Reducing surgical site infections among paediatric patients undergoing cardiac surgery: a multi-disciplinary quality improvement initiative

Summary

Introduction

Sternal wound surgical site infections (SSIs) in paediatric cardiac surgery are associated with significant morbidity, prolonged hospitalization, and elevated healthcare burden. In response to baseline surveillance at our cardiac centre, between July and December 2024 13 SSIs were identified among 128 open-heart paediatric cardiac surgeries (10.2%), exceeding national and international benchmarks; a structured quality-improvement initiative was implemented to reduce SSI rates and enhance SSI prevention practices.

Methods

An evidence-based SSI-prevention bundle that included preoperative chlorhexidine gluconate (CHG) preparation, optimal antibiotic selection, dosing, timing, and redosing, standard wound care, sterile delayed sternal closure protocols, and improved environmental cleaning was implemented from January to December 2025 a by a multi-disciplinary team. Plan–Do–Study–Act (PDSA) cycles, statistical process control charts, compliance audits, and mixed qualitative feedback were used to measure impacts. The measures were the SSI rate and bundle adherence reliability. Essential elements include strengthening adherence to perioperative bundle components across all phases; a sterile delayed sternal closure setup; and intensified environmental cleaning consistent with national guidelines, supported by staff education, real-time process and outcome monitoring with feedback, electronic health record prompts, daily audits, and ongoing staff and leadership engagement.

Results

During the baseline period (July–December 2024), 13 SSIs occurred among 128 paediatric cardiac surgeries (10.2%). After bundle implementation (January–December 2025), eight SSIs were identified among 357 procedures (2.2%); representing a relative reduction of more than 75% in the overall SSI rate with considerable improvements seen in superficial, deep, and delayed-sternal-closure-related infections. Bundle adherence increased from a baseline mean of 37% to 77%, with sustained compliance above 80% from June 2025 onwards.

Conclusion

A comprehensive, multi-disciplinary SSI-prevention care bundle was associated with reduced paediatric cardiac SSIs and improved care reliability. The approach is sustainable, adaptable to other contexts with appropriate modifications, and provides a practical model for enhancing surgical safety in high-risk paediatric groups.

Introduction

Early correction, advances in surgical techniques, and postoperative care have led to improved clinical outcomes and significantly increased survival rates. Despite these advancements, surgical site infections (SSIs) remain a major postoperative complication in paediatric cardiac surgery, contributing to prolonged hospitalization, increased healthcare costs, and greater clinical complexity [1,2]. Reported risk factors for SSIs in this population include younger age (in particular <1 year), high surgical complexity, longer cardiopulmonary bypass duration, preoperative length of stay, delayed sternal closure, and extracorporeal membrane oxygenation closure [1].

The Centers for Disease Control and Prevention/the National Healthcare Safety Network (NHSN) has established standardized definitions and surveillance criteria for SSIs. According to these guidelines, SSIs are classified into three types based on the depth and anatomical location of infection (superficial, deep, and organ/space). Timeframes are determined by the procedure and the presence of implanted materials, ranging from 30 to 90 days post-surgery [3]. SSIs continue to be a significant postoperative complication seen in 1.7–6 per 100 paediatric cardiac surgical patients, with incidences being higher in younger infants and complicated congenital heart disease cases [4,5]. A retrospective review of paediatric cardiac surgery over 5 years at a tertiary care centre in Riyadh found an SSI rate of 7.8% (118 SSIs among 1510 surgeries) [6].

