PRE-OP PUSH The on-time delivery of antibiotics is just one aspect covered by a bundled approach to patient care.

How certain are you that your surgeons and staff are doing all they can to prevent surgical site infections? Are they prescribing pre-op showers with chlorhexidine gluconate, warming patients effectively, delivering antibiotic prophylaxis and practicing sterile technique in the OR? Infection control bundles — multidisciplinary programs based on adherence to published evidence and best practice guidelines — eliminate the guesswork and ensure each patient receives care designed to prevent SSIs.

Add and adapt
It's best to develop bundles based on frontline feedback rather than mandates handed down from administration. You should also simplify the bundle's protocols and identify the stakeholders along the continuum of care: the physicians and nurses who educate patients about the importance of following infection control directives well before surgery, the pre-op nurses who warm patients, and the surgical team who must always maintain sterile technique and ensure other intraoperative processes are followed.

Establishing a standardized approach to preventing SSIs isn't easy if your facility hosts various specialties. Engaging patients and getting infection control protocols started before patients present for surgery can also be a challenge, especially if they come from the practices of numerous surgeons.

So how do you create a bundle framework that's right for your facility? Look at your rates of infections to determine where you might have a problem, and where your infection control efforts need to improve most urgently. Perhaps you have a high infection rate following colectomies. Identify your priorities for improving the care of these patients and put a data-driven plan in place. Review relevant literature and ask other facilities about how they handle similar patients. There are also established bundles available that you can access and use. Map out the stakeholders for each element of the bundle and get them all onboard with making the necessary process improvements.

Bundles provide the basic structure and framework of effective infection control protocols, but each surgical specialty and case has unique requirements, so a standardized approach to SSI prevention actually involves using one-off bundles in some cases. It's up to you and your infection preventionist to create an adaptive work environment that lets staff adjust the bundles' protocols for individual patients. Electronic medical records have the potential to help by alerting your staff to the care individual patients require. For example, the EMR could flag patients who are scheduled for joint replacement procedures, so they're placed on a care pathway that ensures they're treated with the required bundle.

Proven results
Evidence touting the effectiveness of bundled care is out there. Researchers at Duke University Medical Center in Durham, N.C., created an SSI-prevention bundle — it included staff educational materials, disinfecting showers before surgery, antibiotics administration and wound care — in 2011 and compared infection rates in 346 patients who underwent colorectal surgery before the bundle was implemented and 213 who were operated on afterward. The bundle helped reduce the rate of superficial SSIs from 19% to 6% and post-op sepsis from 8.5% to 2.5%, according to the findings, which were published in JAMA Surgery (osmag.net/dQ7gZP).

At Johns Hopkins, we implemented a bundled approach to prevent SSIs during colorectal procedures. The bundle established best practices for antibiotic selection and dosing, skin preparation, maintenance of normal body temperature and intraoperative sterile technique. The interventions were implemented gradually over 5 years, during which time our infection rate dropped from 30% to 6%. Our findings show that a standardized, team-led approach to infection prevention works. They also show that it takes time and a lot of work to get the staff engaged, gather feedback about issues they face on the front line and implement the changes needed to make real improvement happen.

Expected evolution
Surgical teams appreciate transparency and structure. Bundles provide that. Teams also want feedback about their performance. That's where you come in. Educate staff so they're aware of the different standards and policies that cover the best ways to prevent infections. Every stakeholder in the process must receive that message. If you share how and why a bundle was built with clinical managers, also include the frontline staff in the conversations so they have an ownership stake in the process. Monitor their performance on a weekly or monthly basis to ensure they're complying with the bundle's protocols.

Once you build the framework for implementing bundled care for cases with the most critical need of improvement, you'll more easily apply the same principles to other areas of concern. A bundled approach also dovetails with the emerging trend of the continuum of care, which involves placing patients on specific pathways that optimize their treatment as they move from the clinic to the OR and back home after discharge. It's where health care is heading, and your infection control efforts should follow. OSM