With 0% surgical infection rate, improvement needed

Some process are identified as 'unreliable'

You might think that with a surgical site infection rate of 0% you could rest on your laurels, but that's not the attitude of the quality professionals and staff members at Hawaii Medical Center East in Honolulu. Despite achieving such a "perfect" score, they decided to dig deeper and find additional ways to improve.

"Our baseline surgical site infection [SSI] rate in 2005 was 0%," recalls Jennifer Watarai, director of quality management. "This was attributed to our strong infection control practices. However, when we examined this in detail, we found alarming discrepancies between procedure standards and practice."

What were some of those discrepancies? "Pre-initiative results for administering antibiotics within one hour of incision was only 37%; selecting the recommended antibiotics was 77%; and discontinuing antibiotics within the recommended time frame was only 19%," Watarai says.

"Our medical center chose to work on this initiative since we did not have reliable processes in place to assure that our surgical patients were receiving antibiotic prophylaxis appropriately," she continues. "We wanted to do all that we could to minimize the risks of SSIs in our patient population."

A team approach

An interdisciplinary committee was formed and tasked with leading the improvement efforts, says Watarai. The team included:

  • cardiovascular surgeon (co-chair and physician champion);
  • director of quality management (co-chair);
  • chief of surgery (physician champion);
  • orthopedic surgeons;
  • chief of anesthesiology;
  • hospital administrator;
  • operating room manager;
  • ambulatory care services (ACS)/PACU nurse manager;
  • med-surg nurse manager;
  • cardiac catheter lab nurse;
  • infection control nurse;
  • pharmacists;
  • clinical data analyst;
  • health information management manager.
  • The team referenced a number of resources and tools used by other organizations, including:
  • Ohio KePRO SCIP (Surgical Care Improvement Project) pilot package;
  • Guidelines for surgical prophylaxis at the University of Louisville Hospital;
  • Southwest General Health Center's physicians order for adult pre-operative antibiotic for surgical prophylaxis;
  • Mountain Pacific Quality Health Foundation's "time out" checklist form.

"Other resources were found at the Institute for Healthcare Improvement: 100,000 Lives Campaign — Preventing Surgical Site Infections web site," she adds.

The facility adopted a perioperative antibiotic administration process similar to that instituted at Baystate Medical Center in Massachusetts, where it decreased its SSI rate from 3.8% to 1.4%, notes Watarai, who adds that "our objective was to implement reliable processes for appropriate and timely surgical antibiotic prophylaxis to prevent complications of infection from surgery and maintain our 0% surgical site infection rate."

Broad staff education effort

Watarai says a number of different strategies were used to make sure the staff understood what was expected of them. "We provided staff education on the SCIP through our medical center's "JCAHO WATCH" newsletter and posters posted in nursing units that highlight revised forms and orders," she says.

"We also provided education and feedback on the SCIP to physicians through medical staff department meetings, the medical center's medical staff newsletter, and a poster placed in the OR physician's lounge that highlighted revised forms and orders. Additionally, we developed and implemented SCIP education for surgical residents during their orientation."

The project began with data collection on patients discharged on July 1, 2005, with project initiation in December 2005. Most of the actions were implemented by July 1, 2007, and efforts have been ongoing.

"We revised and implemented a space for systematic documentation of antibiotic administration on every patient chart, as well as revised existing pre-printed orders according to guidelines for the administration of prophylactic antibiotics," says Watarai. "We included the following in the preoperative checklist: prophylactic antibiotic ordered and sent with patient to OR (to be started in OR, except Vanco, Cipro, and Levo)." White boards are used in the OR suites to document prophylactic antibiotic time, as well as to serve as reminders."

The SCIP team oversees and monitors the process and timeliness of surgical antibiotic prophylaxis and analyzes data, says Wataria. Findings are reported to and feedback is solicited from the OR committee, department of surgery, department of anesthesia, department of cardiology, department of EENT, nursing, and the patient safety quality council on a regular basis.

Here are some of the immediate "next steps" included in the process:

• pharmacy will flag SCIP patients on the pharmacy computer system to trigger pharmacists to follow SCIP recommendations;

• pharmacy will implement automated "hard" stops on all surgical prophylactic antibiotics after 24 hours or after 48 hours for CABG and cardiac procedures;

• revised pre-printed pre- & post-op orders will be posted in PACU and ACS;

• revised post-op orders will be placed in an accessible area in PACU;

• the revised post-op orders and pre-op checklist will be bundled with the revised pre-op orders;

• nurse managers will discard outdated orders and place the revised pre- & post-op orders in their units;

• the SCIP education module for surgical residents' orientation will be updated;

• two physician champions will personally hand-deliver to each surgeon a packet containing:

  • surgeon's individual report card;
  • pre-printed ACS pre-op orders;
  • pre-printed pre-op orders;
  • pre-printed post-op orders;
  • information on how to appropriately;
  • document infection;
  • information that post-op antibiotics are unnecessary;
  • educational information on VTE prophylaxis;
  • educational information on beta-blockers;

• the chief surgical officer will push to make pre-printed orders mandatory.

"Longer term, a computerized physician order entry system will be implemented with automated options/orders that are in compliance with SCIP guidelines," Watarai adds.

All of the team's goals have been accomplished, she reports. "Dramatic improvements were made in administering antibiotics within one hour of incision from 37% to 81% in the fourth quarter 2006 and 100% in January 2007," Watarai says. "Selecting the recommended antibiotics went from 77% to 89% in the fourth quarter 2006 and 81% in January 2007, and discontinuing antibiotics within the recommended time frame went from 19% to 72% in the fourth quarter 2006 and 63% in January 2007.

"Most importantly," she concludes, "we were successful in maintaining our SSI rate at 0%."

[For more information, contact:

Jennifer Watarai, Director of Quality Management, Hawaii Medical Center East, 2230 Liliha Street, Honolulu, HI 96817-9979. Phone: (808) 547-6011.]