Introduction of a care bundle effectively and sustainably reduces patient-reported surgical site infection in patients undergoing colorectal surgery

Published:April 11, 2020DOI:



      Surgical site infection (SSI) is one of the most common healthcare-associated infections and is particularly prevalent following colorectal surgery. It is associated with an increase in patient morbidity and healthcare costs. SSI is difficult to monitor as it frequently presents after discharge from hospital, especially if enhanced recovery programmes are in place.


      To develop an effective method for measuring patient-reported 30-day SSI in patients undergoing colorectal resection. To implement a new care bundle capable of delivering a sustainable reduction in SSI.


      The Public Health England SSI surveillance questionnaire was used. Several data collection methods were tested including postal and telephone-based systems. A new SSI bundle was introduced in our centre incorporating four evidence-based interventions: 2% chlorhexidine skin preparation; repeat-dose antibiotics after 4 h; dual-ring wound protectors; and triclosan-coated sutures for wound closure. System changes were introduced to ensure that the change was sustainable.


      The most reliable method of measuring patient-reported SSI was found to be postal questionnaire with telephone calls made to non-responders. Response rates to the SSI surveillance questionnaire were consistently >75%. Introduction of the new care bundle produced a significant reduction in SSI from 20% to 10% (P ≤ 0.0001) which has been sustained for six years.


