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Risk Stratification and Care Bundle Approach including Endoscopic Vein Harvesting Reduces Sternal and Donor Site Infection Rates to 0%
Rashmi Yadav, Melissa Rochon, Terri Ann Russell, Cesare Quarto, Richard Trimlett, Anthony DeSouza.
Royal Brompton Hospital, London, United Kingdom.

OBJECTIVE: Surgical Site Infection (SSI) after Coronary Artery Bypass Surgery causes significant morbidity but to date there is lack of a risk stratification tool to identify patients at high risk of SSI. We report a risk stratification model developed at our institution, and externally validated at three further institutions. The risk stratification model was used to focus our efforts at reduction of SSI at the highest risk group.
METHODS: The Brompton Harefield Infection Score (BHIS) was developed using binary logistic regression analysis to identify independent predictors of SSI in CABG patients. Area under Receiver Operating Characteristic (ROC) for the model was 0.727. A series of "care-bundle" interventions were targeted at patients identified by the BHIS score as high risk. These included extended preoperative antibacterial wash, endoscopic vein harvesting, modified sternal closure, extended antibiotic prophylaxis, negative pressure wound therapy (PICO) and patient involvement in self-care using wound photographs at hospital discharge.
RESULTS: Diabetes, HbA1c >7.5%, body mass index>3, female gender, left ventricular ejection fraction<45% and emergency surgery were identified as independent risk factors for SSI. Patients with score of 4 or more were identified as high-risk with a predicted SSI risk in excess of 16%. Concerted effort was made to implement the care-bundle approach for high-risk patients belonging to two consultant firms. Remainders of patients in the institution were treated routinely. Between October 2013 and October 2015, in the high-risk group (n=29) treated with the care-bundle approach, the SSI rate was reduced to 0%. In the same time period, SSI rate in high-risk patients not treated with the care-bundle approach was 12.5% (7 out of 56). The difference between the two groups did not reach statistical significance (p=0.08 by Fisher's exact test).
CONCLUSIONS: The BHIS score identified high-risk patients for SSI, in whom a targeted multidisciplinary care-bundle approach was successfully implemented. While the data are not statistically significant, the abolition of sternal and leg wound infections in the highest risk group had a great impact on Quality Improvement for our patients. This model and treatment approach warrants further validation because of its potential to have significant impact on SSI post CABG.

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