Given Medicare’s addition of several orthopedic procedures to its fee schedule, an increasingly graying population and a post-COVID effect that has predisposed...
OR Excellence Awards: Infection Prevention: Thorough and Diligent
By: Joe Paone | Senior Editor
At Ascension Saint Thomas DeKalb Hospital, consistent attention to well-developed protocols has kept patients infection-free for years.
Unfortunately, there’s not a magic, all-encompassing solution for preventing surgical site infections (SSIs). Instead, it’s a never-ending process that requires exacting coordination of providers, patients, policies and protocols that do the work, day in and day out.
Ascension Saint Thomas DeKalb Hospital in Smithville, Tenn., is laser-focused on SSI prevention. It doesn’t do anything remarkable or cutting-edge. It simply stays on top of the literature and executes the fundamentals consistently and diligently. As a result, over the last two-and-a-half years, only one patient has left its doors with an SSI at a facility that performs more than 700 surgeries and endoscopies per year. That’s why Ascension Saint Thomas Dekalb is the winner of the 2023 OR Excellence Award for SSI Prevention.
OR Manager Amanda Parsley, RN, vividly remembers that single infected patient. “He was noncompliant in every aspect — diabetic, a smoker, and just didn’t listen to anything,” she says. “He had the dressing pulled off, got up and walked on the incision on his foot. Honestly, despite our best efforts and no matter how good of a job we were doing, this patient was going to be infected.”
The fact that this one patient was so memorable is because it was such an extreme outlier in an environment with such a strong culture of safety. Ms. Parsley lays out all of the moving parts of the hospital’s infection prevention efforts.
• Chlorhexidine gluconate (CHG) preps. Ms. Parsley says the standard for patients scheduled for surgery is three days of CHG showers in advance of the procedure. For urgent and emergent cases where advanced preparation time doesn’t exist, patients are wiped down with CHG wipes three times before they are brought to the OR. “We explain to patients that it helps reduce SSIs and they are usually compliant,” she says. “Occasionally we’ll have an outpatient who might not have been as compliant, so my staff run them through the shower when they get here.”
• Nasal decolonization. To reduce MRSA risks, every outpatient receives a povidone-iodine nasal swab three times in each nostril before surgery.
• Hair removal. About five years ago, Ascension Saint Thomas nurses began clipping hair rather than shaving it. “Shaving irritates the skin and could lead to an open skin laceration near the surgical site which is more prone to infection,” says Ms. Parsley. “It also irritates the hair follicles. With the clipper, it’s not a fresh smooth shave but it gets the hair out of the way without irritating the hair follicles.” Once clipping is completed, tape is used to clean up any loose hair — again, to avoid any trauma or irritation to the follicles.
• Skin prep. “Once we get the patient into the OR and get them positioned, we expose only the area that we need to access,” says Ms. Parsley. “We then prep the skin going from clean to dirty. Once the prep is on, the circulator calls a time out, and the prep is given a minimum of three minutes. Then a time out is called out again to let everybody in the room know that the prep should be dry.”
• Temperature monitoring and recording. Patient temperatures are tracked and kept within appropriate ranges throughout the entire episode of care. In pre-op, a typical thermometer is used; during surgery, a skin thermometer is applied; in post-op, both traditional thermometers and tympanic membrane thermometers are used. Active warming is employed, and warm blankets cover the area around the incision in the OR.
At Houston Methodist The Woodlands Hospital, the intraoperative normothermia compliance rate in its 25 ORs was 56%, far below pre-op and PACU rates. Within a year, it rose to nearly 75%. “The causes were nuanced and the solutions layered, but we simply had to do something to improve,” says Jennifer A. Rose, BSN, MSML, RN, CNOR, an RNIV in perioperative services. Here’s how:
• Improved awareness. Busy OR staff were not paying enough attention to patient temperature as a vital sign. Once they saw the literature that shows the danger and expense of SSIs that can result without proper intraoperative monitoring and maintenance of normothermia, they better understood its importance and focused on it more.
• Improved pre-op monitoring. Ms. Rose discovered that patients’ temperatures were taken when they arrived at the facility, but often not before they left pre-op. “Now we take temperatures shortly before patients are rolled into the OR, so the data we’re working with isn’t setting the OR staff up for failure as we measure how well they keep patients warm,” she says.
• Consistent core temperature monitoring. Providers now use technology that measures core temperature throughout the perioperative process. “This assists in real-time temperature data capture and helps keep data clean for analysis by ensuring each area measures with the same tool,” says Ms. Rose.
• IV fluid warming. Ms. Rose found a budgetfriendly way to warm fluids in ORs while purchasing fluid-warming cabinets for the core.
• Active warming. Active warming gowns and warmed linen blankets are used throughout the surgical process. Pre-op bays, ORs and OR beds are pre-warmed. Exposure is limited during positioning, prep and conclusions of cases.
Ms. Rose ensured the changes stuck through direct observation and education during rounds and morning huddles. Staff became so energized that they compete with their sister hospitals to achieve the highest rate. Champions in pre-admit, pre-op, OR, recovery and anesthesia monitor and encourage compliance in their units.
“There’s no one fix,” says Ms. Rose. “So we offer our nurses a tool belt with lots of choices that allow them to customize appropriate care for their patients. Warming, fundamentally, is a nurse intervention. That’s exciting and empowering.”
Ms. Rose says the keys were that the solutions were staff-friendly, and a collective realization that the issue never dies. “It’s why we continually educate, communicate and collaborate on ways to sustain success,” she says. “None of us have it all figured out, but by collaborating, we can make huge gains for our patients.”
• Morning OR wipe-downs. “Our team starts the day by wiping our ORs down before our first case, even though they are terminally cleaned every night,” says Ms. Parsley. “No matter how clean, fresh and sterile you want to think they are, there’s a good 12 hours in between when it’s cleaned until we come back in the next morning to start a case. Little things can fall from the air vents and ducts; there could be dust mites here and there. As a matter of good protocol and policy, we wipe down all horizontal surfaces when we come in.”
• Facility-laundered scrubs. “The sterility of surgical scrubs is a top priority of every member of the team,” says Ms. Parsley, who has dived deeply into the literature on the subject. “If they’re laundered at home, it’s supposed to be at a minimum of 160 degrees, color-safe bleach, nothing else washed with them, hands washed before and after. Somebody could come in and say they have done all that at home, but that doesn’t mean that really occurred. So surgical scrubs are laundered by the facility.”
• Limited OR door openings. OR doors are closed and traffic is limited while in use. “We always use the phone if we need more pain medicine or something from pharmacy, and they’ll bring it to the door,” says Ms. Parsley.
Ms. Parsley notes that physician support for SSI prevention protocols, especially in terms of smoking cessation and diabetes controls, is strong. Surgeries have been postponed when patients don’t comply with preoperative requirements.
“Safety is our number-one priority with everything we do at this facility,” says Ms. Parsley. OSM
Change, especially in today’s head-spinning, fast-paced world, can be trying for an organization and its employees and leaders....
Recently I was asked to put together a presentation on avoiding common mistakes in credentialing, privileging and peer review....