A Team-Based Approach to Reducing SSIs


Limiting post-op infections demands understanding how frontline staff perceive and implement evidence-based practices.

Surgical site infections (SSIs) are among the most common and costly of all healthcare complications, yet as many as half are considered preventable. While costs of treating SSIs vary widely based on the degree of infection and the site of surgery, the estimated average expense can be more than $25,000. 

At my former hospital, we worked hard to implement the infection prevention guidelines and recommendations contained in the national Surgical Care Improvement Project. However, frustrations continued to mount as our 20% post-op infection rate persisted. We knew we had to do something more to improve patient care.

After quizzing the perioperative staff, we realized that they were familiar with best practices, but undervalued how important it was to abide by them during each case. A mix of working with them to get them to think differently about the practices and realize how important they are, along with streamlining and standardizing our processes led to a 13% decrease in SSIs in just a few months. To improve upon those results, I implemented a facility-wide SSI prevention protocol for colorectal surgery to explore the impact a standardized closing process had on infection rates, because the practice had been largely decided on a case-by-case basis as well as by surgeon preference.

The project was based on AORN guidelines for reducing infection in colorectal surgery using the bundle methodology and included 26 circulating and scrub nurses. The study took place over a period of three months with the surveillance data for SSIs coming from the month prior to the study’s implementation and for two consecutive months (the time that corresponds with how SSIs are defined). As a result of the initiative, colorectal surgery infections were reduced to 7%. Here are some of the keys to our success. 

Standardized approach. The only main consistency of the wound closing practice had been that staff and surgeons changed their gloves and gowns if they were visibly soiled. The surgical team also followed standardized skin asepsis and disinfection protocols that required patients to use an antibacterial and antimicrobial skin cleanser the night before and day of surgery. A chlorhexidine gluconate surgical scrub solution was also applied to the patient’s skin just before incisions were made. New initiatives included closing wounds with a new set of sterile instruments and supplies, re-prepping and draping the surgical site and having all scrubbed team members don new surgical attire — regardless of how soiled the garments were.

Assessing perceptions. The higher risk for infection associated with colorectal surgery is multifactorial and involves modifiable as well as non-modifiable risk factors. By nature, colorectal surgeries involve lengthier surgical times, and surgery lasting longer than three hours is an independent risk factor for SSIs due to increased trauma to the bowel and intestinal contamination. Additionally, there are two distinct phases of colorectal surgery — contaminated and non-contaminated — that must be acutely appreciated by the entire surgical team. They must make every effort to not contaminate the closing of the wound with bowel contents.

I designed the project to address and alleviate some of the modifiable risk factors during the time of wound closure. I placed specific emphasis on how well nurses understood best practices by using the Evidence-Based Practice Beliefs (EBPB) Scale and how their perceptions impacted the mitigation of SSIs risks. The EBPB Scale has been extensively used with reliability and validity, and is considered a gold standard in the study of beliefs, perceptions and knowledge base of evidence-based practice. It contains 16 items on a five-point Likert scale that are used to evaluate the strength and intensity of agreement, with the number one representing strong disagreement and the number five representing strong agreement.

LAST STEP The author explored the impact of implementing a standardized closing process.

The scale covers two general areas: It asks nurses to self-reflect on their knowledge and skills of evidence-based practice and to relay their comfort level with the use of the practices. I administered the scale in a pre-and post-educational intervention format to assess the impact of the teaching component of the project, which dealt with strengthening the knowledge base of evidence-based practice and showing how it related to improved clinical outcomes. The assessment of nurses’ perceptions of evidence-based practice offers a window into the role of indicators in the implementation of change. This examination offers helpful insight on compliance and standardization of new practice, which are the ultimate goals of successful change and quality improvement.

Current research overwhelmingly shows that gaps in nursing practice are mitigated not only by the discovery of new research but, perhaps more importantly, its translation, implementation and dissemination. My hope was that improved patient outcomes were in some way the result of a favorable knowledge base and perceptions of evidence-based practices.

An analysis of the nurses’ perceptions on the EBPB Scale before the project revealed that while they expressed relatively positive thoughts toward evidence-based practice in general, they did not have an appreciation for its relevance and application to everyday practice. It was also apparent that nurses who had more experience and knowledge of evidence-based practices had significantly higher scores in beliefs related to the difficulty and time of implementing them as well as the value of doing so, as compared to nurses reporting less familiarity and exposure.

Making it stick. A major goal of the project was to improve standardization and eliminate the personal preferences of surgical staff with respect to the closing process. Decreased variability in the process was established through the bundle enhancements, which as mentioned now include closing with a new set of sterile instruments and supplies, re-prepping and draping the surgical site, and having all scrubbed team members don new surgical attire. This was important, as standardization is known to promote efficiency and quality control, while reducing ambiguity and allowing involved parties to take ownership of the process. Standardization is a vital component of process or quality improvement in establishing one correct way of conducting tasks with clearly defined terms and measurable results.

The inclusion of frontline staff and those affected by the change can promote a sense of empowerment that could overcome resistance to new ideas.

There is often resistance to change in health care, so it’s important for leaders to have a rich appreciation for opening the lines of communication and developing relationships and buy-in from the stakeholders involved with proposed changes. This is especially important in the operating room setting where the issues of communication and trust between surgeons and OR nurses represent major hurdles to overcome. The inclusion of frontline staff and those affected by the change can promote a sense of empowerment that could overcome resistance to new ideas. Leaders must also understand the powerful connection between nurses’ abilities to embrace change and their beliefs and perceptions with respect to translating evidence to practice and outcomes.

Promising results

BASES COVERED Perioperative staff might be familiar with best practices, but undervalue how important they are to follow during each case.

Data analysis revealed that after the first month of the initiative, the rate of SSIs decreased from 20% to 11%. In the second month, the rate of SSIs decreased again from 20% to 7% — the impressive result mentioned previously. The gradual decline in infection rates suggests the impact of workflow or learning curve issues that may have been present initially, but worked themselves out by the second month.

The EBPB Scale revealed a pre-test mean of 48.65, compared to a post-test mean of 63.62. The beliefs and perceptions scale scores improved by close to 15 points after the education intervention as the nurses came to understand the importance of initiating a standardized protocol. Achieving results that were statistically significant gave a certain degree of confidence that the findings were real, reliable and not likely due to chance. OSM

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