At Mercy Tiffin, a rural community hospital in Tiffin, Ohio, with a separate ASC attached, the key to driving down post-op surgical site infection rates was to use a comprehensive approach. Joan Conine, BSN, RN, CNOR, RNFA, needed buy-in from everyone, and she got it a remarkable top-to-bottom effort that earned the 2015 OR Excellence Award for Infection Prevention.
"It wasn't just the OR, it wasn't just pre-op and it wasn't just central processing," says Ms. Conine, the hospital's manager of perioperative services. "The entire staff took ownership: surgery techs, nurses, central processing, surgeons, environmental services, plant operations, infection control, quality and risk. Everybody. That's how we were able to move forward so quickly."
And move forward they did, quickly cutting the rate from a peak of 1.1% in late 2014 to its current level of about 0.3%.
Old and new
Ms. Conine and her staff "started at the bottom and reviewed everything basic OR 101," she says. That meant introducing some new ideas, as well as scrutinizing all the old ones. The strength of the comprehensive approach is that in any given facility, there may not be a single identifiable cause of SSIs. Rather, any number of factors might be contributing. Ms. Conine suggests numerous steps that any facility can implement as part of a process improvement to help reduce infections:
- Update your checklist for cleaning ORs between cases, and review the terminal cleaning process done by environmental services (EVS). Consider having the EVS supervisor round on a weekly basis to ensure that procedures are being performed properly.
- Scrutinize the decontamination and sterilization being done by central processing. For example, make sure they aren't adding excessive towels to instrument trays. You may be able to reduce lint by using sterile packs of towels instead.
- Ensure that air exchange is optimal by keeping OR doors closed between surgeries.
- Review proper wound classification with the staff.
- Review the importance of warming gowns and blankets for all procedures.
- Post antibiotic administration times on a white board and make them a discussion point during time outs.
- Create a quarterly schedule for cleaning all OR vents.
- Review proper prepping techniques with the staff, including making sure nurses always wear long sleeves and gloves.
- Initiate using smoke-evacuation devices in the ORs.
- Make silver dressings available to surgeons, along with instructions.
- Provide bottles of chlorhexidine soap to all surgeons' offices, with instructions that they're to be given to patients to use both the night before and morning of surgery.
- Use CHG wipes on patients in pre-op.
- Obtain MRSA nasal swabs, at least for high-risk procedures.
- Move hand hygiene dispensers to more convenient locations.
Some of these steps are fairly simple, says Ms. Conine, while others may be more challenging. Using silver dressings, for example, may require some education. "We've had success with silver dressings," she says. "They work well when you want to leave the dressing on for a few days, because they're waterproof and you can shower with them. Our surgeons have embraced them."
At Mercy Tiffin, it took 6 weeks to implement the process improvements, but the payoff came quickly. Within 6 months, they reduced their infection rate by 70%. In attacking SSIs on numerous fronts, there are costs to consider, of course. But considering the financial implications that can be associated with a single infection, the cost of taking a slow or overly cautious approach has the potential to be much higher. "You always want to look at costs, but patient safety has to be the top priority. It overrides and trumps everything else," says Ms. Conine.
Mercy Tiffin's SSI rate is now below the national target rate, and the goal is to keep going and get as close to zero as possible. "After all," says Ms. Conine, "if it's your family member or yourself having surgery, you'd want the facility to do everything they could to provide the best prevention possible."
LAKELAND SURGICAL & DIAGNOSTIC CENTER
Confronted by varied, and occasionally conflicting, advice on how to minimize surgical site infections, the Lakeland Surgical & Diagnostic Center in Lakeland, Fla., decided the best approach was the toughest approach.
"We tried to look at all the recommendations from APIC, AORN and SHEA, and then use the ones that were most stringent," says Emily Duncan, RN, BS, CASC, CNOR, who serves as CEO of the center's two multi-specialty campuses.
It's a strategy that has paid remarkable dividends (the facility's 2014 SSI rate was 0.1%), but instead of becoming satisfied or complacent, Lakeland implemented several additional goals and objectives for 2015 and has continued to push its SSI rate down even lower. Remarkably, it reached the coveted zero mark for the second quarter of 2015.
With so much success, no goal is considered out of reach. For example, the center has its sights set on a 96% participation rate for flu shots. The goal for hand hygiene compliance is 90% or higher, with an emphasis on designating infection prevention champions and finding new and innovative ways to conduct surveillance.
No detail is too small. Recent goals have included replacing wallpaper in clinical areas with texture and paint, and making sure all bay curtains are laundered at least annually, and more often if soiled. There are hand hygiene stations at all entrances, and signs are posted during flu season, asking all visitors to be sure to use them before they step inside. As an extra precaution, greeters are stationed by the entrances to make sure requests are followed.
Getting patients to actively participate and increasing compliance have been a recent focus area, including:
- Partnering with physicians' offices and vendors to provide patients with CHG wipes and track and document compliance.
- Asking patients to take full-body showers with CHG products both the night before and the day of surgery.
- Asking patients having general surgery to gargle and rinse with antiseptic mouthwash on the day of surgery.
- Using CHG 4% wipes on operative sites and surrounding areas, and allowing sufficient drying time.
- Asking patients with artificial nails to perform an additional 3-minute hand scrub.
- In-servicing techs and circulators on proper skin-prepping techniques, and standardizing preps.
- Modifying the online patient portal health questionnaire to include questions about compliance and conditions such as open sores, illness, fever or whether patients have traveled outside the country in the previous month.
"We have a low infection rate already," says Ms. Duncan, "but we wanted to get as low as we possibly could."