Surgical site infection prevention bundle: changes in staff nurses’ practices and SSI outcomes

Sumana Bhunia; Amita Paul; Narendra Kumar Tiwary

doi:10.18203/2394-6040.ijcmph20263597

Authors

Sumana Bhunia Department of Nursing, Mansarovar Global University, Bhopal, Madhya Pradesh, India
Amita Paul Faculty of Nursing Science, Mansarovar Global University, Bhopal, Madhya Pradesh, India
Narendra Kumar Tiwary Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), Nagpur, Maharashtra, India

DOI:

https://doi.org/10.18203/2394-6040.ijcmph20263597

Keywords:

Surgical site infection, Bundle care, Nursing practice, Infection prevention, Postoperative patients, Quality improvement

Abstract

Background: Surgical site infection (SSI) remains an important postoperative problem, and prevention depends on consistent care. This study examined changes in nurses’ observed SSI-prevention practice and in-hospital SSI occurrence after a structured bundle intervention.

Methods: A pre-post interventional study was conducted from November 2025 to April 2026 in General Surgery and Orthopaedic Surgery wards of a tertiary hospital in Kolkata. Seventy-six nurses were observed before and after intervention using a 10-item checklist. Patient surveillance included 386 patients before and 470 after intervention. The bundle combined teaching, demonstration, bedside reinforcement, observation and feedback. Practice scores were compared using the Wilcoxon signed-rank test and SSI proportions using Pearson’s chi-square test. Risk estimates and multivariable logistic regression were calculated.

Results: Mean practice score increased from 5.21±1.36 to 6.78±2.96; median score increased from 5 to 8, and good practice from 2.6% to 53.9% (Z=-4.01, p<0.001; r=0.46). SSI decreased from 20.21% (78/386) to 14.89% (70/470) (χ²=4.185, p=0.041). RR was 0.74 (95% CI 0.55-0.99) and ARR 5.32 percentage points (95% CI 0.17-10.45). Adjusted odds were lower after intervention (AOR=0.70, 95% CI 0.489-0.999; p=0.0495).

Conclusions: The bundle was followed by better observed nursing practice and lower in-hospital SSI occurrence. The adjusted result was close to the 0.05 threshold; the absence of a concurrent control group and post-discharge surveillance limits causal interpretation.

References

World Health Organization. Global guidelines for the prevention of surgical site infection. 2nd ed. Geneva: World Health Organization; 2018. Available at: https://www.who.int/publications/i/item/9789241550475. Accessed on 10 September 2026.

Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-91.

Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, et al. Strategies to prevent surgical site infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44(5):695-720.

Gillespie BM, Harbeck E, Rattray M, Liang R, Walker R, Latimer S, et al. Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients. Int J Surg. 2021;95:106136.

GlobalSurg Collaborative. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis. 2018;18(5):516-25.

Centers for Disease Control and Prevention. 2025 NHSN Surgical Site Infection (SSI) Checklist. Atlanta (GA): Centers for Disease Control and Prevention; 2025. Available at: https://www.cdc.gov/nhsn/pdfs/checklists/2025-NHSN-Surgical-Site-Infection-SSI-Checklist-FINAL.pdf. Accessed on 10 Sep 2026.

World Health Organization. Implementation manual to support the prevention of surgical site infections at the facility level: turning recommendations into practice. Geneva: World Health Organization; 2018. Available at: https://www.who.int/publications/i/ item/WHO-HIS-SDS-2018-18. Accessed on 10 Sep 2026.

Sonpar A, Hundal CO, Totté JEE, Wang J, Klein SD, Twyman A, et al. Multimodal strategies for the implementation of infection prevention and control interventions-update of a systematic review for the WHO guidelines on core components of infection prevention and control programmes at the facility level. Clin Microbiol Infect. 2025;31(6):948-57.

Aktaş FO, Damar HT. Determining operating room nurses' knowledge and use of evidence-based recommendations on preventing surgical site infections. J Perianesth Nurs. 2022;37(3):404-10.

Feng W, Sae-Sia W, Kitrungrote L. Knowledge, attitude, and practice of surgical site infection prevention among operating room nurses in southwest China. Belitung Nurs J. 2022;8(2):124-31.

Radman I, Poklepovic Pericic T, Krizanac Z, Babic A, Bodys-Cupak I, Bala MM, et al. Developing a standardised surgical site infection prevention bundle: a scoping review of clinical practice guidelines. J Hosp Infect. 2026;174:170-84.

Pop-Vicas AE, Abad C, Baubie K, Osman F, Heise C, Safdar N. Colorectal bundles for surgical site infection prevention: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2020;41(7):805-12.

Zywot A, Lau CSM, Fletcher HS, Paul S. Bundles prevent surgical site infections after colorectal surgery: meta-analysis and systematic review. J Gastrointest Surg. 2017;21(11):1915-30.

Weiser MR, Gonen M, Usiak S, Pottinger T, Samedy P, Patel D, et al. Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections. Br J Surg. 2018;105(12):1680-7.

Bagga R, Suri V, Thami M, Nehra R, Dhaliwal N, Biswal M, et al. A simple infection prevention 'bundle' including preoperative bath with hair-wash to reduce surgical site infection (SSI) following elective caesarean and gynaecological surgery in India. J Family Med Prim Care. 2022;11(5):1970-9.

Albert H, Bataller W, Masroor N, Doll M, Cooper K, Spencer P, et al. Infection prevention and enhanced recovery after surgery: a partnership for implementation of an evidence-based bundle to reduce colorectal surgical site infections. Am J Infect Control. 2019;47(6):718-9.

White C, Kurtz S, Lusk L, Wilson B, Britton V, Hayden K, et al. Implementation of a colorectal surgical site infection prevention bundle and checklist: a quality improvement project. AORN J. 2023;118(5):297-305.

Dhandapani S, Raja K, Priyadarshi K, Sastry AS. Implementation of surgical site infection care bundle in patients undergoing gastrointestinal surgeries. Indian J Med Microbiol. 2024;51:100670.

Cheng H, Chen BPH, Soleas IM, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration increases risk of surgical site infections: a systematic review. Surg Infect (Larchmt). 2017;18(6):722-35.

Dukes KC, Schacht Reisinger H, Schweizer M, Ward MA, Chapin L, Ryken TC, et al. Examining barriers to implementing a surgical-site infection bundle. Infect Control Hosp Epidemiol. 2024;45(1):13-20.