Multiple quality-improvement interventions have shown that bundled perioperative infection-prevention interventions are able to significantly decrease the rates of SSI among this population [4,7,8]. A larger single-centre quality improvement (QI) initiative with the implementation of a standardized sternal wound bundle found a reduction in the overall incidence of SSI, rates of which dropped from 3.8% (33 SSIs among 872 procedures) to 2.1% (17 SSIs among 804 procedures), with the greatest decrease observed in patients with delayed sternal closure (10.6 to 3.9%) after implementation of the bundle of chlorhexidine bathing, antibiotic optimization, and standardized wound care [7]. Similarly, a paediatric cardiothoracic programme that implemented multi-disciplinary wound-prevention approaches, standardized wound-closure strategies, and extended use of negative-pressure or silicone dressings reduced the annual SSI rate from 2.83 (one SSI per 35 surgeries) to 1.15% (one SSI per 87 surgeries) following the intervention [4]. More recently, an academic paediatric centre implemented a comprehensive bundle spanning preoperative, intraoperative, and postoperative care, including optimized antibiotic prophylaxis, environmental hygiene, and bedside sterile procedures, and sustained bundle compliance and demonstrated improvement trends [8].

Collectively, these studies identify that structured, multi-disciplinary, and regularly supervised SSI-prevention bundles, such as standardized skin antisepsis, antibiotic optimization, operative sterility practices, and postoperative wound care, are effective in preventing SSIs in paediatric cardiac surgery. This evidence strongly endorses implementing a targeted, data-driven, and multi-disciplinary QI approach to reduce SSI rates in our paediatric cardiac population [8,9].

The quality improvement team was established in December 2024 with the following objectives: (1) to reduce the SSI rate in paediatric patients undergoing cardiac surgery by 30% to reach a rate of <5.0% SSIs/100 paediatric surgeries within 9 months; and (2) to evaluate, implement, and enhance compliance with evidence-based protocols intended to prevent SSIs.

Methods

Context

This project was a single-centre, prospective QI initiative conducted to reduce sternal wound SSIs at the 186-bed cardiac centre, a national tertiary referral centre providing advanced paediatric cardiac surgical care. The paediatric cardiac programme performs approximately 320–400 NHSN-coded cardiac surgeries annually, including high-complexity neonatal operations, staged repairs, and cases requiring delayed sternal closure. Care is delivered across two dedicated paediatric cardiac operating rooms, a specialized paediatric anaesthesia service, and a 14-bed paediatric cardiac surgical intensive care unit and cardiac step-down unit. The study followed SQUIRE 2.0 guidelines for reporting quality improvement work and used an iterative Plan–Do–Study–Act (PDSA) framework to test and refine interventions over time.

All paediatric patients (<14 years of age) undergoing open-heart cardiac surgery with cardiopulmonary bypass at our institute were included and followed for SSI outcomes according to CDC/NHSN definitions for 30–90 days postoperatively, depending on procedure type. A study flow diagram summarizing the baseline period, intervention design, and phased implementation with PDSA cycles over time is presented in Figure 1.

Figure 1.

Study flow and intervention timeline. PDSA, Plan–Do–Study–Act; SSI, surgical site infection.

Interventions

Phase one: assessment and gap analysis. Our institution adopted a standardized process for identifying and reporting sternal wound infections in paediatrics, and baseline data were collected from July to December 2024, during which a steady rise in reported SSIs was observed. The SSI cases reported as a total of 13 cases for 128 cardiac surgeries, the rate was 10% in both quarters, exceeding national and international benchmarks. SSI cases analysis showed that nine patients (70% of SSI cases) were below 1 month of age. Most of the SSIs were superficial SSIs 10 (7.8%), deep SSIs 2 (1.5%), and one case of space/organ SSI (mediastinitis) (0.7%). Methicillin-susceptible Staphylococcus aureus, accounting for 30% of SSI cases, coagulase-negative Staphylococcus (23%), and methicillin-resistant Staphylococcus aureus (MRSA) (7%), were the most isolated organisms, although most cultures were negative. All patients who had SSI had prolonged hospitalization for SSI management (e.g., antimicrobial treatment, central line insertion, dressing, etc.) with a length of stay ranging between 2 and 4 weeks; many patients required reoperation for wound debridement.

