OR Excellence Awards: Infection Prevention: Thorough and Diligent

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.

• 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