A Checklist for Clean Cuts: Isolation Bundle Reduces SSIs in High-Risk Surgeries

Katherine Hayes, BSN, RN, CNOR; Tiffany Reyna, BSN, RN, CNOR; Rachel Miller, MSN, RN, CNOR, NPD-BC, at AORN 2025.

At Houston Methodist West Hospital, a focused team of perioperative nurses, Katherine Hayes, BSN, RN, CNOR; Tiffany Reyna, BSN, RN, CNOR; Rachel Miller, MSN, RN, CNOR, NPD-BC; launched a practical yet powerful initiative to curb surgical site infections (SSIs) in high-risk procedures—specifically, hysterectomies and colorectal surgeries.

To share how they tackled this problem, the perioperative nurses presented a poster titled “Interoperative Isolation Bundle to Reduce Citric Surgical Site Infections for Hysterectomies and Colorectal Surgical Procedures” at the Association of periOperative Registered Nurses (AORN) Global Surgical Conference & Expo held April 5 through 9, 2025, in Boston, Massachusetts.

These procedures inherently pose elevated infection risks due to the challenges of maintaining sterility between clean and contaminated fields. By standardizing intraoperative isolation practices with a detailed checklist, the team not only improved staff compliance but also significantly reduced infection rates.

In early 2022, hospital leadership noted a troubling trend—rising SSIs in these procedures. A 3-month observational period followed, during which departures from recommended isolation protocols were identified. Surgeons and operating room (OR) staff were found to use inconsistent techniques when transitioning between the contaminated and clean portions of procedures. This variance posed direct risks for cross-contamination.

“The unit's Innovation and Evidence-Based Practice Committee discovered the use of a standardized interoperative isolation bundle to establish clear boundaries between the clean and contaminated portions of these procedures can reduce in size, such as a change of gowns and gloves when moving from dirty to clean, use of a separate closing tray, irrigation of the wound, etc,” the authors wrote.

The group also added a dedicated surgical checklist to standardize these steps.

Staff education was pivotal. All OR personnel received training on the new bundle, including its rationale, components, and practical application. A pre-education survey assessed staff knowledge and revealed significant variability in existing practices—underscoring the urgency for change.

Six months after implementation, the results were telling. Outpatient SSIs dropped to zero by April 2024. While inpatient SSIs still occurred, their overall frequency decreased. Notably, the checklist helped establish a consistent practice in the OR and increased awareness among both surgeons and nurses. Staff found the visual and procedural cues helpful in maintaining the “dirty-to-clean” discipline critical in these operations.

The team developed a series of next steps to build on this success. These include incorporating the checklist into OR preference cards to reinforce its use during applicable procedures. New staff will be introduced to the bundle during orientation while existing staff will receive ongoing education and reeducation. Additionally, the hospital plans to collaborate with med-surg and floor nurses to establish a postoperative wound care bundle to extend infection prevention beyond the OR.

Monitoring compliance will be key. The team aims to integrate bundle adherence tracking into the electronic health record, coupled with periodic spot checks.