The effect of care bundle development on surgical site infection after hemiarthroplasty: an 8-year review.
BACKGROUND
Proximal femoral fracture is the most common reason for emergency orthopedic admission in the United Kingdom with an annual cost of £ 1.7 billion to the National Health Service. Surgical site infection (SSI) after proximal femoral fracture increases patient morbidity and mortality. Methicillin-resistant Staphylococcus aureus (MRSA) poses a particular risk in this patient cohort as a large proportion of these patients are residents of long-term care facilities and are therefore transient or chronic carriers of MRSA. We recorded the effect of three stages of care bundle development on the infection and specifically the MRSA rate after hemiarthroplasty over an 8-year period.


METHODS
Data were collated retrospectively from the surgical site infection surveillance service. These data were prospectively collected and independently collated. The data were analyzed using the χ(2) test and the normal test for differences between two proportions.


RESULTS
Between October 2001 and June 2009, 1,830 hemiarthroplasties were performed. A statistically significant difference (p < 0.05) in SSI and MRSA rate was identified. The most effective care bundle included double skin preparation using alcoholic chlorhexidine, a single dose of intravenous co-amoxiclav (1.2 g) and gentamicin (240 mg) at induction, and implanted gentamicin-impregnated equine collagen at wound closure.


CONCLUSIONS
Adoption of our care bundle approach led to a reduction in SSI rate after hemiarthroplasty. The care bundle we propose is tailored to reduce MRSA infection and minimize risks associated with antibiotic prophylaxis. It is a simple and cost-effective improvement in the clinical care of this vulnerable group.


METHODS
IV, therapeutic study.
Department of Trauma and Orthopaedics, University Hospital of North Staffordshire, Stoke on Trent, Staffordshire, United Kingdom. bjohnso25@yahoo.co.uk
Benjamin
B
Johnson
Ian
I
Starks
Gordon
G
Bancroft
Philip J
PJ
Roberts
D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D004343:Drug Implants; D005264:Femoral Fractures / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification*; D009017:Morbidity / Q000639:trends; D012189:Retrospective Studies; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D013530:Surgical Wound Infection / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D015996:Survival Rate / Q000639:trends; D007507:Therapeutic Irrigation; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology
D000900:Anti-Bacterial Agents; D004343:Drug Implants