NO BUGS: Nosocomial operative best-practices for unplanned infections in gynecologic surgery: A 6-month retrospective.
Authors: Aliabadi Arya , Malone Allyson , Johnson Caitlin Ruth , Cohen Joshua Garrett , Chan John K , Lai Tiffany , Karlan Beth Y. , Salani Ritu 
Published: June 2023

e18765

Background: An estimated 94,000 women have newly diagnosed gynecologic cancer (ovarian, uterine, cervical, and vulvovaginal) annually–with rates increasing over the last 20 years. Surgical site infections (SSIs) complicate up to 4% of all hysterectomies in the United States. Other surgical sequelae, such as operative length, estimated blood loss, wound dehiscence, and 30-day readmission, further complicate the post-surgical course of this vulnerable population. Methods: A quality improvement initiative was conducted in a large academic health system between January to June 2022 to investigate whether implementing an SSI bundle, defined as a set of 11 evidence-based practices performed collaboratively, can reduce intraoperative and postoperative complications. The study population included women who received gynecologic oncologic surgery. To evaluate trends following the implementation of an SSI prevention bundle, we studied two time periods: 1/1/22-3/31/22 and 4/1/22-6/30/22. Trends were analyzed using chi-squared and a two-sample t-test. Results: Over our six-month study period, 233 patients underwent primary gynecologic oncologic surgery. Robotic-assisted hysterectomies were the most common (27.89%, n = 65), followed by total abdominal hysterectomies (21%, n = 49), laparoscopic hysterectomies (7.72%, n = 18), and supracervical hysterectomies (3%, n = 7). An invasive, abdominal approach was needed for less than half of the surgeries for whom intraoperative and postoperative outcomes were measured (46.35%, n = 108). Following the implementation of our SSI bundle, there was a rise in estimated blood loss (134.49 to 252.67 mL), operative length (199.24 to 227.23 min), and length of stay (1.58 to 2.20 days). Yet, there was a decline in the SSI rate from 4.62% to 3.7% (p = 0.97) and 30-day all-cause readmission from 12.96% to 7.4% (p < 0.05). The overall incidence of 30-day wound dehiscence also declined over six months from 3.7% to 1.85% (p = 0.74). Upon intersectional analysis, patients with SSI were older (55.93 vs. 62, p = 0.39) and were more likely to be obese (BMI 27.04 vs. 31.06, p < 0.05). Individuals with functional status limitations, ECOG score > 2, had longer lengths of stays (4.7 vs. 1.76 days, p < 0.05), estimated blood loss (230 vs. 185.9 mL, p = 0.12), and operative length (374 vs. 205.2 min, p < 0.001). Those with a supracervical hysterectomy also had a longer length of stays (4 days, p < 0.05), blood loss (921.43 mL, p < 0.001), and operative lengths (315.14 min, p < 0.001). Conclusions: Following the implementation of an evidence-based SSI quality improvement project, cancer patients had fewer SSI, hospital readmissions, and wound dehiscence. High ECOG scores, supracervical hysterectomies, and obesity were all associated with worse postoperative outcomes. Prospective studies on postoperative surgical quality are needed to improve care for our most vulnerable patients.