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How to navigate the journey to where the wild things (SSIs) are in the OR

Publish Date: 3/29/2012

Sharon A. McNamara, MSN, RN, CNOR and Shelby Lassiter BSN, RN, CPHQ, CIC, helped attendees navigate the defect analysis process for finding and preventing surgical site infections (SSIs) in the session “Where the Wild Things are: Surgical Site Infection Defect Analysis and Prevention.” Surgical site infections are the wild things in the OR and are frightening for health care providers and patients. They can be life- threatening, life-ending, and most certainly life-altering occurrences for patients who contract them, and they are costly for everyone. McNamara stated that of the more than 50 million surgical procedures that are performed each year, 300,000 SSIs occur and of those patients, 8,000 die. These infections cost approximately $60,000 per patient to treat and increase each patient’s hospital stay by six days. She reminded the audience that these costs are not reimbursed as these infections are deemed preventable events.

McNamara said that SSIs are preventable and can almost always be tied to issues of normalized deviance   where lapses in practice become accepted practice and lead to complications   or sources of infection that the patient brings with him or her that are not recognized preoperatively. On the patient side of the equation, acquiring an SSI depends on a patient’s age, body weight and condition, immune function, habits (eg, smoking), chronic diseases (eg, diabetes), and the presence of a pre-existing infection. Health care, especially surgery, provides contributing factors that include hand hygiene, skin prep, environmental cleaning, hair removal, gentle tissue handling, surgical attire, antibiotic prophylaxis, prevention of hypothermia, wound management, and keeping OR time to a minimum.

Once an SSI has been identified, a defect analysis must occur to determine how it happened, why it happened, and how future infections can be prevented. This requires asking questions, observing practices, and not making assumptions. It requires a team to make these assessments so that the problems can be viewed through the “multiple lenses” that team member’s experience and observations provide. The sooner a problem is identified the better, to correct the current problem as quickly as possible and prevent extended complications for patients and to correct any normalized deviance that may have lead to the problem. Normalized deviance that is often seen in the OR includes inconsistent hand hygiene practices; cutting corners to increase turn over time; not changing, using, or removing gloves appropriately; and wearing artificial nails. Excuses for these deviant practices include thinking that the rules are “stupid,” Lassiter said that some rules may be stupid and it is not wrong to challenge them, but this requires investigation and research to determine how to best replace or change the rule in question, not just” disregarding the rule and doing your own thing.” Lassiter also included new technology, complex work environment, competing priorities, and under appreciating the risk and its consequences. She noted that in the OR,” if you don’t practice good hand hygiene, it may not be apparent to you how that affects SSI rates.” This makes the consequences vague and so disregarding the rule to wash hands after the removal of gloves may not seem that important.

Lassiter stressed the importance of performing a Gemba walk, which is observing the actual practices that are occurring in all areas that have had contact with the patient, to identify lapses in practice. Not surprisingly, actual practice may vary significantly from what administrators or managers say is routine practice in their facilities. She encouraged attendees to have a process to analyze these defect observations that use a standard investigative tool and not to be afraid to challenge clinical practices and traditional ways of providing patient care. An investigator needs to provide what Lassiter called an environment of psychological safety so that practitioners feel comfortable discussing the problem and learning from the experience. A punitive environment will not be effective.

After all the evidence has been gathered Lassiter said the team must prioritize the issues and decide which one must be acted on first to prevent future problems. Risk factors must be reduced and the results of these efforts must be monitored and measured to see if the efforts are successful. One of the most important points she said, is that the information learned and the changes made must be communicated to the entire facility and anyone involved in caring for patients. This may include family members and the patient if appropriate. On a final note, she told attendees “Work culture influences patient outcomes,” and encouraged them to take a closer look at there own cultures and practices for the sake of patients.

Guidelines for Perioperative Practice


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