Staying Ahead of SSIs


Identify gaps in care and act quickly to implement protocols that improve infection prevention practices.

When post-op infections occurred among patients who underwent colon and gynecology procedures at University of Wisconsin (UW) Health, clinical leaders wondered if a lack of compliance with the infection prevention bundle created for the service lines was to blame. Enter the Strike Team, a multidisciplinary group of surgical professionals who were assembled to find out why infections occurred and prevent them from happening again. They identified issues that could have caused the bundle to fail, and addressed them immediately to ensure it didn't again. They also drilled down to the root causes of infections and made sure staff understood the importance of completing the bundle's elements during each case and for every patient.

Their efforts proved successful. The service lines haven't had a reportable surgical site infection in the last 18 months thanks to the team's hard work and dedication to implementing strategies to reduce risks of SSIs.

  • Gathering data. The first step involved identifying the issues that needed to be addressed. During every procedure, the surgical team fills out a Strike Form, on which they check off that essential elements of the bundle — such as ensuring glove changes are conducted at appropriate times during the case, the patient's skin is properly prepped and that the OR's ambient temperature stays within the recommended range — have been met. They also note specific concerns, if they have any, about what they observed during the case. The checkmarks and frontline feedback present a comprehensive report of what occurred in the OR.

SAME PAGE Savannah Shortess, MSN, RN, CNOR, manager of perioperative services, huddles with members of the surgical team to discuss the infection prevention bundle.

Care team leaders review the form after every case, and immediately huddle with the surgical team if elements of the bundle are not completed. Issues are addressed and corrected on the spot, before the next case begins. The leaders collect the forms throughout the week and enter the data into an Excel spreadsheet, which is used to track staff performance over time.

"We have immediate access to real-life data," says Ahmed Al-Niaimi, MD, FACOG, FACS, head of UW Heath's surgical quality outcome for the department of OBGYN and the chair of the Quality Improvement and Review committee. "That's allowed us to identify gaps in care and respond more frequently and urgently, which is key to lowering infection rates."

  • Assessing root causes. If an SSI occurs, Michelle Schmitz, CIC, the clinical infection control practitioner, fills out a case review form and hands it off to a care team leader, who reviews the spreadsheet filled with Strike Form data to determine if the bundle's criteria were met during the case in question. She also checks to see if surgical team members noted specific concerns about the care that was provided. UW Health always tracked overall rates of SSIs, but didn't know what occurred during cases that resulted in the infections. "We'd learn about SSIs long after they'd happen, and couldn't always determine the root cause," says Dr. Al-Niaimi. "We now have access to real-time information about what our providers are doing on a daily basis. That provides a more complete picture of our infection control practices."
  • Acting swiftly. The Strike Team meets monthly to review the Strike Forms, identify trends in infections and implement strategies that reduce the risk of SSIs. How did infections happen? What can be done differently moving forward? Collaborating as a group to come up with answers to those questions generates fresh ideas and creates team-wide ownership of the proposed process improvements.

The Strike Team has full authority to recommend changes to infection prevention protocols and final say in what must be done to improve patient care. "When the team decides to implement a new policy, it gets done, no questions asked," says Dr. Al-Niaimi. "Our administration made it clear from the beginning that reducing the SSI rate was mission critical, and gave the Strike Team the power and autonomy to make it happen." Enhancements to the bundle are passed down through service line managers to the frontline staff, who provide in-the-moment feedback on how effectively the changes are being implemented.

The communication between clinical leaders and staff must be consistent, transparent and professional in order to solve problems in real time. "When the team identifies an issue or amends protocols, the change is immediately acted upon and monitored," says Dr. Al-Niaimi. "There's real power in changing and implementing protocols at the same time."

  • Collaborating and communicating. During quality improvement projects, key stakeholders — surgeons, nurses and anesthesia providers — often work in silos, points out Ms. Schmitz. "But true success occurs when they collaborate, which allows them to see how their workflows are interrelated," she says. "There are various viewpoints involved and you work as a team, not as a group of individuals, to develop solutions to problems that often prove successful because of the various experts involved in coming up with them
  • .

"A dedicated team keeps moving forward and comes up with innovative ideas beyond evidence-based standards to improve the care of specific patient populations and adjusts practices accordingly to fit a facility's needs."

The Strike Team discusses overarching issues that need to be addressed and comes up with proposed solutions to problems that engaged members of the frontline staff make happen. "What's accomplished in the meetings is great, but it's imperative that staff in the ORs are aware of why the work is being done," says Jay Radlund, RN, care team leader for the general surgery team. "They have to see and experience the successes just as much as we do. It's very important to cascade that information down to them so they know their efforts matter."

Ms. Schmitz says the real-time tracking of data lets them identify trends over time, which helps them implement effective interventions that are more likely to succeed. "Leaders are the catalyst of change, but it's the frontline workers who sustain it," she says. "They're the ones who see the everyday value in the proposed process improvements."

  • Flattening the hierarchy. Each member of the Strike Team feels empowered to express their opinions. They also relay the thoughts and feedback of frontline staff whose insights and contributions are highly valued. Real-time and honest communication among all members of the Strike Team, regardless of their clinical roles, is key to the group's success.

"Medicine is inherently hierarchical, but no one is above or below anyone here," says Dr. Al-Niaimi. "If issues related to our bundle must be addressed, the communication is immediate — no matter who is involved."

What's accomplished in meetings is great, but it's imperative that OR staff are aware of why the work is being done.
— Jay Radlund, RN

Maintaining momentum

The Strike Team's efforts provide opportunities for frontline leaders to evolve in their positions while contributing to excellent patient care, says Savannah Shortess, MSN, RN, CNOR, manager of perioperative services. "We've also been able to leverage the results to advance organization-wide efforts, such as working toward our Magnet designation," she adds.

Ongoing education that focuses on implementing individual elements of the bundle to acceptable standards prevents staff from drifting into old habits. "Making change happen is important," says Ms. Schmitz, "but it's the sustainment of the change that matters most."

Strike Teams are being formed in UW Health's neurosurgery and orthopedic service lines, where team members hope to replicate the successes their colleagues have already achieved. "Every member of the Strike Team contributed to the creation of the bundle, implementing its elements and tracking compliance progress in real time," says Dr. Al-Niaimi. "They were empowered to make change happen, and they did. We're happy to share our methodologies and hope other facilities learn from our success." OSM

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