      This is a reliable method for measuring 30-day patient-reported SSI rates. The introduction of this new care bundle has halved the rate of SSI from 20% to 10%.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hospital Infection
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hübner M.
        • Diana M.
        • Zanetti G.
        • Eisenring M.-C.
        • Demartines N.
        • Troillet N.
        Surgical site infections in colon surgery.
        Arch Surg. 2011; 146: 1240
        • Kalakouti E.
        • Simillis C.
        • Pellino G.
        • Mughal N.
        • Warren O.
        • Mills S.
        • et al.
        Characteristics of surgical site infection following colorectal surgery in a tertiary center: extended-spectrum β-lactamase-producing bacteria culprits in disease.
        Wounds. 2017; 30: 108-113
        • Humphreys H.
        • Newcombe R.G.
        • Enstone J.
        • Smyth E.T.M.
        • McIlvenny G.
        • Fitzpatrick F.
        • et al.
        Four Country Healthcare Associated Infection Prevalence Survey 2006: risk factor analysis.
        J Hosp Infect. 2008; 69: 249-257
        • Broex E.C.J.
        • van Asselt A.D.I.
        • Bruggeman C.A.
        • van Tiel F.H.
        Surgical site infections: how high are the costs?.
        J Hosp Infect. 2009; 72: 193-201
        • Jenks P.J.
        • Laurent M.
        • McQuarry S.
        • Watkins R.
        Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital.
        J Hosp Infect. 2014; 86: 24-33
        • Wick E.C.
        • Shore A.D.
        • Hirose K.
        • Ibrahim A.M.
        • Gearhart S.L.
        • Efron J.
        • et al.
        Readmission rates and cost following colorectal surgery.
        Dis Colon Rectum. 2011; 54: 1475-1479
        • Sandy-Hodgetts K.
        • Carville K.
        • Leslie G.D.
        Determining risk factors for surgical wound dehiscence: a literature review.
        Int Wound J. 2015; 12: 265-275
        • Itatsu K.
        • Yokoyama Y.
        • Sugawara G.
        • Kubota H.
        • Tojima Y.
        • Kurumiya Y.
        • et al.
        Incidence of and risk factors for incisional hernia after abdominal surgery.
        Br J Surg. 2014; 101: 1439-1447
        • Kirkland K.B.
        • Briggs J.P.
        • Trivette S.L.
        • Wilkinson W.E.
        • Sexton D.J.
        The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.
        Infect Control Hosp Epidemiol. 1999; 20: 725-730
        • Astagneau P.
        • Rioux C.
        • Golliot F.
        • Brücker G.
        Morbidity and mortality associated with surgical site infections: results from the 1997–1999 INCISO surveillance.
        J Hosp Infect. 2001; 48: 267-274
        • Kobayashi M.
        • Mohri Y.
        • Inoue Y.
        • Okita Y.
        • Miki C.
        • Kusunoki M.
        Continuous follow-up of surgical site infections for 30 days after colorectal surgery.
        World J Surg. 2008; 32: 1142-1146
        • Tanner J.
        • Khan D.
        • Aplin C.
        • Ball J.
        • Thomas M.
        • Bankart J.
        Post-discharge surveillance to identify colorectal surgical site infection rates and related costs.
        J Hosp Infect. 2009; 72: 243-250
        • Serra-Aracil X.
        • García-Domingo M.I.
        • Parés D.
        • Espin-Basany E.
        • Biondo S.
        • Guirao X.
        • et al.
        Surgical site infection in elective operations for colorectal cancer after the application of preventive measures.
        Arch Surg. 2011; 146: 606
        • Ikeda A.
        • Konishi T.
        • Ueno M.
        • Fukunaga Y.
        • Nagayama S.
        • Fujimoto Y.
        • et al.
        Randomized clinical trial of oral and intravenous versus intravenous antibiotic prophylaxis for laparoscopic colorectal resection.
        Br J Surg. 2016; 103: 1608-1615
        • Public Health England
        Surveillance of surgical site infections in NHS hospitals in England: 2016 to 2017.
        PHE, London2017 (Available at:) ([last accessed April 2020])
        • Abercrombie J.
        General surgery GIRFT programme national specialty report.
        2017 (Available at:) ([last accessed April 2020])
        • National Institute for Health and Care Excellence
        Surgical site infection: prevention and treatment of surgical site infection.
        NICE Clinical Guideline. 2008; 74 ([updated and replaced by NICE guideline NG125])
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • Lipsitz S.R.
        • Breizat A.-H.S.
        • Dellinger E.P.
        • et al.
        A surgical safety checklist to reduce morbidity and mortality in a global population.
        N Engl J Med. 2009; 360: 491-499
        • Weiser T.G.
        • Haynes A.B.
        • Dziekan G.
        • Berry W.R.
        • Lipsitz S.R.
        • Gawande A.A.
        • et al.
        Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.
        Ann Surg. 2010; 251: 976-980
        • Harrington P.
        • Wloch C.
        • Elgohari S.
        • Lamagni T.
        Protocol for the surveillance of surgical site infection, version 6.
        • Darouiche R.O.
        • Wall M.J.
        • Itani K.M.F.
        • Otterson M.F.
        • Webb A.L.
        • Carrick M.M.
        • et al.
        Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis.
        N Engl J Med. 2010; 362: 18-26
        • Lee I.
        • Agarwal R.K.
        • Lee B.Y.
        • Fishman N.O.
        • Umscheid C.A.
        Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection.
        Infect Control Hosp Epidemiol. 2010; 31: 1219-1229
        • Noorani A.
        • Rabey N.
        • Walsh S.R.
        • Davies R.J.
        Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery.
        Br J Surg. 2010; 97: 1614-1620
        • Edwards J.P.
        • Ho A.L.
        • Tee M.C.
        • Dixon E.
        • Ball C.G.
        Wound protectors reduce surgical site infection.
        Ann Surg. 2012; 256: 53-59
        • Zhang M.-X.
        • Sun Y.-H.
        • Xu Z.
        • Zhou P.
        • Wang H.-X.
        • Wu Y.-Y.
        Wound edge protector for prevention of surgical site infection in laparotomy: an updated systematic review and meta-analysis.
        ANZ J Surg. 2015; 85: 308-314
        • Mihaljevic A.L.
        • Müller T.C.
        • Kehl V.
        • Friess H.
        • Kleeff J.
        Wound edge protectors in open abdominal surgery to reduce surgical site infections: a systematic review and meta-analysis.
        PLoS One. 2015; 10e0121187
        • Zhang L.
        • Elsolh B.
        • Patel S.V.
        Wound protectors in reducing surgical site infections in lower gastrointestinal surgery: an updated meta-analysis.
        Surg Endosc. 2018; 32: 1111-1122
        • Fujita S.
        • Saito N.
        • Yamada T.
        • Takii Y.
        • Kondo K.
        • Ohue M.
        • et al.
        Randomized, multicenter trial of antibiotic prophylaxis in elective colorectal surgery.
        Arch Surg. 2007; 142: 657
        • Galal I.
