Does a Care Bundle Reduce Racial Disparities in Postcesarean Surgical Site Infections?

Tetsuya Kawakita; Jason G. Umans

doi:10.1055/s-0039-1688822

American Journal of Perinatology, Table of Contents

Am J Perinatol 2019; 36(13): 1325-1331
DOI: 10.1055/s-0039-1688822

SMFM Fellowship Series Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Does a Care Bundle Reduce Racial Disparities in Postcesarean Surgical Site Infections?

Tetsuya Kawakita

¹Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia

,

Jason G. Umans

¹Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia

²Department of Medicine, Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia

³Department of Obstetrics and Gynecology, Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia

› Author Affiliations

Abstract

Objective To examine the effect of a care bundle on racial disparities in surgical site infections (SSIs).

Study Design This was a retrospective cohort study of women undergoing cesarean delivery at ≥23 weeks' gestation. The care bundle included routine antibiotics (both cefazolin and azithromycin), chlorhexidine skin preparation, clippers, vaginal cleansing, placental removal by cord traction, subcutaneous tissue closure, suture skin closure, dressing removal in 24 to 48 hours, and postoperative chlorhexidine soap. Our primary outcome was SSI (superficial incisional, deep incisional, and organ/space) occurring up to 6 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) were calculated, adjusting for predefined covariates.

Results Of 2,696 women, 1,947 were black (1,014 in the preimplementation period and 933 in the postimplementation period) and 749 were nonblack (370 in the preimplementation period and 379 in the postimplementation period). Regardless of race, women in the postimplementation period had lower rates of SSI compared with those in the preimplementation period (black: 2.9 vs. 5.2%, aOR: 0.53 [95% CI: 0.33–0.85]; nonblack: 1.1 vs. 3.5%, aOR: 0.28 [95% CI: 0.09–0.89]). There was no interaction by race (p for interaction = 0.94).

Conclusion The care bundle decreased SSI in both black and nonblack women but did not reduce racial disparities.

Keywords

care bundle - cesarean delivery - racial disparities - surgical site infections

Full Text

References

References
1 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018; 67 (01) 1-55
2 Blumenfeld YJ, El-Sayed YY, Lyell DJ, Nelson LM, Butwick AJ. risk factors for prolonged postpartum length of stay following cesarean delivery. Am J Perinatol 2015; 32 (09) 825-832
3 Tita AT, Szychowski JM, Boggess K. , et al; C/SOAP Trial Consortium. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med 2016; 375 (13) 1231-1241
4 Haas DM, Pazouki F, Smith RR. , et al. Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol 2010; 202 (03) 310.e1-310.e6
5 Costantine MM, Rahman M, Ghulmiyah L. , et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008; 199 (03) 301.e1-301.e6
6 Mackeen AD, Khalifeh A, Fleisher J. , et al; CROSS Consortium. Suture compared with staple skin closure after cesarean delivery: a randomized controlled trial. Obstet Gynecol 2014; 123 (06) 1169-1175
7 Peleg D, Eberstark E, Warsof SL, Cohen N, Ben Shachar I. Early wound dressing removal after scheduled cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol 2016; 215 (03) 388.e1-388.e5
8 Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004; 103 (5 Pt 1): 907-912
9 Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991-1997. Obstet Gynecol 2003; 101 (02) 289-296
10 Olsen MA, Butler AM, Willers DM, Gross GA, Fraser VJ. Comparison of costs of surgical site infection and endometritis after cesarean delivery using claims and medical record data. Infect Control Hosp Epidemiol 2010; 31 (08) 872-875
11 American Institute for Economic Research. Cost of Living Calculator. Available at: https://www.aier.org/cost-living-calculator . Accessed February 20, 2019
12 Boggess KA, Tita A, Jauk V. , et al; Cesarean Section Optimal Antibiotic Prophylaxis Trial Consortium. Risk factors for postcesarean maternal infection in a trial of extended-spectrum antibiotic prophylaxis. Obstet Gynecol 2017; 129 (03) 481-485
13 Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health 2006; 96 (12) 2113-2121
14 Green AR, Carney DR, Pallin DJ. , et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007; 22 (09) 1231-1238
15 Jain JA, Temming LA, D'Alton ME. , et al. SMFM Special Report: putting the “M” back in MFM: reducing racial and ethnic disparities in maternal morbidity and mortality: a call to action. Am J Obstet Gynecol 2018; 218 (02) B9-B17
16 Howell EA, Brown H, Brumley J. , et al. Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle. Obstet Gynecol 2018; 131 (05) 770-782
17 Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Matern Health Neonatol Perinatol 2017; 3: 12
18 Kittur ND, McMullen KM, Russo AJ, Ruhl L, Kay HH, Warren DK. Long-term effect of infection prevention practices and case mix on cesarean surgical site infections. Obstet Gynecol 2012; 120 (2 Pt 1): 246-251
19 Tita AT, Hauth JC, Grimes A, Owen J, Stamm AM, Andrews WW. Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis. Obstet Gynecol 2008; 111 (01) 51-56
20 Tuuli MG, Liu J, Stout MJ. , et al. A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med 2016; 374 (07) 647-655
21 Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011; (11) CD004122
22 Haas DM, Morgan S, Contreras K, Enders S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev 2018; 7: CD007892
23 Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database Syst Rev 2008; (03) CD004737
24 Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol 2004; 103 (5 Pt 1): 974-980
25 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. ; Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999; 27 (02) 97-132
26 Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR. 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 (10) 1045-1052
27 Cima R, Dankbar E, Lovely J. , et al; Colorectal Surgical Site Infection Reduction Team. Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program--driven multidisciplinary single-institution experience. J Am Coll Surg 2013; 216 (01) 23-33
28 Johnson MP, Kim SJ, Langstraat CL. , et al. Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery. Obstet Gynecol 2016; 127 (06) 1135-1144
29 Myles TD, Gooch J, Santolaya J. Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery. Obstet Gynecol 2002; 100 (5 Pt 1): 959-964
30 Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health 2011; 32: 399-416
31 Temming LA, Raghuraman N, Carter EB. , et al. Impact of evidence-based interventions on wound complications after cesarean delivery. Am J Obstet Gynecol 2017; 217 (04) 449.e1-449.e9
32 Carter EB, Temming LA, Fowler S. , et al. Evidence-based bundles and cesarean delivery surgical site infections: a systematic review and meta-analysis. Obstet Gynecol 2017; 130 (04) 735-746
33 Colby S, Ortman J. Projections of the Size and Composition of the U.S. Population: 2014 to 2060: Current Population Reports. Washington, DC: US Census Bureau; 2014: P25-P1143
34 Sacco RL, Gardener H, Wang K. , et al; FL-PR CReSD Investigators and Collaborators. Racial-ethnic disparities in acute stroke care in the Florida-Puerto Rico collaboration to reduce stroke disparities study. J Am Heart Assoc 2017; 6 (02) e004073
35 Ravi P, Sood A, Schmid M. , et al. Racial/ethnic disparities in perioperative outcomes of major procedures: results from the National Surgical Quality Improvement Program. Ann Surg 2015; 262 (06) 955-964
36 Aparicio HJ, Carr BG, Kasner SE. , et al. Racial disparities in intravenous recombinant tissue plasminogen activator use persist at primary stroke centers. J Am Heart Assoc 2015; 4 (10) e001877