Discussion

The surgical infection control literature shows colorectal bundles to be effective in SSI prevention. A 2020 meta-analysis found an overall SSI reduction of 44%, with complex, ≥ 11 element-bundles consisting of both traditional and newer interventions demonstrating the greatest SSI reduction. ^{Reference Pop-Vicas10} Our survey suggests variable success in the implementation of guideline-recommended SSI prevention bundle elements in acute care hospitals. Intra-operative antibiotic prophylaxis and skin prep with alcohol-chlorhexidine solutions, recognized as very important elements of SSI prevention, were reported as consistently used by most participating hospitals. On the other hand, mechanical bowel prep combined with oral antibiotics was reported to be consistently used by only half of the participating hospitals and was considered important by less than one-third of participants. Perhaps this finding reflects reticence in fully adopting an intervention that has been a debated topic in the surgical literature. The controversy has primarily centered around the use of mechanical bowel prep, viewed by some experts as minimally effective, ^{Reference Liu11} while associated with potential abdominal discomfort and dehydration for some patients. However, in combination with oral antibiotics, mechanical bowel prep has been shown to reduce SSI, postoperative ileus, anastomotic leak, and 30-day mortality in colorectal surgery by multiple studies. ^{Reference Toh12–Reference Scarborough14} The recent MOBILE2 randomized clinical trial, conducted to help clarify this dispute, reinforced the effectiveness of mechanical bowel prep combined with oral antibiotics in preventing SSI and anastomotic dehiscence in surgeries involving rectal resection. ^{Reference Koskenvuo15} There is a growing consensus, emphasized in the most recent updated guidelines ^{Reference Calderwood7} that the essential practice for prevention is the combination of oral and intravenous antibiotics rather than the mechanical bowel prep component, ^{Reference Rybakov16,Reference Lee17} which by itself has not been shown effective in randomized trials. ^{Reference Nelson, Hassan and Grant18,Reference Rollins, Javanmard-Emamghissi and Lobo19} Further research is needed to elucidate the form of bowel prep that is most effective in preventing SSI in colorectal surgery.

Expert consensus in colorectal surgery also supports the use of a mini bundle dedicated to incision closure (sterile tray, pre-closure glove change, antimicrobial sutures), besides impervious wound protectors/retractors and antiseptic wound lavage. ^{Reference Ruiz-Tovar20} Our survey indicates that many hospitals have implemented some of these elements (pre-closure glove change 69%, separate instrument tray 63%, wound edge protectors or retractors 55%), although there is room for improvement. The use of antimicrobial-impregnated sutures was low, which may reflect cost constraints in some settings.

Our study found that few hospitals monitored bundle adherence through routine audit and feedback, which is recommended as an essential practice in SSI prevention. ^{Reference Calderwood7} Audit and feedback has long been recognized as an effective strategy in changing professional practice, especially when delivered frequently in settings with low adherence, ^{Reference Jamtvedt21} and has been associated with significant reduction in SSI rates. ^{Reference Manivannan22} In colorectal surgery, audit and feedback are generally well regarded, being perceived as important in increasing individual awareness and accountability and helpful in adopting recommended SSI prevention interventions. ^{Reference Nessim23}

Of course, successfully implementing complex SSI prevention bundles in clinical practice requires a multifaceted, multidisciplinary approach, ^{Reference Hatharaliyadda24,Reference Lin25} preferably under the leadership of a surgeon-champion. ^{Reference Pop-Vicas26,Reference Massimo Sartelli and Abu-Zidan27} While audit and feedback have been cited as the most frequently used strategy, organizational culture, monitoring the performance of healthcare delivery, using reminders, and increasing education have also been recognized among the “top five” implementation strategies to prevent SSI. ^{Reference Tomsic28} Employed together in a multi-modal implementation approach, these strategies were associated with a 52% risk reduction in SSI, as reported in the systematic review by Tomsic et al. ^{Reference Tomsic28} In our study, respondents identified lack of audit and feedback, need to change organizational culture, and need for more educational support as persistent implementation barriers in 25%–40% of the participating hospitals, underscoring the need for further work in improving these aspects of SSI prevention bundle implementation.

Our study has several limitations. Since the survey was anonymous, we do not have data on the colon SSI rates for each participating hospital and cannot analyze how any of the bundle elements and implementation strategies studied are correlated with SSI prevention. The lower survey response rate and the survey distribution to only hospitals participating in the SRN are shortcomings, as the findings may not be generalizable to all acute care settings. In addition, the limitations inherent to survey studies, such as potential for response bias, inability to verify the accuracy of self-reported data, and difficulty capturing the complexity of the implementation of SSI prevention through discrete survey questions apply here as well.

In conclusion, our study highlights variability in the implementation of complex SSI prevention bundles in acute care hospitals. Further research is essential to refine the strategies needed to optimize the effectiveness of these bundles by increasing their adoption in the clinical setting.