Surgical site infections (SSIs) are the most costly type of healthcare-associated infection and remain one of the most complicated infection types to reduce. The need for bundled interventions, agreement from multiple parties, and difficulty assessing proven reduction methods makes sustaining improvement processes difficult. To help drive improvement work, a standardized SSI review process centered around apparent case analysis (ACA) was implemented. This review process was paired with a data dashboard to assess overall compliance with the Centers for Disease Control and Prevention (CDC) category IA recommendations.

Surgical services, surgeons, and infection prevention agreed to use CDC category IA recommendations to reduce SSIs as standard benchmarks to identify gaps in best practice. A standardized ACA template specific to SSIs was created to review infections. Deviations in care were communicated to site leadership and system perioperative committees. Process improvement tactics were generated at the hospital level based on site needs. Needs were determined through a baseline assessment of compliance with CDC category IA recommendations. Deficiencies were tracked systematically across each hospital and analyzed for trends through the use of a data dashboard.

Implementation of the ACA process has led to increased surgeon understanding of SSI reduction elements and the value of infection prevention case review and surveillance. All hospitals within the healthcare system have implemented the CDC SSI reduction guidelines and are working toward 90% compliance with category IA recommendations.

Apparent cause analysis has shown to be a reliable and engaging tool to bridge communication between infection prevention and surgical services at a multi-hospital healthcare system. Using a standardized ACA reporting tool in conjunction with real-time data has allowed surgical leadership to drive change and increase compliance with CDC category IA recommendations.