In response to the findings, to identify interventions that mitigate this increase, a multi-disciplinary paediatric cardiac SSI task force was established, involving paediatric cardiac surgeons, intensivists, anesthesiologists, nursing, infection prevention specialists, antimicrobial stewardship pharmacists, wound care team, environmental service representatives, infectious disease specialists, and a QI specialist. The team performed a thorough retrospective root-cause and case-review analysis using Ishikawa diagram process mapping, and direct observation of perioperative workflows, focusing on three key aspects of the operative journey. This assessment identified several opportunities for improvement across the continuum of care, including the preoperative, intraoperative, and postoperative phases. Key gaps identified across the perioperative pathway included variability in preoperative chlorhexidine gluconate (CHG) bathing; antibiotic choice, dosing, timing, and redosing; sterile technique during delayed sternal closure bedside practices; wound dressing management; routine wound assessment and SSI prevention bundle documentation; operating room sterility and environmental control and surveillance practices.

Phases two–three: intervention development and implementation

Based on the literature review, baseline analysis, and stakeholder input, the team developed a comprehensive SSI-prevention bundle spanning five domains: preoperative care, intraoperative care, postoperative care, environmental hygiene, surveillance and feedback (Supplementary Appendix A).

The intervention was implemented from January to December 2025, with staggered rollout using sequential PDSA cycles.

• 1.Preoperative interventions. Standardized CHG bathing protocols, stratified by age and eligibility. Universal MRSA screening with mupirocin decolonization for carriers. Standardized antibiotic prophylaxis protocols, including agent selection, dosing, timing, redosing, and duration. Integration of documentation prompts and eligibility exceptions within the electronic health record. Education sessions and quick-reference tools for clinical staff.
• 2.Intraoperative interventions. Standardization of sternal closure techniques, including mediastinal irrigation for both delayed and primary sternal closure. Reinforcement of OR sterility practices, including traffic minimization and attire compliance. Intraoperative antibiotic redosing is monitored by anesthesia teams. Real-time audits with just-in-time feedback.
• 3.Postoperative interventions. Standardized guidance for bedside delayed sternal closure, emphasizing sterile field creation and environmental control. Daily bathing protocols, including CHG for patients with invasive devices. Development of a uniform wound-care policy and wound assessment tool. Daily wound assessments by surgical advanced practice providers. Structured education for staff and caregivers on postoperative wound care.
• 4.Environmental hygiene. (i) Effective implementation of the environmental cleaning programme according to the updated hospital cleaning policy, procedure, and checklists, which aligned with the national manual of environmental cleaning in healthcare facilities [12]. (ii) Focusing on maintaining a consistently clean environment suitable for maintaining a sterile field during bedside delayed sternal closure procedures. (iii) Providing education and training for critical area staff involved in cleaning and disinfection using high-level disinfectants, proper use, and terminal cleaning and fumigation. (iv) Enhancing infection prevention measures and practices through daily audits (hand hygiene, personal protective equipment, environmental cleaning) with immediate, constructive feedback.
• 5.Surveillance and feedback. (i) Weekly active multi-disciplinary SSI surveillance using NHSN-aligned criteria. (ii) Real-time data review, root-cause analysis, and corrective actions. (iii) Monthly compliance dashboards shared with clinical teams and surgeons. (iv) Continuous staff engagement and feedback.

Study of the interventions

Given the low-frequency but high-impact nature of the outcome, a bundle approach was selected rather than testing individual interventions. To evaluate the impact of the SSI-prevention interventions that were implemented across the perioperative continuum. We used an iterative PDSA approach supported by continuous surveillance, real-time auditing, and standardized outcome measurement.

Process measures. Four core bundle components were monitored monthly that reflect the most modifiable contributors to SSI identified in the literature: (a) MRSA screening and decolonization, (b) preoperative CHG use, (c) use of surgical prophylaxis (choice, timing, dose, redosing, and duration), and (d) overall compliance rate to all preoperative elements (appropriate use of surgical prophylaxis, CHG use, and decolonization).

Outcome measures. The primary outcome measure was the sternal wound SSI rate, measured by SSI events (superficial, deep, and organ/space mediastinitis) as defined per NHSN criteria, per 100 paediatric cardiac surgical procedures, reported monthly/quarterly. SSI cases weredetected using readmission data, antibiotic usage, cardiac surgery database, outpatient clinic data, wound care team, and child caregiver feedback.

