Infection Prevention: Getting as Close to Zero SSIs as Possible

By: Adam Taylor

Published: 9/1/2020

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Improved hand hygiene and proper antibiotic administration are part of the protocols that keep infection rates low at Kaiser Permanente Tysons Corner ASC.


While the infection rates at Kaiser Permanente Tysons Corner ASC in McLean, Va., were already low, the facility’s leadership wanted to do even better. They researched the issue and realized improved hand hygiene practices and proper antibiotic administration protocols were the best ways to further reduce risks of surgical site infections (SSIs).

The facility set a goal of having an SSI rate of less than 1% for hip and knee replacements, hernia repairs and breast implant surgeries by September 2019. Leadership created a multi-point action plan to achieve the benchmarks and conducted regular education sessions for staff on how to implement it. The center’s successful efforts to reduce most of their target SSI rates garnered the seven-OR facility the 2020 OR Excellence Award in Infection Prevention.

“We think our plan will allow us to get our SSI rates even lower,” says Daiva Mercado, RN, clinical operations manager. “The staff has been very receptive. We explain that the plan’s action items are AORN standards and evidence-based, and that they’re our policy.”

Hand hygiene and antibiotic prophylaxis are known to reduce infections, so the facility took significant steps to fill gaps in these practices, according to Barbara Wolaver, BSN, RN, CNOR, a co-lead of the unit-based team at the ASC. Covert observations of hand hygiene practices took place monthly, and facility leaders tracked whether antibiotics were administered within one to two hours before surgical incisions, depending on the antibiotic used. It turned out that some OR staff weren’t always compliant with the facility’s hand hygiene protocols and, while antibiotics were being administered, there were issues with the types of antibiotics being chosen, the timing with which they were administered, and the following of weight-based dosing and re-dosing protocols.

The center’s leadership also implemented the following action plan to ensure that the SSI rates don’t go above 1%:

  • Smart sanitizer placements. Hand sanitizer dispensers are placed at the entrances and exits of all rooms in the facility. Employees must treat their hands after they touch patients or any surfaces in the rooms. Some dispensers were moved to more user-friendly locations if old spots were hard to reach. Locations were also added based on staff feedback and suggestions.
  • Long sleeves in the OR. Before prepping patients, staff must practice proper hand hygiene, slip on long sleeve scrub jackets and don sterile gloves. A large inventory of jackets is always available for nurses to wear. The jackets are laundered at the facility and are never allowed to be taken home.

“We had to educate the staff on why they’re so important and we incentivized the practice until everyone got used to it,” says Ms. Salinas. “Now, everyone wears a jacket — nurses, techs, anesthesia staff, surgeons — until they’re scrubbed in.”

Honorable Mention
One of Georgia's Best Colon Care Bundles
NOSE TO TOES Staff at St. Joseph's/Candler Hospital prep patients undergoing colon procedures with CHG wipes and nasal decolonization.   |  St. Joseph's/Candler Hospital

In 2015, surgical leaders at St. Joseph’s/Candler Hospital in Savannah, Ga., began to research ways to reduce risks of surgical site infections in patients undergoing colon surgery. They eventually implemented best practices outlined by the Association of periOperative Registered Nurses (AORN), the Agency for Healthcare Research and Quality, and the National Healthcare Safety Network. Now their colon surgery SSI rates are among the lowest in hospitals across the state of Georgia.

“The prevention bundle we created was implemented at other St. Joseph’s/Candler campuses, resulting in a system-wide reduction in colon SSIs,” says Mary Owen, RN, MSN-Ed, BSN, CNOR, St. Joseph/Candler’s perioperative clinical nurse educator.

The bundle starts with pre-screening interviews of patients and educating them on proper SSI prevention protocols, including instructions on the use of chlorhexidine gluconate (CHG) wipes the night before their scheduled procedures. On the day of surgery, staff members prep patients again using CHG wipes and remove hair around the surgical site using vacuum clippers. During procedures, the surgical team performs skin antisepsis with CHG, practices correct hand antisepsis, uses wound protectors, administers copious amounts of irrigation fluid in the abdomen, changes gowns and gloves before closing incisions, and uses separate closure instruments.

