Quality-Improvement Effort Decreases Deep Sternal Wound Infections After Surgery

NEW ORLEANS, LA—A standardized initiative to prevent deep sternal wound infections in patients undergoing cardiac surgery more than halved the rate of this risky complication over 4 years, according to results from a single US hospital.

The team reduced the rate from 2.1% in 2021-2022 to 0.7% in 2023-2024 (P = 0.04) by introducing and adopting a bundle of interventions and processes to be followed for each cardiac surgery.

“What really made the big difference is our commitment to standardized perioperative care—in terms of how patients are prepared for surgery, both physically in terms of the CHG [chlorhexidine gluconate] baths that they get and the specific timing of those baths, but also how we’re caring for the wounds after surgery,” Alice Vinogradsky, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), who presented the results at the recent 2025 Society of Thoracic Surgeons (STS) Annual Meeting, told TCTMD.

It’s been a multidisciplinary initiative and commitment—one that was developed after physicians at NewYork-Presbyterian-Columbia University Medical Center identified a “persistently elevated” rate of infections compared to other area hospitals—but Vinogradsky credited the nurses with enforcing the bundle and ensuring its success.

“We have nurses who are champions of their aspects of the care protocol,” she said. “In the operating room, our circulating nurses really take it upon themselves to make sure that whatever component of the intraoperative checklist we’re adhering to, that’s being documented and recognized, and whatever component we’re not adhering to, that’s also being documented and recognized and highlighted.”

Sternal wound infections are known to be associated with increased morbidity, mortality, healthcare costs, and prolonged hospitalizations after cardiac surgery. Core components of the bundle include preoperative patient education on preventing infection, skin preparation protocols, a standardized intraoperative checklist printed in pink, and postoperative wound care. Some of the biggest differences with the protocol, Vinogradsky said, included glove changes—every 2 hours and after specific surgical maneuvers—and adhering to standardization in general.

“There definitely was an intraoperative checklist, but it wasn’t a checklist that was printed and circulated,” she said, adding that it didn’t specify things like when and how to clean dressings and which dressings to use. “When you’re trying all these different things iteratively, there’s not really a standardized protocol for which patient gets what, and then I think that keeps you from being able to home in on what the actual root causes were of these infections.”

Commenting on the findings for TCTMD, Maria Alcina Fonseca, DNP, RN (Morristown Medical Center, NJ), who has previously implemented a similar initiative at her hospital, said the Columbia program was “very well done.” Further, she added, “I am a true believer that a bundle and an interdisciplinary approach [as] has been demonstrated previously is the most successful way to reduce infections.”

Clear Results

To assess the effectiveness of the intervention, Vinogradsky and colleagues conducted a propensity score-matched analysis of two groups of 802 patients (mean age 66 years; 74%) undergoing isolated CABG, isolated valve, or combined valve/CABG surgery from before (2021-2022) and after (2023-2024) their hospital instituted the initiative to prevent sternal wounds.

Surgical times and the number of bypass grafts remained similar between the time periods, but bilateral internal thoracic artery harvest increased (36.2% vs 46.0%) as did the percentage of patients transfused with platelets (26.8% vs 34.3%) and those extubated in the OR (3.1% vs 9.0%; all P < 0.01). Also, after the bundle was implemented, ICU stay length decreased (56.1 vs 51.9 hours; P = 0.02), more patients were discharged early (9.7% vs 14.0%; P = 0.01), and total ventilation time went down (8.2 vs 5.4 hours; P < 0.01). Notably, the rate of postoperative atrial fibrillation increased (27.8% vs 33.7%; P = 0.01).

Infection rates dropped, save for superficial ones, as did rates of readmission over 30 days.

Infection Rates Over Time: Before vs After Bundle*

*SWI = sternal wound infection

There was a trend toward annual event rates of any sternal wound infections dropping over the study period (P = 0.06), but the difference became significant when the 2 years before and after the bundle were grouped (P = 0.03).

Independent predictors of any sternal wound infection on multivariate analysis included diabetes, higher body mass index, and surgery before the bundle was implemented.

Interestingly, researchers noted changes in culture isolates, including an almost tripling of candida infections. This led to slight changes in the protocol to reduce the duration of triple antibiotic ointment use.

‘A Lot of Enthusiasm’

Vinogradsky said her department has generally been supportive of the changes in protocol, especially with results like they’ve seen, and of the weekly check-ins to track adherence.

“Everybody recognizes how much of a burden [infections are] to the patient and to the healthcare system and how sternal wound infections in general just threaten the integrity of the entire operation that you performed,” she said. “Once we were able to show our community that . . . we are seeing significant improvements, there’s [been] a lot of enthusiasm for learn[ing] more about this [and being] part of this effort.”

To those looking to start a similar quality improvement initiative at their institution, Vinogradsky recommends starting small.

“When you’re starting out, you have limited manpower, limited resources, limited buy-in, and then a myriad of other things that you can be choosing to focus on to improve about your program overall,” she said. “Identify something actionable, measurable, and concrete where you can have a specific intervention.”

A challenge with implementing and assessing bundles is “you can’t really identify what specific factors are responsible for success,” Vinogradsky continued. “And when you’re first starting out, I think it’s easier in the sense that it’s more effective to focus on specific things that you think are relevant to your experience.”