SSI data and bundle compliance were extracted from the health records by trained infection prevention staff and pharmacists and validated by infection control consultants. Quantitative analysis used statistical process control charts and run charts to identify special-cause variation. Descriptive statistics were used to compare pre- and post-intervention outcomes.

Qualitative data were obtained by structured observations, multi-disciplinary feedback sessions, and documentation reviews to assess feasibility, barriers, and contextual elements influencing implementation.

Results

Following initial implementation, the improvement in prevention bundle compliance and documentation was gradual from January to December 2025. A total of 357 open-heart paediatric cardiac surgeries with cardiopulmonary bypass were performed, enrolled, and surveilled. Almost 95% of surgeons, anaesthesiologists, operating room, intensive care unit, and surgical ward staff were directly involved in surgical patient care and management over all phases (preoperative, intraoperative, and postoperative), and received specific training and education with competency assessment tailored for their roles in patient care.

Following the implementation of the paediatric cardiac SSI prevention bundle in January 2025, overall compliance showed a progressive, sustained upward trend. As shown in Figure 2, bundle adherence improved markedly from a baseline average of 0.37 (37%) during July–December 2024 to a post-intervention average of 0.77 (77%), with an upper control limit (UCL) of 0.99. The process-control chart demonstrated a temporal shift in SSI occurrence following implementation, consistent with special-cause variation and sustained process improvement.

Figure 2.

Overall surgical site infection bundle compliance.

From Figure 3, MRSA/methicillin-susceptible S. aureus (MSSA) screening and decolonization achieved and maintained 100% compliance since implementation in January 2025. Preoperative CHG skin preparation: increased to 96–100%, indicating consistent execution of asepsis measures. Appropriate antibiotic prophylaxis (choice, timing, dose, redosing, duration): improved from variable pre- intervention levels (55–65%) to sustained 82–96%, with a transient dip in April 2025 (75%) related to stock turnover and documentation issues that were immediately addressed.

Figure 3.

Compliance bundle rate comparison pre- vs post-quality-improvement (QI).

Overall, the data illustrate strong adoption of evidence-based SSI-prevention practices, with bundle reliability maintained above 80% from June 2025 onward, confirming the positive and sustained impact of the QI interventions on perioperative care processes and patient safety.

During the post-implementation period, we identified eight SSIs out of 357 surgeries with a total rate of 2.2% for the year of 2025; the descriptive data of SSI cases reported type of infection as follows: five superficial SSIs (rate 1.4%), two deep SSIs (rate 0.5%) and one case as organ/space mediastinits SSI (rate 0.2%) occurred within the surveillance period. Four patients were under 1 month old. Reported procedures included repair of coarctation of the aorta, transposition of the great vessels, tetralogy of Fallot, truncus arteriosus, ventricular septal defect, and atrial septal defect. Three patients had delayed sternal closure. MSSA (25% of SSI cases), MRSA (25%), and once Corynebacterium (12%) were isolated, although most cultures were negative. In root cause analysis of SSI cases, reoperative nonadherence of the preoperative bundle was observed in three patients who had received inappropriate timing of antibiotic prophylaxis because the antibiotic was not readily available in the operating room. In addition to the previously highlighted risk factors (the neonatal period, delayed chest closure), one patient had a redo procedure that was a narrowed procedure performed 8 months prior to the currently surveyed one.

Following implementation of the paediatric cardiac SSI reduction initiative, SSI incidence declined markedly and remained low compared with 2024 data across all categories.

As shown in Figure 4, the overall SSI rate decreased by more than 50%, from a baseline average of 0.11 (11%) during July–December 2024 to 0.022 (2.2%) during January–December 2025. The process control chart demonstrates a clear special-cause variation after the intervention, indicating a statistically significant and sustained system improvement.

Figure 4.

Paediatric cardiac overall surgical site infection (SSI) rate July 2024 to December 2025.

