APIC 2026: How a Standardized Surgical Checklist Helped Eliminate Colon Surgical Site Infections

A community hospital in central Florida eliminated additional colon surgical site infections (SSIs) after implementing a standardized perioperative checklist designed to improve adherence to evidence-based prevention practices, according to research presented at the Association for Professionals in Infection Prevention and Epidemiology Annual Conference and Exposition (APIC 2026) held from June 15 to 17, 2026, in Nashville, Tennessee.

The poster, "Reducing Colon Surgical Site Infections Through a Standardized Perioperative Checklist Process," was presented by Mary L. Prinzivalli, DHSc, RN, CPHQ, CIC, LTC-CIP, cowritten with Fabiola Sterlin, MD, MS-IDGH, MPH, CIC, both infection preventionists (IPs) at Orlando Health South Lake Hospital. The project highlights how multidisciplinary collaboration and standardized processes can strengthen adherence to colorectal surgery prevention bundles and improve patient outcomes.

Colon surgical site infections (SSIs) remain among the most challenging health care-associated infections because colorectal procedures expose health care personnel to bacteria from the gastrointestinal tract. Even small deviations from recommended prevention practices can significantly increase infection risk.

The initiative was launched after infection prevention staff identified 2 colon SSIs at the 270-bed community hospital in late 2024. Those infections resulted in an estimated standardized infection ratio (SIR) of 1.288 and prompted a comprehensive review of perioperative practices.

Prinzivalli told Infection Control Today^® (ICT^®), “Standardizing perioperative processes through a multidisciplinary checklist significantly improved antibiotic prophylaxis adherence and contributed to eliminating additional colon SSIs, highlighting the critical role of consistent bundle [adherence].”

According to Prinzivalli and Sterlin, root cause analyses revealed inconsistencies in adherence to the elements of the colorectal SSI prevention bundle. "Root cause analyses identified inconsistent adherence to colorectal SSI prevention bundle elements, including omission of recommended prophylactic antibiotics and variation in clean-dirty instrumentation practices," the authors reported.

“The key issues included: Inconsistent administration of recommended prophylactic antibiotics, Variability in clean vs dirty instrumentation practices, and Lack of standardization across surgical teams,” Prinzivalli told the audience at the poster theatre. “These gaps created variability in practice, increasing infection risk. So, our goal was to standardize care processes and improve adherence to evidence-based prevention strategies.”

Recognizing that multiple departments influenced surgical outcomes, the organization assembled a multidisciplinary team that included anesthesiologists, surgeons, operating room leadership, administrators, and infection prevention professionals.

Together, the team, which included surgeons, anesthesiologists, operating room leadership, IPs, and administrative leadership, developed a standardized perioperative checklist to ensure that critical preventive measures were consistently performed and documented. The checklist incorporated preoperative and intraoperative verification of recommended prophylactic antibiotic administration, specifically cefazolin plus metronidazole when appropriate. It also included documentation of clean-dirty instrument separation and required gown and glove changes during key phases of surgery.

The intervention focused heavily on improving antibiotic stewardship and adherence to established guidelines. Prinzivalli said at the poster theatre, “The goal was to ensure consistent execution of infection prevention practices for every colon procedure.”

Before implementation, audits revealed substantial opportunities for improvement. Baseline adherence to recommended prophylactic antibiotic regimens was only 29%, while nearly one-third of patients received inappropriate agents or experienced missed doses.

Following the implementation of the checklist, performance steadily improved.

The researchers audited 52 colon procedures performed between January and November 2025. Adherence to recommended prophylaxis increased to 50% during April through June and further improved to 55% during July through September.

At the same time, inappropriate prophylaxis rates declined significantly.

"After implementing the perioperative checklist, adherence improved to 50% by April–June and 55% by July–September, while inappropriate prophylaxis declined to 18%," the authors reported.

By October and November, the gains were sustained. Recommended prophylaxis adherence remained at 50%; alternative antibiotic agents were used only when clinically indicated todue of allergies; and investigators reported no missed antibiotic doses.

The checklist also reinforced adherence to intraoperative practices. Adherence with clean-dirty instrument separation protocols, along with required gown and glove changes, remained at 100% throughout the monitoring period.

Most notably, no additional colon SSIs occurred among the audited procedures after the intervention was implemented.

The authors noted that the project demonstrated a strong association between improved adherence with prevention bundle elements and reductions in infection risk.

"Implementation of a standardized perioperative checklist improved adherence to recommended prophylactic antibiotics and other key SSI prevention measures," Prinzivalli and Sterlin concluded.

They added that "strengthened antibiotic adherence was associated with the elimination of additional SSIs in 2025," underscoring the importance of consistent execution of evidence-based practices.

The findings reinforce a lesson frequently emphasized in infection prevention: preventing surgical site infections often depends less on developing new interventions and more on ensuring reliable implementation of practices already known to work.

For health care organizations seeking to reduce colorectal SSIs, the Orlando Health experience demonstrates that standardized checklists can serve as an effective tool for improving accountability, reducing variability, and enhancing patient safety across the perioperative continuum.