WINNING HANDS With our 'secret shoppers' always on the lookout, we raised our hand-hygiene compliance rate to more than 90%.

Like most surgical facilities, we take infection prevention seriously and we pride ourselves on our low SSI rates. We know the risk of infection accompanies any surgery, and that the risk with orthopedic procedures, many of which require implants, is even higher. So we're proud of the fact that for 2013 and prior years, our infection rate has averaged 0.2%, compared with the national average of 1.43%, the figure cited by the Ambulatory Surgery Center Association.

We've discovered that infections can be caused by many easy-to-overlook factors and they can usually be prevented by a series of relatively simple precautions. On the whole, surgical facilities do a terrific job of keeping infection rates down, but we should all be striving for zero. Here's our formula for keeping infections to an absolute minimum:

1. Anoint an infection preventionist
It's valuable to have someone in your team who is responsible for infection prevention education and patient follow-up. We have a dedicated RN who attends classes and conferences and is certified in this role. She follows up with our physicians monthly, and when an infection occurs, she completes a chart review and looks into the sterile processing logs for clues. She also reports quarterly to the QI committee, the medical advisory committee and the governing board. We always have timely information about potential and actual infections, our charge nurses and teams are able to stay up to date with current infection prevention practices, and we always know how well we're doing.

2. Explain the reason behind their actions
Frequently remind your teams that they aren't just cleaning a room or piece of equipment, processing instrument trays or cleaning their hands. They're preventing infections. When teams view their roles and actions from that perspective, it can improve their attitudes and help them realize that what they do is important — that they themselves can help prevent infections and keep patients safe.

3. Have 'clean' competition
Our "secret shoppers" are always on the lookout, monitoring surgical teams and physicians for proper hand hygiene after they remove gloves, before and after they care for patients, and after all other events that can contaminate hands and increase the risk of infection. Then we post scores every month and break them down by teams — MDs, RNs, surgical techs and anesthesia providers. The competition is healthy. Our heightened awareness has improved compliance to between 90% and 100%. When you see poor hand hygiene practices, it's important that you point it out in a kind, professional or even fun manner. That's the approach that's most likely to improve compliance.

ON-TIME ANTIBIOTICS Document when antibiotics are administered and the incision time, so your infection prevention specialist can keep track of compliance.

4. Administer antibiotics on time
When you order a pre-op antibiotic, it works best to have the anesthesiologist administer cefazolin during the pre-op consult, within the required time, right before incision. This prevents the need for a second dose if the pre-op RN administers it and the case ends up being delayed. Our pre-op staff prepares the antibiotic and places the labeled syringe at the patient's bedside for the anesthesiologist to administer. On those rare occasions that we use vancomycin, the pre-op RN administers it according to guidelines. Document when antibiotics are administered and the incision time, so your infection preventionist can track compliance.

5. Keep patients warm
To reduce the risk of infection from hypothermia, we strive to keep patients warm during the entire perioperative phase. When someone is heading into surgery for a more invasive procedure — such as a spine or total hip — we make sure the patient is pre-warmed in pre-op, using warm blankets and/or a forced-air patient warmer. But it's always good practice to put a patient warmer on any patient who feels cold before surgery, or who's about to have a longer procedure. Keep the warmer on patients during the procedure, if possible, and be sure to cover them as quickly as possible in the OR to minimize body temperature drop. Keeping patients warm, comfortable and at a stable temperature reduces the risk of infection.

PROPHYLACTIC WARMING You'll reduce the risk of infection if you keep patients warm during the entire perioperative phase.

6. Have the right
equipment and enough of it
If your instrument trays aren't keeping up with your caseload, you can get caught in an instrument and equipment crunch and end up relying too much on flashing between procedures. When that happens, it's time to purchase more inventory and to think about ways to better accommodate all of your cases. Having enough inventory not only reduces the need to flash, it also reduces stress and tension among staff. And if you have a happy, cohesive, productive team, the workflow will be smoother, and there will be fewer errors, less inefficiency, and a reduced risk of infections or other problems. You'll be able to focus on each patient that enters a department, instead of on how to cope with a potential equipment shortage.

There's a good chance you'll even save money in the long run. By striving to have the right equipment on hand, and in the right amounts, we boost staff morale and productivity. We also reduce the time wasted trying to manage equipment, and the downtime between surgeries and, worse, downtime during surgery. We also do very little flashing and — most importantly — we keep our patients safe.

7. Thin the herd in the OR
The more people there are in an OR, the more distractions there are and the higher the risk is for contaminating the field and compromising air quality. Keep the number in the OR to the minimum you need. And keep traffic in and out of the OR to a minimum. How? Make sure the OR team and the charge nurse are empowered to manage traffic and that they feel comfortable asking anyone who isn't needed to please leave. Managing the number of vendors and visitors in the OR requires continuous vigilance.

8. Plan for all eventualities
Have you ever had one of those days when some poor RN ends up running ragged between the OR and the supply room, fetching products? Not only is it exhausting, it disrupts the clean airflow, which can increase the risk of infection. Why does it happen? There are several reasons: The case wasn't pulled accurately (which could be because preference cards aren't current). The team didn't prepare well for the case. The surgeon didn't plan well for the case. Maybe the case turned into something unexpected. Regardless, it shouldn't happen. Teams have to be prepared for all cases. They should check the equipment and supplies before surgery starts. They should talk with the surgeon if they haven't been given enough detail. They should know exactly what the procedure is and make sure everything they need is in the room.

Tip: Have dedicated staff manage preference cards during downtime to make sure they're up to date and accurate. It's a great task for surgical techs, who tend to be most aware of what surgeons want and need.

9. Educate patients and families
Once patients leave the center, it's up to them and their families to manage the risk of infection. So education is vital. Patients and their families need to understand how to keep dressings and wounds clean and dry, and when to report to their physicians. Prevention and early detection are essential when it comes to managing any potential problems. Provide simple written instructions and contact information if they need further help.