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Infection Prevention
Four Evidence-based Measures For Preventing Infections
Daniel Johnson
Publish Date: October 10, 2007   |  Tags:   Infection Prevention

The Institute for Healthcare Improvement's 100,000 Lives Campaign is based on four evidence-based measures for preventing infections. Here are tips for making the measures work from someone who's been through a successful implementation.

1. Appropriate use of antibiotics
Does this pre-op routine sound familiar? Pre-op nurses get the patient into the OR, anesthesia prepares and begins induction, and physicians focus on the details of the surgery. Obviously, members of the OR team should do what they're best at, but to successfully meet the goal of appropriate use of antibiotics, we had to open up the communication between these groups while meeting the challenges posed by fully electronic ordering (there are no paper charts or oral orders). Here's the step-by-step.

When a case is booked, the resident or attending orders antibiotics; a physician actually enters the order to our automated system. Pharmacy verifies each order on its end, sending an electronic message back to the computerized drug dispenser in surgery, both as a double-check and for inventory tracking purposes. It's up to nursing to ensure the order is in the system and verified, and to then retrieve the drugs from the dispenser.

While the pre-op nurses bring the bag back to the patient, they don't administer the drugs. This is the key to our success in meeting the IHI's requirements that you administer the correct prophylactic antibiotics one hour before surgical incision (some drugs, such as Vancomycin, require longer lead times) and repeat if needed based on the length of the case. Our anesthesia providers check that the right antibiotics have been retrieved and that they don't pose drug interaction or allergy risks. They also administer the drugs there in the pre-op bay or in the OR. Anesthesia's involvement has been a real boon, helping us achieve a 95 percent compliance rate, because they are best equipped to gauge administration time.

2. Appropriate hair removal
We went razor-free, but of course had a couple stragglers who would bring razors up to the OR from the floors. We've come up with two fixes. First, we looked at all the hair removal options and purchased the supplies needed to accommodate the surgeons. For example, one urology surgeon insisted on razors for his scrotal cases - until we were able to find him a clipper designed specifically for that purpose. Once he had a tool he felt comfortable with, he was happy to change, and we're in compliance with the IHI's no-razors requirement. Second, any surgeon who brings a razor into the room is disciplined, no ifs, ands or buts, by the chief of his specialty.

3. Perioperative glucose control
While this applies only to major cardiac surgery patients under the IHI campaign, studies show that glucose intolerance and hyperglycemia commonly arise from surgical stress of any kind, so implementing perioperative glucose management procedures is worth considering regardless of specialty and surgical setting. Even if you don't have time for pre- and post-op testing and other measures that would be included in such a protocol, you can take this small step to help keep patients' blood sugar readings from going over 200. Look at the antibiotics you're giving patients; if they come in a D5 mixture, you're putting sugar right into their systems. We changed to saline, and controlling glucose became immediately easier.

4. Perioperative normo-thermia
The IHI prescribes this for a specific population - colorectal patients - but preventing hypothermia is an important intervention for all procedures, as it's been proved that being cold adversely affects patients' metabolic rates, clotting, and the cardiovascular, central nervous, immune and respiratory systems. We started keeping rooms above 70 degrees, added patient temperature to the nurse's OR documentation and stepped up use of intraop and post-op warming devices, but we also enacted patient warming in pre-op holding. Using whatever methods patients can tolerate, we aim to raise patient temperatures at least a half-point before they enter the OR, as that's what they're going to lose upon induction.

Saving 5 million
While we've reduced infections and the potential for infections through the 100,000 Lives Campaign, our greatest achievements to my mind are strengthened collaborative practice among the surgical services team members and a greater awareness among nurses of the clinical implications of the SSI interventions. It's a pleasure to observe nurses preparing for cases by communicating with anesthesia and to see case coordination improve. We look forward to continuing on with the expanded 5 Million Lives Campaign.