Notably, the deep SSI rate decreased from 1.5% in 2024 to 0.5% in 2025, while the mediastinitis rate declined from 0.7% to 0.2% by the end of 2025 (Figure 5). No clusters or upward trends were observed after March 2025, confirming the durability of the improvement.

Figure 5.

Paediatric cardiac surgical site infection rate comparison pre- vs post-quality improvement (QIP).

By December 2025, the overall SSI rate had reached 0.02 (2.2%), well below both national and international paediatric cardiac benchmarks. These data demonstrate that the QI initiative successfully achieved its target, resulting in a sustained, progressive reduction in SSI incidence over 12 months post-intervention.

An exploratory comparison of the proportions of patients developing SSI before and after implementation was performed using Fisher’s exact test because of the small number of infection events. SSI occurred in 13 of 128 procedures during the baseline period compared with eight of 357 procedures during the intervention period, corresponding to rates of 10.2% and 2.2%, respectively. This unadjusted difference was statistically significant (two-sided Fisher’s exact test, P<0.001). However, because this was a non-randomized quality-improvement initiative with unequal observation periods and no concurrent control group, the statistical result should be interpreted as supportive evidence of an association rather than proof that the intervention alone caused the reduction.

After reviewing unscored structured observational audits, which do not measure compliance for all elements and represent a process of real-time observation with feedback, conducted by the infection prevention and control staff and units' champions in operating room, paediatric surgical intensive care unit (PSICU), environmental services, and wound care team, we initially flagged hand hygiene, appropriate surgical attire, personnel traffic, wound assessment and documentation, and disinfection as areas of focus. After bundle implementation, the observational audits revealed consistent improvement in these three areas. The audits showed overall consistency in compliance with sterile technique guidelines during bedside procedures in the PSICU. Monthly hand hygiene compliance in the PSICU ranged from 90% to 96% during the post-implementation period, exceeding the unit's previous range of 79–87%. Wound documentation was audited in the electronic record, and staff wound-care competencies were assessed through direct observation. The observational audit findings were summarized as monthly compliance percentages, integrated into the quality initiative data, and used to inform iterative PDSA refinements.

Discussion

The observed reduction in paediatric cardiac SSIs appears strongly associated with the integrated SSI-prevention bundle implemented across the perioperative continuum. Improvements in preoperative CHG treatment, accurate and timely antibiotic prophylaxis, standardized wound-protection practices, enhanced bedside sterility for delayed sternal closure, and strengthened environmental cleaning collectively increased process reliability from baseline variability to sustained high compliance. As bundle adherence rose, SSI rates declined in a corresponding, time-aligned manner, suggesting a temporal association consistent with established quality-improvement literature [[4], [5], [6], [7], [8]].

Our findings align with published evidence from high-performing paediatric cardiac centres, where comprehensive SSI-prevention bundles have reduced infection rates by roughly 30–50%. Similar single-centre quality-improvement initiatives using multi-disciplinary bundles, including sternal wound, postoperative care, and protocolized perioperative packages, have achieved absolute reductions of 30–70% in overall SSI rates, even among patients with delayed sternal closure. Although many of these studies, including ours, involve modest sample sizes and relatively short follow-up periods, they collectively provide clinically important evidence that reliable implementation of perioperative bundles can substantially improve outcomes in paediatric cardiothoracic surgery [[7], [8], [9], [10], [11], 13,14].

Deep sternal wound infection and mediastinitis are strongly influenced by delayed sternal closure due to prolonged exposure and the complexity of the bedside procedure [12]. Previous research has shown that standardized bedside sterility protocols and better environmental controls have a significant positive effect on reducing this risk – findings that are reflected in the current project [4,5,7].

There were several contextual factors that likely contributed to the extent and sustainability of the improvement achieved. Leadership engagement, staff willingness to adopt standardized guidelines, and the presence of a high-volume paediatric cardiac programme enhanced rapid testing and the refinement of interventions. The same facilitators are constantly mentioned as major enablers of successful SSI-reduction programmes in paediatric cardiac surgery [4,5]. Early compliance inconsistencies, mostly associated with documentation issues, staff attrition, and workflow modifications, were managed successfully by focusing on targeted education, checklist optimization, and more infection-prevention personnel bedside presence, which was also suggested in previous QI sources.

