Working Toward Our Goal of Zero SSIs

• Antimicrobial showers and prep. Skin prep and nasal decolonization are two components of any effective SSI-prevention protocol. To that end, our total joints and spine patients are instructed to shower using a 4% chlorhexidine soap both the night before and the morning of their surgery. When they arrive on the day of surgery, they’re screened for MRSA and MSSA, with any positive results treated with a mupirocin antibiotic ointment as part of our nasal decolonization protocol, as well as IV vancomycin preoperatively.

Patients have generally demonstrated compliance with the two preoperative chlorhexidine showers, but for added assurance, all total joint and spine patients are also instructed to give themselves a head-to-toe, rinse-free prep in pre-op with 2% CHG disposable cloths for long-lasting antimicrobial protection. We give them six wipes and show them how to treat their skin through diagrams in the preoperative bay. They wipe down whatever they can on their own, and then we help them to make sure they are covered from head to toe.

• Reducing flash sterilization. After discovering immediate use steam sterilization (IUSS) was being employed too frequently — due to a lack of instruments because of backlogs or because we only had one of a certain item in the facility — our center took measures to correct this unsafe tendency. Ultimately, the problem was solved by shifting to rigid containers that also reduce the use of blue wrap and the associated risk of holes and tears that could go unnoticed and possibly result in contaminated instruments as well as the need to quickly reprocess tools needed for a case.

The goal was to reduce IUSS to less than 10%, but our monthly tracking has shown the rate has stayed below 3% since we moved to the rigid containers. If we ever see sudden increases, we immediately dig into the potential reasons. 

For instance, in February there were times when instrumentation wasn’t readily available for cases, so we examined whether we needed to purchase more instruments. By tracking our IUSS rate and making sure we stay below the 3% threshold, we uncovered insights into our overall operational efficiency we wouldn’t have otherwise.

• Adenosine triphosphate (ATP) testing. We employ heightened environmental cleaning surveillance throughout our facility, especially in our ORs, using a device that detects the presence of ATP, which is indicative of live bacteria. By swabbing high-touch surfaces, we can monitor trends and adjust our cleaning and disinfection practices — and share opportunities for more thorough cleaning with our OR and housekeeping staff. One example of an improvement we made using these results was the purchase of keyboard covers for the ORs. The covers allow for easier disinfection of keyboard surfaces that had failed the cleanliness threshold.

Our OR supervisor leads the ATP testing efforts and performs it monthly in each operating room, but she has also tested other areas such as our recovery room and, at the height of COVID-19, even our waiting room, just to make sure we were keeping surfaces clean enough everywhere. Every quarter we report results or new findings to the quality improvement team to make sure we’re always meeting standards for cleanliness.

• Patient warming. We apply active warming in pre-op and in the OR on all patients scheduled for procedures expected to last longer than 60 minutes. We primarily warm patients to minimize risks of complications and infections. Inadvertent perioperative hypothermia is linked to greater intraoperative blood loss and increased chances of surgical wound infection.

• Hand hygiene. Secret hand hygiene audits monthly use an observation method to verify compliance and share results. The audits include observations of our entire patient care team —staff, surgeons and anesthesiologists. One unique feature of the program: a supervisor doesn’t perform the audits. Instead, team members volunteer to participate. While they’re working, they’re also observing their colleagues’ hand hygiene practices for a certain period. 

The volunteers observe everyone — transporters, anesthesiologists, surgeons, nurses, radiology techs — who might touch a patient for appropriate use of gloves when indicated and hand washing before and after patient contact. Nobody ever knows when or who is performing the audits, and the resulting statistics are reported on in quarterly quality improvement meetings.

• Pandemic precautions. As knowledge about COVID-19 evolves, we continue to modify our policies to reflect evidence-based information. It hasn’t required too much on top of what we already do. Our standard of patient care has always been to wear gloves and, besides additional staff and patient masking requirements, not much has changed because of the pandemic. The real work has been outside of direct patient care. We increased our cleaning of the waiting room, spaced patients apart and added signage everywhere we could to make sure people wore masks. We use a decision tree that guides our practice with employees and patients, and it’s updated as our understanding of COVID-19 changes. While we never required patients to get COVID tests, we did perform extensive screening during preoperative phone calls, at the door and at check-in, and many cases were reviewed by our anesthesiologists. If we found that patients had cold symptoms, for example, we took extra precautions to make sure it would be safe to perform surgery on them at our center.

Our SSI-prevention program is comprised of multiple tried-and-true protocols that are consistently applied to every patient we treat. That’s paid off in some desired ways (low SSI rates) and some unexpected ways, as well.

For instance, when a consultant visited our facility to provide objective feedback about our sterile processing department, we asked if she could give us any recommendations. The consultant not only didn’t have a single recommendation for us, she asked to use some of our practices as a model for other facilities she visits. Specifically, she liked how many rigid containers we have, that we didn’t stack instrument sets that were wrapped in blue wrap and that we allotted plenty of space to store sterilized instruments.

It may be impossible to achieve the coveted zero-SSIs mark, but you should never stop trying. We get as close to zero as we can every month and a multipronged strategy — constantly enforced and evaluated — allows us to adjust protocols, policies and behavior quickly at the first sign of trouble. Our patients benefit from that constant vigilance. OSM