescorla FJ, Billmire DF. Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics. J Pediatr Surg. 2010;45(7):1509-13.  [PMID:20638534]
  2. Bucher BT, Warner BW, Dillon PA. Antibiotic prophylaxis and the prevention of surgical site infection. Curr Opin Pediatr. 2011;23(3):334-8.  [PMID:21494149]
  3. Bucher BT, Guth RM, Elward AM, et al. Risk factors and outcomes of surgical site infection in children. J Am Coll Surg. 2011;212(6):1033-1038.e1.  [PMID:21398150]
  4. Chandramouli B, Srinivasan K, Jagdish S, et al. Morbidity and mortality of colostomy and its closure in children. J Pediatr Surg. 2004;39(4):596-9.  [PMID:15065035]
  5. Feng C, Sidhwa F, Cameron DB, et al. Rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the National Surgery Quality Improvement Program. J Pediatr Surg. 2016;51(6):970-4.  [PMID:27018086]
  6. Nordin AB, Sales SP, Besner GE, et al. Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery. J Pediatr Surg. 2017.  [PMID:29108847]
  7. Porras-Hernandez J, Bracho-Blanchet E, Tovilla-Mercado J, et al. A standardized perioperative surgical site infection care process among children with stoma closure: a before-after study. World J Surg. 2008;32(10):2316-23.  [PMID:18509611]
  8. Tanner J, Padley W, Assadian O, et al. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015;158(1):66-77.  [PMID:25920911]
Last updated: May 7, 2019