OR Excellence Awards: Infection Prevention & Control: Focus on the (Many) Finer Points

Waupun Memorial Hospital has banished total joints SSIs by meticulously tracking and recalibrating numerous aspects of its prevention program.

The goal of a project launched at Waupun (Wis.) Memorial Hospital in August 2022 was to reduce surgical site infections (SSIs) in a few service lines. In its crosshairs particularly were total joints cases, from which it logged six SSIs that year. It wanted to halve that number to reduce hospital readmissions and return to surgery.

By the end of 2023, after numerous interventions, process changes and reinforcement of best practices, it achieved that goal, with only three total joint SSIs for the year. For the past 16 months and counting, however, there have been zero. “Our last SSI was in May 2023 and we haven’t had an SSI in 2024 yet either,” says OR Manager Melissa Souders, RN.

This achievement was challenging for numerous reasons. One example: some of its patients are incarcerated and had suffered the majority of the SSIs. The culprit was hygiene, particularly a lack of compliance with preoperative CHG bathing, so Waupun personnel collaborated with the Wisconsin Department of Corrections to ensure that members of this vulnerable patient population present for surgery like most other patients, having taken their night-before and morning-of CHG baths.

It’s that kind of dedication, attention to detail and commitment to excellence that make Waupun Memorial the 2024 OR Excellence Award winner in the category of Infection Prevention & Control.

Comprehensive adjustments

Waupun made numerous changes over the last two years, all tracked for compliance and efficacy.

• Preoperative antibiotic prophylaxis. The team was struggling to meet timing goals for vancomycin administration before surgery. The biggest barrier was getting the timing right based on the patient’s weight, says Ms. Souders. “We asked pharmacy to give us a list of all the doses so we knew the correct time we needed to start the medication,” she says. Further improving the situation was that, after a meeting with an epidemiologist, surgeons requested swabbing for MRSA preoperatively. “That really cut down on our use of vancomycin,” she says.

• Hair removal. Too often, intraoperative staff were forced to clip hair in the OR because the task wasn’t being completed to the surgeon’s specifications in pre-op. In-servicing corrected the problem, while clipper vacuums were purcahsed to keep the process tidier while lowering contamination risk.

• Warming. Pre-op staff were struggling to apply warming gowns to patients. “Many patients don’t like the gown because it gets very warm and sticky,” says Ms. Souders. Staff was instructed to explain the benefits of warming to the patient to better secure their compliance, while increasing monitoring of pre-op temperatures to ensure patients were at normothermia before entering the OR.

• OR traffic. Staff were too often entering and leaving the room during implant cases, which increased infection risk. “Do Not Enter” signs are now placed on both the main and sub-sterile doors to the OR during procedures. The hospital provided phones for staff to easily call outside the OR for needed items, and tracked requests and usage of various items to determine which to store in OR supply cabinets.

• Wound closure. The facility switched to antimicrobial sutures. Sterile closing trays were implemented to prevent possible contamination from instruments used inside the patient, and providers are required to change to clean gloves when closing.

• Prep sticks. Not enough agent was being applied, so a vendor rep was invited to demonstrate proper application for various areas of the body. “It was helpful for staff to have that visual education,” says Ms. Souders. The rep returned to observe preps and provide feedback. “That extra set of eyes could see things we possibly were missing,” she says.

• Checklist. Hard stops related to SSI reduction measures were added to the EHR. “If they missed nasal decolonization or any other pre-op measures, it won’t let them close out the chart,” says Ms. Souders.

• Tracking sheets. Provided each day to periop staff and then entered by managers into a computer application, results are presented to staff monthly. Ms. Souders says they heighten staff awareness and execution of Waupun’s many SSI reduction components. “They’re a reminder to them to make sure they are doing these things,” she says.

Waupun consistently engages staff about the importance of the measures they are expected to perform and document. Says Ms. Souders, “It makes them feel like they’re part of a team.” And that team is winning the fight against SSIs. OSM

Honorable Mention: Inclusive Audits Keep SSIs at Bay

University of Iowa Healthcare Tracks — And Prevents — Infections to Perfection

LET’S ROUND Nurse leaders Molly Kucera (fourth from left) and Aimee Cusic (holding notebook) regularly round their unit to audit infection prevention practices, and on many occasions they bring company — from frontline staff to administrators.  |  University of Iowa Healthcare

Since 2019, an HOPD at University of Iowa Healthcare in Iowa City has tracked surgical site infections (SSIs) across six surgical service lines. In that time, just one SSI was reported.

How did it achieve this nearly spotless record? Nothing glamorous. Just persistent auditing, monitoring, analysis, rounding, education, reinforcement and adaptability. “Our goal was to decrease the potential risk of SSIs by implementing evidence-based infection prevention practices, enhancing staff education and maintaining rigorous surveillance,” says Molly Kucera, MBAHC, BSN, RN, CNAMB, CNOR, associate director of the HOPD, who worked closely with Aimee Cusic, RN, BSN, CAPA, assistant nurse manager, pre/post/PACU, on the project.

Its regimen includes use of CHG soap twice preoperatively, administration of preoperative antibiotics one hour prior to incision and integration of hospital epidemiology into scheduled monthly reviews. Nursing leaders perform 200 monthly unannounced audits to gauge hand hygiene among all providers who touch the patient. Through these audits, leaders observe and log correctable behaviors. For example, says Ms. Kucera, “In the recovery room, you don’t think you’re leaving a ‘patient room,’ it’s more like leaving their area of the curtain. With private rooms, you’re used to leaving with hand sanitizer, but in the PACU, the bays with the curtain seem ‘open.’”

The audits consistently show compliance of at least 92%. “We’ve been auditing for a long time, but formally tracking it for the past year,” says Ms. Kucera. “Hand hygiene metrics are captured through a survey and entered into a report. You can really dive into that. Where are you having the most issues? In what area? Who is it? You can pull the data up anytime and slice it however you want. We present it to our frontline team: ‘Here are some things we saw that we need to do better, here are some things we saw that we’re doing great on.’”

It’s not just nurses who are rounding. Epidemiologists, compliance officers, the medical director, administration and frontline staff often join to examine and discuss processes. “We call them environmental rounds,” says Ms. Kucera. “We meet and walk around the unit. They’ll ask questions, and we’ll discuss things we could do better or are doing well, and they can get on board with things that may need to be adapted or changed. You can ask the experts for help.”

The data awareness and open communication is paying off. Everyone feels they have a role to play in SSI prevention. “It’s teamwork, and everybody’s part of the team,” says Ms. Kucera. — Joe Paone