OR Excellence Awards – Infection Prevention: SSI-Free for Nearly Three Years

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Ascension St. Vincent Mercy Hospital’s sterling record is the result of teamwork, proactivity and an all-encompassing patient-first philosophy.


The surgical services team at Ascension St. Vincent Mercy Hospital in Elwood, Ind., is well into year three without a single surgical site infection (SSI). That impressive run has earned its staff the 2022 OR Excellence Award for Infection Prevention. Here’s a look inside some of the initiatives that have kept the facility SSI-free: 

Reprocessing. Every care is taken to provide the highest level of sterility possible, from the use of borescopes for instrument inspection to selecting the best packaging and processing, according to Kimberly Jones, DNP, RN, CNOR, RHCNOC, nurse manager-surgical services, oncology, audiology, wound care and medical specialty clinics. “One of my focuses as a manager and leader has been to look forward to see what’s coming and get ahead of the ball instead of behind it. I feel like we’re ahead of the game in a lot of ways,” she says.

For example, a new set of AAMI standards for flexible reprocessing just came out. “There’s a lot we need to do to be compliant because there are so many changes, but in a lot of ways, we are way ahead of our sister facilities,” says Ms. Jones. “I’ve already had a borescope for years. I already have lighted magnification and insulator testers. We’ve already pulled a lot of that technology in to help make what we’re doing safer.”

To better ensure sterility and protect its instrument fleet, the hospital last year acquired rigid containers. “We absolutely love them,” says Dr. Jones. “The ease in putting together instrument sets is tremendous compared to needing to blue wrap things. Also, space is always limited, so being able to stack those containers means I’ve freed up room I didn’t have before.”

In the OR. Antimicrobial prophylaxis, intraoperative skin prep and thermoregulation are all maintained to industry standards. “We’re watching temperatures, making sure we’re using the appropriate antibiotics, prepping with the appropriate agents — all of those things that have been standard for years,” says Dr. Jones, who adds that both patients and appropriate fluids are warmed as well.

This Hospital Operates With Zero Flash
Honorable Mention
DO NOT PASS Nursing leaders and OR staff at Holy Redeemer Hospital ensure that casual use of immediate use steam sterilization without approval is a no-go, effectively eliminating the practice entirely.  |  Holy Redeemer Hospital

Immediate Use Steam Sterilization (IUSS) places patients at an increased risk for post-op infections, but that doesn’t stop many busy surgical facilities from casually engaging in the practice as a matter of convenience or emergency. Holy Redeemer Hospital in Meadowbrook, Pa., which performs between 350 and 425 surgical cases every month, is not one of those facilities.

In March 2021, Holy Redeemer established a new policy that ensures IUSS is never used in a casual manner — and preferably, never at all. Previously, its IUSS rate ranged between 0% and 3%. Since the new policy was put into place a year-and-a-half ago, the hospital’s rate is absolute zero.

“When you’re using IUSS, it’s a shortcut,” says OR Manager Traci Birnbaum, BSN, RN, CNOR. “Our data showed we were utilizing it for convenience, or because we didn’t have enough trays to cover cases. To the staff’s knowledge, it was just a common, everyday thing.”

A surveyor noticed during a visit in February 2021. “She went line by line and asked why we flashed something,” says Director of Surgical Services Linda Beck, MSN, RN. “Then she broke it down and said, ‘The only time you should ever be flashing is if the patient is on the table under anesthesia, it’s necessary for the case, and you don’t have any other backup.’ We said, ‘Okay, we’re not doing this anymore.’”

Saying it is one thing, but doing it is another, and the two leaders set about educating staff and surgeons and establishing a new IUSS policy. They identified only three urgent or emergent instances when staff may consider IUSS: The procedure has begun and the patient is under anesthesia; all other options to secure sterile replacement have been exhausted; and a procedure delay that could cause serious harm to the patient.

Now when an instrument issue arises, a chain of command is in place to guide the response. “If a surgeon wants to sterilize a tool with IUSS, they will come to me as the OR manager,” says Ms. Birnbaum. Surgeons are told they shouldn’t be using IUSS and field suggestions for alternative instruments. “It can be tense with some surgeons,” adds Ms. Birnbaum. In some cases, she simply refers to the instrument’s instructions for use that state it shouldn’t be flashed.

Surgical staff was educated on the IUSS policy, and signs were posted that the hospital no longer supports IUSS unless approved by the OR manager or director. Vendors and surgeons were notified of the new initiative as well.

Ms. Beck has been continually amazed as month after month passes without a report of IUSS. “I never thought we would go a year and a half with no IUSS, to be honest with you,” says Ms. Beck. “I thought we’d lower the rate, but that it wouldn’t be zero.” She’s proud to be consistently proven wrong. “We’ve been successful because we’ve created redundancy with trays and instruments, and we’re supportive of the staff,” says Ms. Beck. “I am really proud of their efforts.”

Joe Paone

OPEN EXPRESSION Interactions like this one between April Wright, RN (left), and environmental services worker Catherine Morgan — common sights at the tight-knit facility — keep everyone on the same page in the collective effort to prevent SSIs.

Pre- and post-op calls. A single nurse at the facility calls patients before their surgeries and endoscopies, generally seven to 10 days in advance. From a patient experience perspective, a consistent contact at the facility is both reassuring and efficient. On special cases where providers want to take that extra step for infection prevention, the nurse goes over instructions with them for CHG showers the night before and in the morning.

Postoperatively, patients receive a follow-up call within the first week. Included in the call is a reiteration of discharge education that reminds the patient to look for signs of infection, as well as a refresher on infection prevention techniques.

The most common SSIs at the hospital before its infection-free run occurred with open bowel resections and exploratory cases. “Certain sections of the population are at greater risk for infections from open-belly surgeries, so that always puts us on heightened alert,” says Dr. Jones. The SSIs ceased when the team successfully implemented CHG irrigation with a patient who’d had multiple hernias repaired.

That engaged commitment to improvement and thoroughness while never cutting corners continues to keep the hospital’s patients SSI-free. “We’re not okay with just doing the minimum, or barely above the minimum,” says Dr. Jones. “We’re going to do it the absolute best we can every single time.” OSM

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