Download PDF
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 
1   Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
,
Jason G. Umans
1   Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia
2   Department of Medicine, Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia
3   Department of Obstetrics and Gynecology, Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia
› Author Affiliations
Further Information

Publication History

13 January 2019

02 April 2019

Publication Date:
14 May 2019 (online)

Also available at
    Permissions and Reprints

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

Note

This paper was presented in part as an oral presentation (#54) at the Society for Maternal-Fetal Medicine 39th Annual Pregnancy Meeting, February 11–16, 2019, Las Vegas, NV.


 

  • 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
    PubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 8 Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004; 103 (5 Pt 1): 907-912
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 11 American Institute for Economic Research. Cost of Living Calculator. Available at: https://www.aier.org/cost-living-calculator . Accessed February 20, 2019
    PubMed
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 17 Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Matern Health Neonatol Perinatol 2017; 3: 12
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 21 Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2011; (11) CD004122
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 23 Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database Syst Rev 2008; (03) CD004737
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Google Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar