Evaluation of a Preventive Surgical Site Infection Bundle in Colorectal Surgery

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array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Juan" "apellidos" => "García-Caballero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Preventiva, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Evaluación de un paquete de medidas para la prevención de la infección de localización quirúrgica en cirugía colorrectal" ] ] "textoCompleto" => "IntroductionIn spite of the improvements in surgical techniques that have been introduced during the last few years, surgical site infections (SSI) continue to be a common complication. It is estimated that slightly over 5% of patients treated with any kind of surgery will suffer a SSI.<a class="elsevierStyleCrossRefs" href="#bib0175">1,2</a>In this kind of infection, the highest rates correspond to colorectal surgery, although in the literature we find a wide variability. For example, in a study conducted in England with follow-up of patients treated with colorectal surgery 30 days following hospital discharge,<a class="elsevierStyleCrossRef" href="#bib0185">3</a> a SSI incidence of 27% was recorded; other multicentre study conducted in 140 English hospitals where 6528 colonic procedures<a class="elsevierStyleCrossRef" href="#bib0190">4</a> were assessed, shows a SSI incidence of 10% (95% CI=9.3–10.8); 40.6% of them were organ/space infections.However, there are studies on colon and rectal surgery that have shown that certain initiatives may have a positive impact for addressing this problem. For example, Hedrick et al.<a class="elsevierStyleCrossRef" href="#bib0195">5</a> implemented a multidisciplinary protocol based on four actions: adequate administration of prophylaxis, to avoid extending prophylaxis for more than 24h, to record and maintain patient normothermia, and to perform perioperative glycaemic control (<200mg/dL). With this protocol, a significant decrease in SSI incidence (from 25.6% to 15.9% [P<.05]) was achieved. Another example is derived from the publication by Forbes et al.<a class="elsevierStyleCrossRef" href="#bib0200">6</a> who conducted a prospective study in two cohorts (pre- and post-implementation of the protocol) of patients who underwent colorectal and hepatobiliary surgery. The protocol consisted in the implementation of Clinical Practice Guidelines (CPG) for the prevention of SSI. Health professionals’ adherence to CPG and SSI rates was assessed and a decrease in SSI incidence from 14.3% to 8.7% (P=.21) was achieved.In addition to these examples, several publications have shown that surgical procedure monitoring based on feedback by surgeons can significantly decrease infection rates.<a class="elsevierStyleCrossRefs" href="#bib0205">7–10</a>The objective of this study is to assess the impact of a SSI improvement programme in colon and rectal surgery on the frequency of surgical infection, its related complications and the mean hospital stay one year and a half after its implementation.Patients and MethodsStudy PopulationA quasi-experimental study was designed comparing a prospective cohort (after the implementation of the protocol) to a historical cohort. The historical cohort consists of 218 patients, who underwent surgery in two periods (first semester of 2008 and first semester of 2011). The cohort assessed after the implementation of the protocol consists of 124 patients, who underwent surgery in the second semester of 2012.This study was carried out in the General Surgery Department of Hospital Universitario La Paz (HULP) [La Paz University Hospital] of Madrid, which performs about 3000 interventions in inpatients yearly and is divided into sections per specialty. Patients hospitalised for more than 48h in the General Surgery Department of HULP and treated by major colon and rectal surgery were included. Patients hospitalised for less than 48h were excluded from the study.A convenience nonprobability sampling was performed and all patients who met the inclusion criteria in the previously defined periods of time were enrolled. The evaluation project was approved by the CEIC (Comité de Ética en Investigación Clínica [Clinical Research Ethics Committee]) of the hospital.ProtocolThe protocol for the prevention of surgical site infection in colorectal surgery is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. For its implementation, the main clinical practice guidelines were reviewed.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Aseptic Preparation of the PatientAntiseptic shower. It is recommended in some guidelines, although some authors consider there is not enough evidence in favour of it compared to a shower with regular soap. In most cases, it is recommended to take a shower with regular soap or with chlorhexidine soap on the same day of the intervention.<a class="elsevierStyleCrossRef" href="#bib0225">11</a>Operative field preparation: current evidence favours a preoperative preparation of the skin with chlorhexidine or chlorhexidine/alcohol solutions such as 2% chlorhexidine in isopropyl alcohol. It is important to allow it to stand (at least 1min) and air dry.<a class="elsevierStyleCrossRef" href="#bib0230">12</a>Antibiotic Prophylaxis<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a.The surgical antimicrobial prophylaxis consists in the administration, preferably single, of at least one antibiotic before the intervention in order to reduce the intraoperative microbial contamination so that it does not overcome the patient's defence mechanisms. The intravenous route is the most frequent route of administration. The antibiotic should be administered between 30 and 60min before incision and at high enough doses to equal or exceed the minimum inhibitory concentration for the microorganism. Such levels should be maintained throughout the intervention and even some hours after it; for that reason, in long surgical procedures, additional doses may be required. In the case of colon and rectal surgery, prophylaxis should be always administered, since it is a surgery which is, at least, contaminated.<a class="elsevierStyleCrossRef" href="#bib0235">13</a></li><li class="elsevierStyleListItem" id="lsti0010">b.In some cases, it will be a dirty surgery, that is to say, infected; therefore, antibiotic administration should be scheduled as empirical therapy. For example, this would be the case of a colonic perforation with associated peritonitis.</li></ul>Colon and rectal surgery requires antibiotic combinations with coverage for the most common microorganisms: anaerobic and gram-negative bacilli. In our protocol, we have taken into account the local and international guidelines.<a class="elsevierStyleCrossRef" href="#bib0240">14</a>Oral antibiotics are not recommended in the current guidelines, since they do not provide better results and may be related to vomiting and abdominal pain.<a class="elsevierStyleCrossRefs" href="#bib0245">15,16</a>Preoperative and Postoperative Glycaemic ControlCardiovascular surgery studies showed that maintaining perioperative glucose levels<200mg/dL led to a lower incidence of SSI compared to controls.<a class="elsevierStyleCrossRefs" href="#bib0255">17,18</a>However, current CPGs do not recommend a strict glycaemic control as a routine surgical practice due to the risk of hypoglycaemia.<a class="elsevierStyleCrossRef" href="#bib0225">11</a> In our case, it is recommended to maintain blood glucose levels<200mg/dL 24h before and after the surgery.Glove ChangeGlove change should be performed when the surgery is longer than three hours, after draining an abscess, after performing a colonic anastomosis, and when there is evidence of perforation, according to the measures proposed by observational studies.<a class="elsevierStyleCrossRefs" href="#bib0265">19–21</a>Partecke et al.<a class="elsevierStyleCrossRef" href="#bib0265">19</a> showed that wearing gloves for 91–150min resulted in the perforation of at least one of them in 18.1% of studied cases. From 150min onwards, this percentage increased to 23.7%. Out of all the perforated gloves, 66.7% corresponded to the dominant hand, and microperforation was more frequently found in the index finger of that hand. Major abdominal surgeries, vascular and heart surgeries were the ones where more perforations were found.<a class="elsevierStyleCrossRef" href="#bib0265">19</a> However, Misteli et al. showed that surgical glove perforation increases the risk of SSI.<a class="elsevierStyleCrossRef" href="#bib0275">21</a>Maintaining Patient Normothermia in the Operating TheatreHypothermia causes vasoconstriction, decreases tissular oxygen and can reduce the immune response. Several studies have shown a decrease in the SSI incidence in patients subject to normothermia control during the intervention and the postoperative period.<a class="elsevierStyleCrossRefs" href="#bib0280">22–24</a>This measure is currently recommended in several CPGs.<a class="elsevierStyleCrossRefs" href="#bib0225">11,25</a>Lastly, it should be noted that other actions that were performed in the past, such as mechanical bowel preparation, have been discarded based on the current evidence, since there are studies which show that it does not decrease faecal microorganism concentration in the intestinal lumen and that it can even change solid faeces into liquid ones, which could facilitate bacteria movement towards the wound and towards the peritoneal cavity.<a class="elsevierStyleCrossRefs" href="#bib0300">26,27</a>At present, mechanical bowel preparation is contraindicated as a routine measure.<a class="elsevierStyleCrossRef" href="#bib0310">28</a>Implementation of the Protocol and Independent and Outcome VariablesThe protocol was presented in two clinical sessions in the Department of Anaesthesia and the Colorectal Surgery Section. Demographic, clinical, epidemiological and microbiological variables and those related to adherence to protocol were collected. For the diagnosis of infection, CDC criteria were used.<a class="elsevierStyleCrossRef" href="#bib0315">29</a>Statistical AnalysisThe quantitative variables are described as mean, median and standard deviation (SD). Qualitative variables are described with absolute and relative frequencies. Comparisons among quantitative variables were made using the Mann–Whitney test. For comparisons among qualitative variables, the Chi-square test or Fisher's test were used. The analysis was performed with the PASW Statistics 18 programme.ResultsA total of 342 patients undergoing colon (256) and rectal (86) surgery were assessed; they were divided into two cohorts: a baseline one made up of 218 patients (years 2008–2011) and another one after the implementation of the programme (year 2012) made up of 124 patients. The descriptive study of the main variables in both cohorts and the comparison between them are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. As it can be noted, there are no statistically significant differences between the cohorts.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Cumulative incidences of total SSI and according to its location, for all patients and by procedure are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. The primary outcome, the incidence of total SSI, is significantly lower after protocol implementation. In the case of SSI, however, the reduction was not statistically significant.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Postoperative mortality; (P=.04).Lastly, the results of the assessment of adherence to protocol are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionIn our hospital, the implementation of a protocol for the prevention of SSI has yielded a decrease from 27.5% to 16.9% in the total frequency of these infections; this decrease is similar to that described by other authors.<a class="elsevierStyleCrossRefs" href="#bib0195">5,30–33</a>For example, Hendrick et al.<a class="elsevierStyleCrossRef" href="#bib0195">5</a> achieved a SSI decrease in colorectal surgery from 25.6% to 15.9% (P<.05) after the implementation of a multidisciplinary protocol, with an increase in the percentage of adequate administration of prophylaxis from 68% to 91% (P<.001), among other measures. The study conducted by Wick et al.<a class="elsevierStyleCrossRef" href="#bib0330">32</a> also shows a 33.3% decrease in SSI in colorectal surgery 12 months after the implementation of a programme based on preoperative patient hygiene with chlorhexidine, standardisation of surgical skin preparation, maintainence of patient normothermia and the adequate administration of antibiotic prophylaxis.In our case, protocol measures were also implemented in a care bundle fashion, that is to say, simple measures, which must be performed together, and which are thus potentiated. One of the measures was the protocolisation of antibiotic prophylaxis, which has shown to be effective in surgical processes since long ago and it is, therefore, a measure applied in hospitals in our region. Nevertheless, it does not fit in with all parameters (type of antimicrobial drug, administration time and withdrawal time) uniformly in all the centres, and even in the same hospital there may be differences among departments or among professionals. We considered that a non-justified variability was not acceptable and were very strict when considering prophylaxis as “inadequate” because it did not meet all the proposed parameters of the protocol.In addition to the positive results on infection, our study shows a significant decrease in postoperative mortality. It is not strange that both results have gone together, since previous publications have already shown this<a class="elsevierStyleCrossRefs" href="#bib0265">19,31</a>: we highlight the publication of Crolla et al.,<a class="elsevierStyleCrossRef" href="#bib0325">31</a> which shows a similar decrease to that of our study in SSI, mean hospital stay and mortality after the implementation of a bundle. For our part, as shown in the Results section, we have conducted a study on risk factors for postoperative mortality in all studied patients and both SSI of any type and organ/space SSI proved to be independent risk factors. For hospital stay, in our study, a decrease was also observed in the post-implementation group with a mean of three days.Adherence to protocol has been evaluated using a series of variables related to compliance with the main measures. As presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>, most items show a significant improvement. Notwithstanding, all measures could not be evaluated; for example, temperature could not be recorded during the intervention, although the use of an electric blanket was satisfactorily recorded. We could not record glove change either; therefore, we do not know adherence to this measure and cannot quantify its impact on final outcomes.Lastly, regarding adherence to protocol, it should be noted that the main advantage we have had is that measures did not require any costs and most of them had already been partially introduced; therefore, its systematisation has not involved any kind of additional reorganisation.In order to conclude the discussion on results, we should mention that in some studies the authors have not observed improvements in SSI rates after the implementation of similar measures. In relation to data from our region, the publication on a multicentre study conducted in 19 Catalonian hospitals stands out. The authors recorded a SSI incidence in colon cancer surgery of 23.2% (95% CI: 18.9–27.6), which did not vary after the application of a bundle of preventive measures.<a class="elsevierStyleCrossRef" href="#bib0340">34</a>Considering study limitations, we should highlight that, due to the outcome assessment design, which compares patients who underwent surgery some years ago, we cannot state that these results are due to the protocol alone, since there may be other uncontrolled factors that could have contributed to this. For example, each surgeon's experience or the technical improvements that may have taken place over the years are difficult-to-control factors. Other factors that may have had an influence on the results include the further knowledge on SSI-related factors acquired over time or, in our case, the specialisation since the General Surgery Department was reorganised in sections.It should also be noted that, although the control or historical cohort was prospectively collected, some variables were retrospectively collected for this study. This implies that some data could not be collected in all patients, for example, patient's height and weight for BMI calculation.Another limitation that should be taken into account is the “observational bias”, given that after protocol implementation and clinical sessions offered in the departments, health professionals knew that they were highly likely to be audited, since we had committed to provide feedback on results at least biannually.Nevertheless, and in spite of the abovementioned methodological limitations, we believe that the implementation of evidence-based, simple, feasible recommendations together with a strong leadership from the responsible clinicians involved, are useful tools to improve surgical patient safety, as shown at a local level. We base such statement on the previously mentioned analysis, where a significant decrease in the frequency of SSI, postoperative mortality and inadequate antimicrobial prophylaxis is verified.Conflicts of InterestThe authors declare that they do not have any conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres468424" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec491082" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres468423" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec491081" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study Population" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Protocol" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Aseptic Preparation of the Patient" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Antibiotic Prophylaxis" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Preoperative and Postoperative Glycaemic Control" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Glove Change" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Maintaining Patient Normothermia in the Operating Theatre" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Implementation of the Protocol and Independent and Outcome Variables" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Statistical Analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-07" "fechaAceptado" => "2014-12-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec491082" "palabras" => array:3 [ 0 => "Colorectal surgery" 1 => "Surgical site infection" 2 => "Postoperative mortality" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec491081" "palabras" => array:3 [ 0 => "Cirugía colorrectal" 1 => "Infección de localización quirúrgica" 2 => "Mortalidad postoperatoria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo assess the effectiveness of a protocol for the prevention of surgical site infection (SSI) in colorectal surgery. Patients and methodsEvaluation of 2 cohorts of patients undergoing colon and rectal surgery in a tertiary public hospital: A historical cohort (2008–2011) and a prospective one (after the implementation of the programme in 2012). The main measures established were: Adequacy of preoperative antimicrobial prophylaxis, maintaining patient normothermia and appropriate glove change during the intervention. Comparability of the two cohorts was determined by a bivariate analysis of age, sex, NNIS index, ASA index, surgical time, perioperative transfusion, diagnosis, diabetes and renal failure. ResultsWe assessed 342 patients (256 underwent colon surgery and 86 rectal surgery), divided into 2 cohorts: prior period (218), and post-implementation period (124). The cumulative incidence of SSI in the first cohort was 27.5% (95% CI, 21.6–33.4), and in the post-intervention cohort 16.9% (95% CI, 10.3–23.5, P=.03). Postoperative mortality was 9.2% (95% CI, 5.4–13) in the first cohort and 3.2% (95% CI, 0.1–6.3) in the post-intervention cohort (P=.04). The inadequacy of prophylaxis decreased from 37.4% (95% CI, 30.4–44.6) to 18.9% (95% CI, 11.9–26.1) (P=.001). ConclusionA significant decrease in the frequency of SSI, post-surgical mortality and inadequate antimicrobial prophylaxis is verified after the implementation of a protocol in colorectal surgery" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEvaluar la efectividad de un protocolo para la prevención de la infección de localización quirúrgica (ILQ) en cirugía colorrectal. Pacientes y métodosEvaluación de 2 cohortes de pacientes intervenidos de colon y recto en un hospital público de tercer nivel: una cohorte histórica (2008–2011) y otra prospectiva (posterior a la implementación del programa en 2012). Las principales medidas establecidas fueron: adecuación de la profilaxis antimicrobiana prequirúrgica, mantenimiento de la normotermia del paciente en el quirófano y adecuación del cambio de guante durante la intervención. Se determinó la comparabilidad de ambas cohortes mediante un análisis bivariable de la edad, sexo, factores e índices de riesgo (índice NNIS, índice ASA, tiempos quirúrgicos, transfusión periquirúrgica, diagnóstico, diabetes, insuficiencia renal). ResultadosSe evaluó a 342 pacientes (256 intervenidos de colon y 86 de recto), distribuidos en 2 cohortes: periodo previo (218) y periodo postimplementación del programa (124). La incidencia acumulada de ILQ de la primera cohorte fue del 27,5% (IC 95%=21,6–33,4), y de la cohorte postintervención 16,9% (IC 95%=10,3–23,5; p=0,03). La mortalidad postoperatoria fue del 9,2% (IC 95%=5,4–13) en la primera cohorte y del 3,2% (IC 95%=0,1–6,3) en la cohorte postintervención (p=0,04). La administración inadecuada de la profilaxis disminuyó del 37,4% (IC 95%=30,4–44,6) al 18,9% (IC 95%=11,9–26,1; p=0,001). ConclusionesTras la implementación de un protocolo para la prevención de la infección quirúrgica en cirugía colorrectal se verifica una disminución significativa de la frecuencia de ILQ, de la mortalidad posquirúrgica y de la profilaxis antimicrobiana inadecuada." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pérez-Blanco V, García-Olmo D, Maseda-Garrido E, Nájera-Santos MC, García-Caballero J. Evaluación de un paquete de medidas para la prevención de la infección de localización quirúrgica en cirugía colorrectal. Cir Esp. 2015;93:222–228." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Actions \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Responsible person \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Preoperative phase</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1. Patient hygiene \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prior shower with chlorhexidine soap used twice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nursing staff \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2. Glycaemic control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain glycaemia <200mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgeons \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Intraoperative phase</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3. Glycaemic control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2% chlorhexidine in the skin area subject to surgery inside the theatre and allow to dry for 1–2min. Use povidone-iodine if the patient is sensitive to chlorhexidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgeons \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4. Standardisation of antimicrobial prophylaxis administration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin-clavulanic acid 2g or metronidazole 1500mg+cefazolin 2gAllergy to Beta-lactams: gentamicin 240mg+metronidazole 1500mgAdminister 30min before the incision Dose repetition: in case the surgery lasts more than 3hWithdrawal: within 48h after the surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SurgeonsAnaesthetists \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">5. Maintain patient normothermia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain normothermia (≈36.6°). Use of electric blanket \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AnaesthetistsCirculating nurse \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">6. Glove change and record \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">When surgery lasts more than 3h, after draining an abscess, after performing a colon anastomosis and when there is evidence of perforation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgeons \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Postoperative phase in the recovery room</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">7. Glycaemic control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Maintain glycaemia <200mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anaesthetists \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Postoperative phase in the ward</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">8. Surgical wound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Aseptic technique to change or remove a surgical wound dressing. Use saline for wound cleansing during the first 48h after the surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Surgeons \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab725140.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Protocol for Prevention of Surgical Site Infections in Colorectal Surgery." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "SD: standard deviation; BMI: body mass index; NNIS: National Nosocomial Infection System." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Pre-implementation cohort \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Post-implementation cohort \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">P \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 (44.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (40.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Men \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (55.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 (59.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Colon surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">163 (74.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Rectal surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 (25.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31(25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ASA≤II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">112 (51.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 (54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ASA≥III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 (48.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (46) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NNIS 0–1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 (37.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 (43.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NNIS 2–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">136 (62.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (56.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Perioperative transfusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (31.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (23.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative glycaemia>200mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Postoperative glycaemia>200mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (10.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">BMI>30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (8.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (18.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (24.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Creatinine>1.7mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab725137.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.3 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.7 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Surgery time \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">172.3 (68.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180.4 (62.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab725141.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Bivariate Study for Baseline Comparability of Both Cohorts." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "SD: standard deviation; SSI: surgical site infection; NNIS: National Nosocomial Infection System;." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Pre-implementation cohortNo.=218 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Post-implementation cohortNo.=124 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">P \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total SSI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60/218 (27.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21/124 (16.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Type of SSI</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Organ/space SSI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24/218 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/124 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Surface SSI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28/218 (12.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9/124 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Deep SSI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8/218 (3.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5/124 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Procedure</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SSI in colon surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44/163 (26.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15/93 (16.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SSI in rectal surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/55 (29.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/31 (19.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">NNIS risk</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SSI NNIS 0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/12 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/14 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SSI NNIS 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10/70 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/40 (15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.85 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SSI NNIS 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33/99 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/48 (14.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SSI NNIS 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/37 (43.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7/22 (31.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reintervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32/218 (14.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12/124 (9.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20/218 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/124 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Days of hospital stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.7 (14.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.7 (12.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Days of postoperative stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.6 (13.08) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.3 (11.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Days between surgery and SSI diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.3 (3.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.6 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab725139.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Primary Outcome Variables Obtained When Comparing Both Cohorts." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Pre-implementation cohortNo.=218 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Post-implementation cohortNo.=124 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">P \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n/No. (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n/No. (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Antimicrobial prophylaxis</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No record of prescription or administration in the medical record \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15/179 (8.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2/117 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.031 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No antibiotic withdrawal (a maximum of 48h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26/179 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6/117 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.018 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Antibiotic not included in the protocol and not clinically justified \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4/179 (2.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1/117 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Insufficient dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20/179 (11.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13/117 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Administration delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2/179 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0/117 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Compliance with all the antimicrobial prophylaxis requirements of the protocol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">112/179 (62.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95/117 (81.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Maintaining normoglycaemia</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Preoperative glycaemic record \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">186/218 (85.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115/124 (95) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Postoperative glycaemic record \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">184/218 (84.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115/124 (93.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Maintaining normothermia</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Use of electric blanket \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51/218 (23.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72/124 (58.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab725138.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Assessment of Adherence to Protocol." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reducing surgical site infections: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. 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Evaluation of a Preventive Surgical Site Infection Bundle in Colorectal Surgery

Evaluación de un paquete de medidas para la prevención de la infección de localización quirúrgica en cirugía colorrectal

Verónica Pérez-Blancoa,

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vperezb@salud.madrid.org

Corresponding author.

, Damián García-Olmob, Emilio Maseda-Garridoc, María Cruz Nájera-Santosa, Juan García-Caballeroa

a Servicio de Medicina Preventiva, Hospital Universitario La Paz, Madrid, Spain

b Servicio de Cirugía General, Hospital Universitario La Paz, Madrid, Spain

c Servicio de Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In spite of the improvements in surgical techniques that have been introduced during the last few years&#44; surgical site infections &#40;SSI&#41; continue to be a common complication&#46; It is estimated that slightly over 5&#37; of patients treated with any kind of surgery will suffer a SSI&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this kind of infection&#44; the highest rates correspond to colorectal surgery&#44; although in the literature we find a wide variability&#46; For example&#44; in a study conducted in England with follow-up of patients treated with colorectal surgery 30 days following hospital discharge&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> a SSI incidence of 27&#37; was recorded&#59; other multicentre study conducted in 140 English hospitals where 6528 colonic procedures<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a> were assessed&#44; shows a SSI incidence of 10&#37; &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;3&#8211;10&#46;8&#41;&#59; 40&#46;6&#37; of them were organ&#47;space infections&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; there are studies on colon and rectal surgery that have shown that certain initiatives may have a positive impact for addressing this problem&#46; For example&#44; Hedrick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> implemented a multidisciplinary protocol based on four actions&#58; adequate administration of prophylaxis&#44; to avoid extending prophylaxis for more than 24<span class="elsevierStyleHsp" style=""></span>h&#44; to record and maintain patient normothermia&#44; and to perform perioperative glycaemic control &#40;&#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; With this protocol&#44; a significant decrease in SSI incidence &#40;from 25&#46;6&#37; to 15&#46;9&#37; &#91;<span class="elsevierStyleItalic">P</span>&#60;&#46;05&#93;&#41; was achieved&#46; Another example is derived from the publication by Forbes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a> who conducted a prospective study in two cohorts &#40;pre- and post-implementation of the protocol&#41; of patients who underwent colorectal and hepatobiliary surgery&#46; The protocol consisted in the implementation of Clinical Practice Guidelines &#40;CPG&#41; for the prevention of SSI&#46; Health professionals&#8217; adherence to CPG and SSI rates was assessed and a decrease in SSI incidence from 14&#46;3&#37; to 8&#46;7&#37; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;21&#41; was achieved&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In addition to these examples&#44; several publications have shown that surgical procedure monitoring based on feedback by surgeons can significantly decrease infection rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7&#8211;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study is to assess the impact of a SSI improvement programme in colon and rectal surgery on the frequency of surgical infection&#44; its related complications and the mean hospital stay one year and a half after its implementation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">A quasi-experimental study was designed comparing a prospective cohort &#40;after the implementation of the protocol&#41; to a historical cohort&#46; The historical cohort consists of 218 patients&#44; who underwent surgery in two periods &#40;first semester of 2008 and first semester of 2011&#41;&#46; The cohort assessed after the implementation of the protocol consists of 124 patients&#44; who underwent surgery in the second semester of 2012&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This study was carried out in the General Surgery Department of Hospital Universitario La Paz &#40;HULP&#41; &#91;La Paz University Hospital&#93; of Madrid&#44; which performs about 3000 interventions in inpatients yearly and is divided into sections per specialty&#46; Patients hospitalised for more than 48<span class="elsevierStyleHsp" style=""></span>h in the General Surgery Department of HULP and treated by major colon and rectal surgery were included&#46; Patients hospitalised for less than 48<span class="elsevierStyleHsp" style=""></span>h were excluded from the study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A convenience nonprobability sampling was performed and all patients who met the inclusion criteria in the previously defined periods of time were enrolled&#46; The evaluation project was approved by the CEIC &#40;Comit&#233; de &#201;tica en Investigaci&#243;n Cl&#237;nica &#91;Clinical Research Ethics Committee&#93;&#41; of the hospital&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protocol</span><p id="par0045" class="elsevierStylePara elsevierViewall">The protocol for the prevention of surgical site infection in colorectal surgery is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; For its implementation&#44; the main clinical practice guidelines were reviewed&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Aseptic Preparation of the Patient</span><p id="par0050" class="elsevierStylePara elsevierViewall">Antiseptic shower&#46; It is recommended in some guidelines&#44; although some authors consider there is not enough evidence in favour of it compared to a shower with regular soap&#46; In most cases&#44; it is recommended to take a shower with regular soap or with chlorhexidine soap on the same day of the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Operative field preparation&#58; current evidence favours a preoperative preparation of the skin with chlorhexidine or chlorhexidine&#47;alcohol solutions such as 2&#37; chlorhexidine in isopropyl alcohol&#46; It is important to allow it to stand &#40;at least 1<span class="elsevierStyleHsp" style=""></span>min&#41; and air dry&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Antibiotic Prophylaxis</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The surgical antimicrobial prophylaxis consists in the administration&#44; preferably single&#44; of at least one antibiotic before the intervention in order to reduce the intraoperative microbial contamination so that it does not overcome the patient&#39;s defence mechanisms&#46; The intravenous route is the most frequent route of administration&#46; The antibiotic should be administered between 30 and 60<span class="elsevierStyleHsp" style=""></span>min before incision and at high enough doses to equal or exceed the minimum inhibitory concentration for the microorganism&#46; Such levels should be maintained throughout the intervention and even some hours after it&#59; for that reason&#44; in long surgical procedures&#44; additional doses may be required&#46; In the case of colon and rectal surgery&#44; prophylaxis should be always administered&#44; since it is a surgery which is&#44; at least&#44; contaminated&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">In some cases&#44; it will be a dirty surgery&#44; that is to say&#44; infected&#59; therefore&#44; antibiotic administration should be scheduled as empirical therapy&#46; For example&#44; this would be the case of a colonic perforation with associated peritonitis&#46;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">Colon and rectal surgery requires antibiotic combinations with coverage for the most common microorganisms&#58; anaerobic and gram-negative bacilli&#46; In our protocol&#44; we have taken into account the local and international guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Oral antibiotics are not recommended in the current guidelines&#44; since they do not provide better results and may be related to vomiting and abdominal pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">15&#44;16</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Preoperative and Postoperative Glycaemic Control</span><p id="par0085" class="elsevierStylePara elsevierViewall">Cardiovascular surgery studies showed that maintaining perioperative glucose levels<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL led to a lower incidence of SSI compared to controls&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">However&#44; current CPGs do not recommend a strict glycaemic control as a routine surgical practice due to the risk of hypoglycaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a> In our case&#44; it is recommended to maintain blood glucose levels<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL 24<span class="elsevierStyleHsp" style=""></span>h before and after the surgery&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Glove Change</span><p id="par0095" class="elsevierStylePara elsevierViewall">Glove change should be performed when the surgery is longer than three hours&#44; after draining an abscess&#44; after performing a colonic anastomosis&#44; and when there is evidence of perforation&#44; according to the measures proposed by observational studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#8211;21</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Partecke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> showed that wearing gloves for 91&#8211;150<span class="elsevierStyleHsp" style=""></span>min resulted in the perforation of at least one of them in 18&#46;1&#37; of studied cases&#46; From 150<span class="elsevierStyleHsp" style=""></span>min onwards&#44; this percentage increased to 23&#46;7&#37;&#46; Out of all the perforated gloves&#44; 66&#46;7&#37; corresponded to the dominant hand&#44; and microperforation was more frequently found in the index finger of that hand&#46; Major abdominal surgeries&#44; vascular and heart surgeries were the ones where more perforations were found&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> However&#44; Misteli et al&#46; showed that surgical glove perforation increases the risk of SSI&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Maintaining Patient Normothermia in the Operating Theatre</span><p id="par0105" class="elsevierStylePara elsevierViewall">Hypothermia causes vasoconstriction&#44; decreases tissular oxygen and can reduce the immune response&#46; Several studies have shown a decrease in the SSI incidence in patients subject to normothermia control during the intervention and the postoperative period&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">22&#8211;24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">This measure is currently recommended in several CPGs&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">11&#44;25</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Lastly&#44; it should be noted that other actions that were performed in the past&#44; such as mechanical bowel preparation&#44; have been discarded based on the current evidence&#44; since there are studies which show that it does not decrease faecal microorganism concentration in the intestinal lumen and that it can even change solid faeces into liquid ones&#44; which could facilitate bacteria movement towards the wound and towards the peritoneal cavity&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">At present&#44; mechanical bowel preparation is contraindicated as a routine measure&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Implementation of the Protocol and Independent and Outcome Variables</span><p id="par0125" class="elsevierStylePara elsevierViewall">The protocol was presented in two clinical sessions in the Department of Anaesthesia and the Colorectal Surgery Section&#46; Demographic&#44; clinical&#44; epidemiological and microbiological variables and those related to adherence to protocol were collected&#46; For the diagnosis of infection&#44; CDC criteria were used&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Statistical Analysis</span><p id="par0130" class="elsevierStylePara elsevierViewall">The quantitative variables are described as mean&#44; median and standard deviation &#40;SD&#41;&#46; Qualitative variables are described with absolute and relative frequencies&#46; Comparisons among quantitative variables were made using the Mann&#8211;Whitney test&#46; For comparisons among qualitative variables&#44; the Chi-square test or Fisher&#39;s test were used&#46; The analysis was performed with the PASW Statistics 18 programme&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0135" class="elsevierStylePara elsevierViewall">A total of 342 patients undergoing colon &#40;256&#41; and rectal &#40;86&#41; surgery were assessed&#59; they were divided into two cohorts&#58; a baseline one made up of 218 patients &#40;years 2008&#8211;2011&#41; and another one after the implementation of the programme &#40;year 2012&#41; made up of 124 patients&#46; The descriptive study of the main variables in both cohorts and the comparison between them are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; As it can be noted&#44; there are no statistically significant differences between the cohorts&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Cumulative incidences of total SSI and according to its location&#44; for all patients and by procedure are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; The primary outcome&#44; the incidence of total SSI&#44; is significantly lower after protocol implementation&#46; In the case of SSI&#44; however&#44; the reduction was not statistically significant&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Postoperative mortality&#59; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;04&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Lastly&#44; the results of the assessment of adherence to protocol are shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">In our hospital&#44; the implementation of a protocol for the prevention of SSI has yielded a decrease from 27&#46;5&#37; to 16&#46;9&#37; in the total frequency of these infections&#59; this decrease is similar to that described by other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5&#44;30&#8211;33</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">For example&#44; Hendrick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> achieved a SSI decrease in colorectal surgery from 25&#46;6&#37; to 15&#46;9&#37; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41; after the implementation of a multidisciplinary protocol&#44; with an increase in the percentage of adequate administration of prophylaxis from 68&#37; to 91&#37; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#44; among other measures&#46; The study conducted by Wick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> also shows a 33&#46;3&#37; decrease in SSI in colorectal surgery 12 months after the implementation of a programme based on preoperative patient hygiene with chlorhexidine&#44; standardisation of surgical skin preparation&#44; maintainence of patient normothermia and the adequate administration of antibiotic prophylaxis&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our case&#44; protocol measures were also implemented in a care bundle fashion&#44; that is to say&#44; simple measures&#44; which must be performed together&#44; and which are thus potentiated&#46; One of the measures was the protocolisation of antibiotic prophylaxis&#44; which has shown to be effective in surgical processes since long ago and it is&#44; therefore&#44; a measure applied in hospitals in our region&#46; Nevertheless&#44; it does not fit in with all parameters &#40;type of antimicrobial drug&#44; administration time and withdrawal time&#41; uniformly in all the centres&#44; and even in the same hospital there may be differences among departments or among professionals&#46; We considered that a non-justified variability was not acceptable and were very strict when considering prophylaxis as &#8220;inadequate&#8221; because it did not meet all the proposed parameters of the protocol&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In addition to the positive results on infection&#44; our study shows a significant decrease in postoperative mortality&#46; It is not strange that both results have gone together&#44; since previous publications have already shown this<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#44;31</span></a>&#58; we highlight the publication of Crolla et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> which shows a similar decrease to that of our study in SSI&#44; mean hospital stay and mortality after the implementation of a bundle&#46; For our part&#44; as shown in the Results section&#44; we have conducted a study on risk factors for postoperative mortality in all studied patients and both SSI of any type and organ&#47;space SSI proved to be independent risk factors&#46; For hospital stay&#44; in our study&#44; a decrease was also observed in the post-implementation group with a mean of three days&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Adherence to protocol has been evaluated using a series of variables related to compliance with the main measures&#46; As presented in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#44; most items show a significant improvement&#46; Notwithstanding&#44; all measures could not be evaluated&#59; for example&#44; temperature could not be recorded during the intervention&#44; although the use of an electric blanket was satisfactorily recorded&#46; We could not record glove change either&#59; therefore&#44; we do not know adherence to this measure and cannot quantify its impact on final outcomes&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Lastly&#44; regarding adherence to protocol&#44; it should be noted that the main advantage we have had is that measures did not require any costs and most of them had already been partially introduced&#59; therefore&#44; its systematisation has not involved any kind of additional reorganisation&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In order to conclude the discussion on results&#44; we should mention that in some studies the authors have not observed improvements in SSI rates after the implementation of similar measures&#46; In relation to data from our region&#44; the publication on a multicentre study conducted in 19 Catalonian hospitals stands out&#46; The authors recorded a SSI incidence in colon cancer surgery of 23&#46;2&#37; &#40;95&#37; CI&#58; 18&#46;9&#8211;27&#46;6&#41;&#44; which did not vary after the application of a bundle of preventive measures&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Considering study limitations&#44; we should highlight that&#44; due to the outcome assessment design&#44; which compares patients who underwent surgery some years ago&#44; we cannot state that these results are due to the protocol alone&#44; since there may be other uncontrolled factors that could have contributed to this&#46; For example&#44; each surgeon&#39;s experience or the technical improvements that may have taken place over the years are difficult-to-control factors&#46; Other factors that may have had an influence on the results include the further knowledge on SSI-related factors acquired over time or&#44; in our case&#44; the specialisation since the General Surgery Department was reorganised in sections&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">It should also be noted that&#44; although the control or historical cohort was prospectively collected&#44; some variables were retrospectively collected for this study&#46; This implies that some data could not be collected in all patients&#44; for example&#44; patient&#39;s height and weight for BMI calculation&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Another limitation that should be taken into account is the &#8220;observational bias&#8221;&#44; given that after protocol implementation and clinical sessions offered in the departments&#44; health professionals knew that they were highly likely to be audited&#44; since we had committed to provide feedback on results at least biannually&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Nevertheless&#44; and in spite of the abovementioned methodological limitations&#44; we believe that the implementation of evidence-based&#44; simple&#44; feasible recommendations together with a strong leadership from the responsible clinicians involved&#44; are useful tools to improve surgical patient safety&#44; as shown at a local level&#46; We base such statement on the previously mentioned analysis&#44; where a significant decrease in the frequency of SSI&#44; postoperative mortality and inadequate antimicrobial prophylaxis is verified&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of Interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres468424"
          "titulo" => "Abstract"
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            0 => array:2 [
              "identificador" => "abst0005"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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          "titulo" => "Patients and Methods"
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              "titulo" => "Study Population"
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          "titulo" => "Protocol"
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            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Aseptic Preparation of the Patient"
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              "titulo" => "Antibiotic Prophylaxis"
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              "titulo" => "Preoperative and Postoperative Glycaemic Control"
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              "identificador" => "sec0040"
              "titulo" => "Glove Change"
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              "identificador" => "sec0045"
              "titulo" => "Maintaining Patient Normothermia in the Operating Theatre"
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              "titulo" => "Implementation of the Protocol and Independent and Outcome Variables"
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              "titulo" => "Statistical Analysis"
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    "fechaRecibido" => "2014-05-07"
    "fechaAceptado" => "2014-12-03"
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          "clase" => "keyword"
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            0 => "Colorectal surgery"
            1 => "Surgical site infection"
            2 => "Postoperative mortality"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Cirug&#237;a colorrectal"
            1 => "Infecci&#243;n de localizaci&#243;n quir&#250;rgica"
            2 => "Mortalidad postoperatoria"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness of a protocol for the prevention of surgical site infection &#40;SSI&#41; in colorectal surgery&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evaluation of 2 cohorts of patients undergoing colon and rectal surgery in a tertiary public hospital&#58; A historical cohort &#40;2008&#8211;2011&#41; and a prospective one &#40;after the implementation of the programme in 2012&#41;&#46; The main measures established were&#58; Adequacy of preoperative antimicrobial prophylaxis&#44; maintaining patient normothermia and appropriate glove change during the intervention&#46; Comparability of the two cohorts was determined by a bivariate analysis of age&#44; sex&#44; NNIS index&#44; ASA index&#44; surgical time&#44; perioperative transfusion&#44; diagnosis&#44; diabetes and renal failure&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We assessed 342 patients &#40;256 underwent colon surgery and 86 rectal surgery&#41;&#44; divided into 2 cohorts&#58; prior period &#40;218&#41;&#44; and post-implementation period &#40;124&#41;&#46; The cumulative incidence of SSI in the first cohort was 27&#46;5&#37; &#40;95&#37; CI&#44; 21&#46;6&#8211;33&#46;4&#41;&#44; and in the post-intervention cohort 16&#46;9&#37; &#40;95&#37; CI&#44; 10&#46;3&#8211;23&#46;5&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;03&#41;&#46; Postoperative mortality was 9&#46;2&#37; &#40;95&#37; CI&#44; 5&#46;4&#8211;13&#41; in the first cohort and 3&#46;2&#37; &#40;95&#37; CI&#44; 0&#46;1&#8211;6&#46;3&#41; in the post-intervention cohort &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;04&#41;&#46; The inadequacy of prophylaxis decreased from 37&#46;4&#37; &#40;95&#37; CI&#44; 30&#46;4&#8211;44&#46;6&#41; to 18&#46;9&#37; &#40;95&#37; CI&#44; 11&#46;9&#8211;26&#46;1&#41; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A significant decrease in the frequency of SSI&#44; post-surgical mortality and inadequate antimicrobial prophylaxis is verified after the implementation of a protocol in colorectal surgery</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la efectividad de un protocolo para la prevenci&#243;n de la infecci&#243;n de localizaci&#243;n quir&#250;rgica &#40;ILQ&#41; en cirug&#237;a colorrectal&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n de 2 cohortes de pacientes intervenidos de colon y recto en un hospital p&#250;blico de tercer nivel&#58; una cohorte hist&#243;rica &#40;2008&#8211;2011&#41; y otra prospectiva &#40;posterior a la implementaci&#243;n del programa en 2012&#41;&#46; Las principales medidas establecidas fueron&#58; adecuaci&#243;n de la profilaxis antimicrobiana prequir&#250;rgica&#44; mantenimiento de la normotermia del paciente en el quir&#243;fano y adecuaci&#243;n del cambio de guante durante la intervenci&#243;n&#46; Se determin&#243; la comparabilidad de ambas cohortes mediante un an&#225;lisis bivariable de la edad&#44; sexo&#44; factores e &#237;ndices de riesgo &#40;&#237;ndice NNIS&#44; &#237;ndice ASA&#44; tiempos quir&#250;rgicos&#44; transfusi&#243;n periquir&#250;rgica&#44; diagn&#243;stico&#44; diabetes&#44; insuficiencia renal&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se evalu&#243; a 342 pacientes &#40;256 intervenidos de colon y 86 de recto&#41;&#44; distribuidos en 2 cohortes&#58; periodo previo &#40;218&#41; y periodo postimplementaci&#243;n del programa &#40;124&#41;&#46; La incidencia acumulada de ILQ de la primera cohorte fue del 27&#44;5&#37; &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#44;6&#8211;33&#44;4&#41;&#44; y de la cohorte postintervenci&#243;n 16&#44;9&#37; &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#44;3&#8211;23&#44;5&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; La mortalidad postoperatoria fue del 9&#44;2&#37; &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;4&#8211;13&#41; en la primera cohorte y del 3&#44;2&#37; &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#8211;6&#44;3&#41; en la cohorte postintervenci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46; La administraci&#243;n inadecuada de la profilaxis disminuy&#243; del 37&#44;4&#37; &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#44;4&#8211;44&#44;6&#41; al 18&#44;9&#37; &#40;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#44;9&#8211;26&#44;1&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Tras la implementaci&#243;n de un protocolo para la prevenci&#243;n de la infecci&#243;n quir&#250;rgica en cirug&#237;a colorrectal se verifica una disminuci&#243;n significativa de la frecuencia de ILQ&#44; de la mortalidad posquir&#250;rgica y de la profilaxis antimicrobiana inadecuada&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez-Blanco V&#44; Garc&#237;a-Olmo D&#44; Maseda-Garrido E&#44; N&#225;jera-Santos MC&#44; Garc&#237;a-Caballero J&#46; Evaluaci&#243;n de un paquete de medidas para la prevenci&#243;n de la infecci&#243;n de localizaci&#243;n quir&#250;rgica en cirug&#237;a colorrectal&#46; Cir Esp&#46; 2015&#59;93&#58;222&#8211;228&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Actions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Responsible person&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Preoperative phase</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&#46; Patient hygiene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prior shower with chlorhexidine soap used twice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nursing staff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&#46; Glycaemic control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain glycaemia &#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgeons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Intraoperative phase</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&#46; Glycaemic control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#37; chlorhexidine in the skin area subject to surgery inside the theatre and allow to dry for 1&#8211;2<span class="elsevierStyleHsp" style=""></span>min&#46; Use povidone-iodine if the patient is sensitive to chlorhexidine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgeons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#46; Standardisation of antimicrobial prophylaxis administration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin-clavulanic acid 2<span class="elsevierStyleHsp" style=""></span>g or metronidazole 1500<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>cefazolin 2<span class="elsevierStyleHsp" style=""></span>gAllergy to Beta-lactams&#58; gentamicin 240<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>metronidazole 1500<span class="elsevierStyleHsp" style=""></span>mgAdminister 30<span class="elsevierStyleHsp" style=""></span>min before the incision Dose repetition&#58; in case the surgery lasts more than 3<span class="elsevierStyleHsp" style=""></span>hWithdrawal&#58; within 48<span class="elsevierStyleHsp" style=""></span>h after the surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SurgeonsAnaesthetists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5&#46; Maintain patient normothermia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain normothermia &#40;&#8776;36&#46;6&#176;&#41;&#46; Use of electric blanket&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AnaesthetistsCirculating nurse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6&#46; Glove change and record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">When surgery lasts more than 3<span class="elsevierStyleHsp" style=""></span>h&#44; after draining an abscess&#44; after performing a colon anastomosis and when there is evidence of perforation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgeons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Postoperative phase in the recovery room</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#46; Glycaemic control&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain glycaemia &#60;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anaesthetists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Postoperative phase in the ward</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#46; Surgical wound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aseptic technique to change or remove a surgical wound dressing&#46; Use saline for wound cleansing during the first 48<span class="elsevierStyleHsp" style=""></span>h after the surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgeons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Protocol for Prevention of Surgical Site Infections in Colorectal Surgery&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; BMI&#58; body mass index&#59; NNIS&#58; National Nosocomial Infection System&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Pre-implementation cohort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Post-implementation cohort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98 &#40;44&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;40&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Men&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120 &#40;55&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74 &#40;59&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Colon surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">163 &#40;74&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Rectal surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55 &#40;25&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ASA<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112 &#40;51&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#40;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">ASA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106 &#40;48&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">NNIS 0&#8211;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82 &#40;37&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54 &#40;43&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">NNIS 2&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">136 &#40;62&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;56&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Perioperative transfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;31&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Preoperative glycaemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Postoperative glycaemia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;10&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">BMI&#62;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;8&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;18&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Creatinine&#62;1&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;3 &#40;13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;7 &#40;13&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Surgery time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">172&#46;3 &#40;68&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">180&#46;4 &#40;62&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Bivariate Study for Baseline Comparability of Both Cohorts&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; SSI&#58; surgical site infection&#59; NNIS&#58; National Nosocomial Infection System&#59;&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Pre-implementation cohortNo&#46;&#61;218&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Post-implementation cohortNo&#46;&#61;124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Total SSI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#47;218 &#40;27&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#47;124 &#40;16&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Type of SSI</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Organ&#47;space SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#47;218 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;124 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surface SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#47;218 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;124 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Deep SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#47;218 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#47;124 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Procedure</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SSI in colon surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#47;163 &#40;26&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#47;93 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SSI in rectal surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;55 &#40;29&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;31 &#40;19&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">NNIS risk</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SSI NNIS 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;12 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;14 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SSI NNIS 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#47;70 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;40 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SSI NNIS 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#47;99 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;48 &#40;14&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SSI NNIS 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;37 &#40;43&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#47;22 &#40;31&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reintervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#47;218 &#40;14&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#47;124 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Death</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#47;218 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#47;124 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Days of hospital stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;7 &#40;14&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;7 &#40;12&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Days of postoperative stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;6 &#40;13&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;3 &#40;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Days between surgery and SSI diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;3 &#40;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;6 &#40;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Pre-implementation cohortNo&#46;&#61;218&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Post-implementation cohortNo&#46;&#61;124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n&#47;No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n&#47;No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Antimicrobial prophylaxis</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No record of prescription or administration in the medical record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#47;179 &#40;8&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#47;117 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;031&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No antibiotic withdrawal &#40;a maximum of 48<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#47;179 &#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#47;117 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;018&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#47;179 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#47;117 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Insufficient dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#47;179 &#40;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#47;117 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Administration delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#47;179 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#47;117 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Compliance with all the antimicrobial prophylaxis requirements of the protocol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112&#47;179 &#40;62&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#47;117 &#40;81&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Maintaining normoglycaemia</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Preoperative glycaemic record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">186&#47;218 &#40;85&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115&#47;124 &#40;95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Postoperative glycaemic record&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">184&#47;218 &#40;84&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115&#47;124 &#40;93&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Maintaining normothermia</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use of electric blanket&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#47;218 &#40;23&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#47;124 &#40;58&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Assessment of Adherence to Protocol&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:34 [
            0 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reducing surgical site infections&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Reichman"
                            1 => "J&#46; Greenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Obstet Gynecol"
                        "fecha" => "2009"
                        "volumen" => "2"
                        "paginaInicial" => "212"
                        "paginaFinal" => "221"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20111657"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surveillance of surgical site infections in NHS hospitals in England 2010&#47;2011"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Health Protection Agency"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "December 2011"
                        "editorial" => "Health Protection Agency"
                        "editorialLocalizacion" => "London"
                      ]
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                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Post-discharge surveillance to identify colorectal surgical site infection rates and related costs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Tanner"
                            1 => "D&#46; Khan"
                            2 => "C&#46; Aplin"
                            3 => "J&#46; Ball"
                            4 => "M&#46; Thomas"
                            5 => "J&#46; Bankart"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2009.03.021"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2009"
                        "volumen" => "72"
                        "paginaInicial" => "243"
                        "paginaFinal" => "250"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19446918"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adverse impact of surgical site infections in English hospitals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Coello"
                            1 => "A&#46; Charlett"
                            2 => "J&#46; Wilson"
                            3 => "V&#46; Ward"
                            4 => "A&#46; Pearson"
                            5 => "P&#46; Boriello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhin.2004.10.019"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hosp Infect"
                        "fecha" => "2005"
                        "volumen" => "60"
                        "paginaInicial" => "93"
                        "paginaFinal" => "103"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15866006"
                            "web" => "Medline"
                          ]
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Article information

ISSN: 21735077
Original language: English

DOI:10.1016/j.cireng.2014.12.016

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	24	5	29
2024 September	74	3	77
2024 August	29	3	32
2024 July	37	3	40
2024 June	41	1	42
2024 May	39	4	43
2024 April	38	6	44
2024 March	57	7	64
2024 February	39	2	41
2024 January	43	7	50
2023 December	51	6	57
2023 November	54	7	61
2023 October	63	9	72
2023 September	19	2	21
2023 August	47	3	50
2023 July	58	5	63
2023 June	36	10	46
2023 May	66	8	74
2023 April	38	7	45
2023 March	32	9	41
2023 February	38	19	57
2023 January	38	3	41
2022 December	29	16	45
2022 November	51	15	66
2022 October	38	13	51
2022 September	79	32	111
2022 August	31	19	50
2022 July	19	6	25
2022 June	17	8	25
2022 May	57	3	60
2022 April	39	8	47
2022 March	42	11	53
2022 February	53	3	56
2022 January	53	7	60
2021 December	24	8	32
2021 November	33	14	47
2021 October	26	11	37
2021 September	18	10	28
2021 August	20	10	30
2021 July	15	5	20
2021 June	24	6	30
2021 May	23	16	39
2021 April	36	11	47
2021 March	28	17	45
2021 February	17	8	25
2021 January	18	16	34
2020 December	25	7	32
2020 November	19	3	22
2020 October	16	6	22
2020 September	23	10	33
2020 August	16	7	23
2020 July	29	9	38
2020 June	23	13	36
2020 May	15	17	32
2020 April	9	4	13
2020 March	14	10	24
2020 February	34	9	43
2020 January	15	14	29
2019 December	20	5	25
2019 November	12	5	17
2019 October	18	6	24
2019 September	24	8	32
2019 August	13	3	16
2019 July	14	12	26
2019 June	42	19	61
2019 May	146	43	189
2019 April	39	21	60
2019 March	15	5	20
2019 February	18	13	31
2019 January	13	7	20
2018 December	13	6	19
2018 November	19	6	25
2018 October	18	4	22
2018 September	20	5	25
2018 August	3	4	7
2018 July	7	0	7
2018 June	9	1	10
2018 May	6	3	9
2018 April	12	2	14
2018 March	9	3	12
2018 February	11	1	12
2018 January	13	6	19
2017 December	9	1	10
2017 November	15	1	16
2017 October	23	3	26
2017 September	9	4	13
2017 August	19	1	20
2017 July	25	3	28
2017 June	54	2	56
2017 May	40	9	49
2017 April	35	8	43
2017 March	40	10	50
2017 February	20	8	28
2017 January	25	12	37
2016 December	19	13	32
2016 November	31	5	36
2016 October	48	13	61
2016 September	72	10	82
2016 August	30	6	36
2016 July	33	5	38
2016 June	35	13	48
2016 May	41	26	67
2016 April	48	23	71
2016 March	47	29	76
2016 February	41	25	66
2016 January	38	16	54
2015 December	23	21	44
2015 November	27	14	41
2015 October	28	15	43
2015 September	33	23	56
2015 August	36	12	48
2015 July	9	9	18
2015 May	0	1	1
2015 April	2	2	4

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