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Inside Our Journey to Zero SSIs
It took evidence-based practices and hard work to eliminate infections.
Diane Kimsey
Publish Date: April 25, 2017   |  Tags:   Infection Prevention
removing hair SHORT CLIP Removing hair in the pre-op area was one of the key elements to the initiative's success.

The quest to do away with surgical site infections began in July 2014 when our hospital's COO put us on notice that the 9% infection rate in our heart and total joint patients was unacceptably high. Challenge accepted. We built a team comprised of representatives from all specialties, gathered in a conference room and got to work. By October, we reduced the infection rate to 2.7%; we reached zero a month later. Our success built momentum, and we soon applied the enhanced infection prevention protocols to all procedures. Here's how we turned a problem into a point of pride.

No stone unturned
The multidisciplinary team was made up of executive leaders, infection preventionists, surgical managers, anesthesia providers, surgeons, nurses and educators. We mapped out all aspects of the care provided to surgical patients, from pre-admission to discharge and beyond into extended care. Getting feedback from representatives from every discipline that would touch patients along the perioperative path was instrumental to our ultimate success. The team came up with these evidence-based action items:

Glucose monitoring. We previously had only checked point-of-care glucose levels if physicians ordered the test or patients were known diabetics. Part of our initiative involved checking blood glucose levels for every surgical patient, and we discovered what had long been suspected: Many patients present for surgery without knowing they're diabetic or have elevated blood glucose levels, which increase SSI risk.

Hair removal. We used to clip hair around surgical sites in the OR and collect the trimmings with tape. To limit the infection risk those hair trimmings posed, we now use clippers with a built-in hair collection system, and primarily in the pre-op area. However, we still clip patients in the OR if the location of the surgical site demands privacy or the prep needs to be revised.

Pre-op CHG wipes. In pre-op, all patients receive 6 wipes impregnated with chlorhexidine gluconate for treating the neck and chest, both arms, both legs and back. Family members or nurses can help apply the wipes before patients slip into a clean patient gown. Total joint patients are instructed to also use CHG wipes the night before and the morning of surgery. The company we purchase the wipes from improves compliance with those directives by sending automated text or email reminders to patients. Total joint patients also receive packets of disposable washcloths and towels to use before and after surgery.

Nasal antisepsis. Pre-op nurses apply 2 minute-long swab applications of povidone-iodine in each nostril to kill Staphylococcus aureus bacteria that populate nasal passages and increase the risk of post-op infection.

The rubber meets the road when staff find out they must spend 15 to 30 extra minutes caring for patients. Our pre-op nurses were the ones who shouldered much of the responsibility for enacting the process improvements we needed to make. They stepped up and took it all on, and deserve a lot of credit for their willingness and effort. We secured their buy-in by providing them with data and plenty of educational content that supported the practice improvements. They ultimately saw the value in what we were proposing and were compliant with the new protocols within a month.

Periop 101
We conducted a "back-to-basics" program that coincided with the rollout of our renewed effort to eliminate surgical site infections. The program, which was mandatory for all staff members, reviewed the practices that serve as the foundation of infection control efforts, including how to properly wear surgical attire, the importance of keeping OR foot traffic to a minimum and steps to maintain a sterile field. We wanted to optimize all of our processes, even the most basic practices, to give the overall goal of zero infections the best chance of success.

Besides, the staff truly benefited from the remedial review, especially the ones who left hair exposed under surgical caps, set up sterile supplies in the OR without wearing a scrub jacket to cover their bare arms, walked around with T-shirts from home hanging out from their scrub tops and wore chandelier earrings into the OR. We also mandated that visiting vendor reps wear disposable surgical scrubs they paid for and accessed from an automated dispensing unit installed in the hospital.

After reeducating staff about proper ways to clean high-touch surfaces in the OR, we conducted periodic spot checks by applying dabs of fluorescent gel to a variety of areas. About 20 times a month, after turnaround teams clean rooms treated with the gel, we shine a black light on the surfaces to find out if they missed any spots. The results were revealing and hammered home the importance of diligent manual cleaning. Message received: Compliance with effective cleaning methods for high-touch items increased from 30% to 80%.

Based on the success of the initial back to basics program, we've decided to conduct annual in-services to reinforce the importance of what should be straightforward infection control practices. We've discovered that even the simplest procedures can have a significant impact on infection rates if they're allowed to lapse.

Constant effort
We invested in the initiative knowing we'd recoup the dollars spent through improved care, better outcomes and less spending on readmissions to treat SSIs. It's been 2 years since we launched the initiative and I'm considering reeducating staff on its core principles to ensure the practices that proved so effective remain priorities. We also haven't hesitated to share our successes, and that gives staff a sense of pride in the improvement they achieved. Updated infection rates are posted next to the doors leading to the locker rooms, so everyone who has a hand in patient care is constantly reminded of the progress they've made, and the importance of remaining committed to the cause. Although our success came quickly, we're playing the long game when it comes to protecting our patients from harm. OSM