        • El-Hindawy K.
        Impact of using triclosan-antibacterial sutures on incidence of surgical site infection.
        Am J Surg. 2011; 202: 133-138
        • Rasić Z.
        • Schwarz D.
        • Adam V.N.
        • Sever M.
        • Lojo N.
        • Rasić D.
        • et al.
        Efficacy of antimicrobial triclosan-coated polyglactin 910 (Vicryl∗ Plus) suture for closure of the abdominal wall after colorectal surgery.
        Coll Antropol. 2011; 35: 439-443
        • Nakamura T.
        • Kashimura N.
        • Noji T.
        • Suzuki O.
        • Ambo Y.
        • Nakamura F.
        • et al.
        Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: a randomized controlled trial.
        Surgery. 2013; 153: 576-583
        • Singh A.
        • Bartsch S.M.
        • Muder R.R.
        • Lee B.Y.
        An economic model: value of antimicrobial-coated sutures to society, hospitals, and third-party payers in preventing abdominal surgical site infections.
        Infect Control Hosp Epidemiol. 2014; 35: 1013-1020
        • Guo J.
        • Pan L.-H.
        • Li Y.-X.
        • Yang X.-D.
        • Li L.-Q.
        • Zhang C.-Y.
        • et al.
        Efficacy of triclosan-coated sutures for reducing risk of surgical site infection in adults: a meta-analysis of randomized clinical trials.
        J Surg Res. 2016; 201: 105-117
        • Pinkney T.D.
        • Calvert M.
        • Bartlett D.C.
        • Gheorghe A.
        • Redman V.
        • Dowswell G.
        • et al.
        Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomized controlled trial (ROSSINI Trial).
        BMJ. 2013; 347: f4305
        • Bull A.
        • Wilson J.
        • Worth L.J.
        • Stuart R.L.
        • Gillespie E.
        • Waxman B.
        • et al.
        A bundle of care to reduce colorectal surgical infections: an Australian experience.
        J Hosp Infect. 2011; 78: 297-301
        • Wick E.C.
        • Hobson D.B.
        • Bennett J.L.
        • Demski R.
        • Maragakis L.
        • Gearhart S.L.
        • et al.
        Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.
        J Am Coll Surg. 2012; 215: 193-200
        • Cima R.
        • Dankbar E.
        • Lovely J.
        • Pendlimari R.
        • Aronhalt K.
        • Nehring S.
        • et al.
        Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program-driven multidisciplinary single-institution experience.
        J Am Coll Surg. 2013; 216: 23-33
        • Keenan J.E.
        • Speicher P.J.
        • Thacker J.K.M.
        • Walter M.
        • Kuchibhatla M.
        • Mantyh C.R.
        The preventive surgical site infection bundle in colorectal surgery – an effective approach to surgical site infection reduction and health care cost savings.
        JAMA Surg. 2014; 149: 1045
        • Weiser M.R.
        • Gonen M.
        • Usiak S.
        • Pottinger T.
        • Samedy P.
        • Patel D.
        • et al.
        Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections.
        Br J Surg. 2018; 105: 1680-1687
        • Tanner J.
        • Padley W.
        • Assadian O.
        • Leaper D.
        • Kiernan M.
        • Edmiston C.
        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: 66-77
        • Anderson D.J.
        • Podgorny K.
        • Berríos-Torres S.I.
        • Bratzler D.W.
        • Dellinger E.P.
        • Greene L.
        • et al.
        Strategies to prevent surgical site infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 605-627
        • Petherick E.S.
        • Dalton J.E.
        • Moore P.J.
        • Cullum N.
        Methods for identifying surgical wound infection after discharge from hospital: a systematic review.
        BMC Infect Dis. 2006; 6: 170
        • Macefield R.C.
        • Reeves B.C.
        • Milne T.K.
        • Nicholson A.
        • Blencowe N.S.
        • Calvert M.
        • et al.
        Development of a single, practical measure of surgical site infection (SSI) for patient report or observer completion.
        J Infect Prev. 2017; 18: 170-179
        • Bluebelle Study Group
        Validation of the Bluebelle Wound Healing Questionnaire for assessment of surgical-site infection in closed primary wounds after hospital discharge.
        Br J Surg. 2019; 106: 226-235
        • Gustafsson U.O.
        • Scott M.J.
        • Schwenk W.
        • Demartines N.
        • Roulin D.
        • Francis N.
        • et al.
        Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
        World J Surg. 2013; 37: 259-284
        • Nygren J.
        • Thacker J.
        • Carli F.
        • Fearon K.C.H.
        • Norderval S.
        • Lobo D.N.
        • et al.
        Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
        World J Surg. 2013; 37: 285-305
        • Chen M.
        • Song X.
        • Chen L.
        • Lin Z.
        • Zhang X.
        Comparing mechanical bowel preparation with both oral and systemic antibiotics versus mechanical bowel preparation and systemic antibiotics alone for the prevention of surgical site infection after elective colorectal surgery.
        Dis Colon Rectum. 2016; 59: 70-78
        • Toh J.W.T.
        • Phan K.
        • Hitos K.
        • Pathma-Nathan N.
        • El-Khoury T.
        • Richardson A.J.
        • et al.
        Association of mechanical bowel preparation and oral antibiotics before elective colorectal surgery with surgical site infection.
        JAMA Netw Open. 2018; 1e183226
        • McSorley S.T.
        • Steele C.W.
        • McMahon A.J.
        Meta-analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical-site infection.
        Br J Surg Open. 2018; 2: 185-194
        • Carmichael J.C.
        • Keller D.S.
        • Baldini G.
        • Bordeianou L.
        • Weiss E.
        • Lee L.
        • et al.
        Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons.
        Dis Colon Rectum. 2017; 60: 761-784
        • World Health Organization
        Global guidelines for the prevention of surgical site infection.
        2016 (Available at:) ([last accessed April 2020])
        • National Institute for Health and Care Excellence
        Surgical site infections: prevention and treatment. NICE Guideline NG125.
        2019 (Available at:) ([last accessed April 2020])
        • Vignaud M.
        • Paugam-Burtz C.
        • Garot M.
        • Jaber S.
        • Slim K.
        • Panis Y.
        • et al.
        Comparison of intravenous versus combined oral and intravenous antimicrobial prophylaxis (COMBINE) for the prevention of surgical site infection in elective colorectal surgery: study protocol for a multicentre, double-blind, randomised controlled clinical trial.
        BMJ Open. 2018; 8e020254
        • Deery S.E.
        • Cavallaro P.M.
        • McWalters S.T.
        • Reilly S.R.
        • Bonnette H.M.
        • Rattner D.W.
        • et al.
        Colorectal surgical site infection prevention kits prior to elective colectomy improve outcomes.
        Ann Surg. 2019 Jan 24; ([online ahead of print])