The health system implemented nursing and surgeon education about the SSI prevention bundle. The education is ongoing and provided during morning huddles, monthly in-service programs and via computer-based learning modules.

The bundle was incorporated into the hospitals’ electronic health record — nurses check the boxes of supplies used and processes followed. This documentation method was tested by the nursing team before full deployment, says Ms. Owen. Staff created a list of practice standards using the latest evidence-based guidelines for colon surgery that is tracked and monitored.

A monthly retrospective chart audit of nursing and surgeon documentation is conducted to assess these standards and report the results to the quality improvement team, which identifies any problems and discusses areas of opportunity for improving practices. “We’re constantly reassessing and re-educating,” says Ms. Owen.

— Adam Taylor

  • Proper hand scrubbing. At the beginning of each day, the center’s clinical team members scrub their hands with soap and water for at least 20 seconds and rub in hand gel. After that, they apply hand gel as needed at patients’ bedsides. Team members are instructed to use three pumps of gel — one for each hand, and a third to apply on the forearms up to the elbows.

Secret shoppers monitoring for compliance offered on-the-spot corrections if they saw errors in application. Presentations on how to apply the sanitizer correctly are now provided during continuing education events and at annual competency reviews.

  • Monitored breaks. The facility’s nurses get 15-minute morning and afternoon breaks. When nurses who are working joint replacement cases return from breaks, they must rescrub, put on new gowns and gloves, and re-enter the OR from the sterile core in order to minimize airflow disruptions. Signs hung near the entrances of each OR alert staff of the traffic restrictions.

“These action items, combined with improved hand hygiene and antibiotic prophylaxis practices, have been effective in achieving our goal of zero SSIs for some procedures, and will allow us to achieve our goal of having a less than 1% infection rate for others,” says Ms. Wolaver. OSM

Honorable Mention
Prepping Switch Lowered Infection Risks
PROPER PREPPING Baystate Medical Center has switched from povidone-iodine to chlorhexidine gluconate for prepping patients undergoing vaginal and abdominal hysterectomies.

The staff at Baystate Medical Center in Springfield, Mass., noticed an increase in infection rates among hysterectomy patients, so they updated and improved their prepping practices — with great results. Over the last two years, infection rates among vaginal hysterectomy patients dropped from 2.17% to zero. The decrease in SSIs for patients who underwent abdominal hysterectomies was even greater — from 8.77% to 2.14%. Baystate Medical acheived these results through research and staff education.

A review of the literature showed povidone-iodine (PVP-I) isn’t an ideal solution for vaginal surgical prepping, as its use can lead to iodine absorption through the vaginal lining, skin irritation, diminished effect of the solution in the normal PH level of the vagina and inactivation by blood, says Karen Paluch, RN, CNOR, Baystate’s supervisor of the IVF, GYN and urology surgical service lines. The facility therefore switched to a 4% chlorhexidine gluconate (CHG) solution, which is recommended by the American College of Obstetricians and Gynecologists (ACOG).

The FDA hasn’t approved CHG for vaginal use, but it’s widely used for prepping GYN patients, a practice the ACOG says is a safe and effective off-label use of the product, according to Ms. Paluch.

All GYN patients are asked to shower the night before surgery with a CHG prep kit provided by the hospital. (Patients with an allergy to CHG can bathe with antibacterial soap.) Pre-op nurses ask patients if they complied with the directive. Those who did not are given CHG wipes to cleanse themselves before they’re brought to the OR. CHG skin prep prophylaxis is documented in the patient’s chart as part of the pre-op checklist.

Random audits and continuing education for new and existing employees are ongoing to keep Baystate’s vaginal hysterectomy SSI rate at zero, says Ms. Paluch.

— Adam Taylor