For centres planning similar initiatives, the findings suggest that implementation should begin with local surveillance validation, case review, process mapping, and identification of context-specific gaps rather than adoption of an identical fixed bundle. Core components that appear consistently across published initiatives include appropriate skin preparation, reliable antimicrobial prophylaxis, standardized wound care, strict sterile technique during delayed sternal closure, environmental hygiene, and multi-disciplinary outcome feedback. Local adaptation may be required according to patient acuity, resources, staffing models, electronic documentation capacity, and the proportion of patients undergoing delayed sternal closure. Measurement of both clinical outcomes and process reliability is important because SSI events are relatively infrequent and may fluctuate over short observation periods.

Overall, the project delivered net institutional value by lowering the burden of postoperative infections, improving patient outcomes, and strengthening long-term safety infrastructure.

The project's internal validity may have been affected by several methodological factors. First, although standardized definitions are used, SSI detection is partly based on clinical judgment and documentation, which introduces the possibility of ascertainment and measurement bias. Second, confounding factors might have led to the improvement, including seasonal changes in case mix, staffing changes, or simultaneous institutional programmes unrelated to this project. Third, direct observation was used to measure some process measures, including CHG treatment and bedside sterility practices, and it carries the risk of the Hawthorne effect, whereby staff temporarily change behaviour due to observation. Fourth, missing or incomplete documentation early in the project may have contributed to the precision in the baseline data. Fifth, because this was a real-life QI study, not randomized and no control group, it is impossible to firmly determine causality between interventions and outcomes. Multiple steps were taken to address these limitations. SSI identification followed CDC/NHSN standardized criteria, reducing classification variability. A consistent infection prevention and control surveillance team, separate from the project team, reviewed all suspected cases to minimize differences in individual interpretation. Process audits were conducted at varying times and by multiple observers to diminish systematic observation bias. Data completeness improved through electronic health record hard stops, standardized documentation templates, and repeated staff education. Finally, The small number of SSI events and the relatively short observation period are important limitations. The baseline period covered 6 months, whereas the intervention period covered 12 months, and the study may therefore be affected by random variation, seasonal changes, differences in case mix, and regression to the mean. Although the unadjusted comparison showed a statistically significant reduction in SSI proportions, the limited number of events prevented robust multi-variable adjustment for factors such as age, surgical complexity, cardiopulmonary bypass duration, reoperation, extracorporeal support, and delayed sternal closure. Therefore, the magnitude and durability of the observed effect should be confirmed through longer follow-up and a larger number of procedures and because all bundle components were introduced as part of an integrated improvement strategy, the study could not determine which individual intervention contributed most to the observed reduction.

In conclusion, this initiative demonstrated that a structured, evidence-based, and multi-disciplinary SSI prevention bundle is associated with a substantial reduction of infections in paediatric cardiac surgery. The initiative has contributed towards improved patient safety, standardized perioperative practices, and strengthened institutional quality systems. By aligning local operating procedures with high-quality evidence, the project has provided a practical and effective model for preventing SSIs in high-risk children.

This work reinforces the necessity of reliable implementation of the prevention bundle, multi-disciplinary collaboration, and real-time data feedback for reducing SSIs. It highlights the need for improved environmental cleaning systems, standardized wound care pathways, and integrated monitoring across the surgical sequence.

Although our findings are encouraging, they arise from a single-centre QI project with a limited number of SSI events and a relatively short follow-up period. Ongoing surveillance, longer-term evaluation, and multi-centre collaboration will be essential to confirm the durability of these improvements and further refine paediatric cardiac SSI-prevention strategies.

Ethics statement

This quality improvement initiative was conducted in accordance with institutional policies. Patient data were collected and analysed in a de-identified manner, and confidentiality was maintained throughout the project.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest statement

The authors declare no conflicts of interest related to this work.

Appendix A. Supplementary data

The following is the Supplementary data to this article: