Initiative reduces SSIs from 7% to 2.6%
(Editor's note: Some of the information in this story was taken from Kaiser Sunnyside Medical Center's [KSMC's] application for the 2013 James A. VOHs Award for Quality, which they won.)
Kaiser Sunnyside Medical Center (KSMC) in Clackamas, OR, implemented a "Pathways to Zero SSIs" that resulted in a statistically significant drop in surgical site infections (SSIs) from approximately 7% (2006-2009) to 2.63% (2010-first quarter 2012).
Kaiser Sunnyside avoided costs of $576,000 by reducing SSIs by 33% for 2010 and 2011, which meant 24 fewer infections. This amount is based on data from the National Healthcare Safety Network (NHSN), which estimates the average cost of an SSI in the Northwest as being $12,000.
What lessons can Kaiser Sunnywide share with others in terms of targeting SSIs? Consider best practices, says Dana Trocino, RN, CIC, regional infection prevention manager with Kaiser in Clackamas, OR. "Create a robust plan with support," Trocino adds.
In July 2005, Kaiser Sunnyside enrolled in the American College of Surgeons' (ACS') National Surgical Quality Improvement Program (NSQIP). Between July 2005 and December 2009, KSMC's SSI rate was approximately 7% in comparison to 5.53% for other participating NSQIP hospitals.
KSMC's Surgical Site Infection Prevention Committee was formed in 2009. The SSI Prevention Committee included the regional chief operating officer for surgical services, regional chief quality & patient safety officer, assistant chief of staff, surgeon champions, director of inpatient and director of outpatient surgical services, infection control specialist or education specialist, and the quality consultant for surgical services. The committee has oversight of all ORs in the region, including three regional ambulatory surgery centers.
In 2010, it launched its "Pathway to Zero" infection reduction effort. Educational elements showed interventions as stones on the pathway to zero infections. The aim was to change the culture from that of "SSIs are inevitable" to that of "all SSIs are preventable."
The Surgical Site Infection Committee hosted a Surgical Summit kickoff meeting for perioperative staff and surgeons from across the Kaiser Northwest Region. Quality data was shared. A video presentation was played that was specifically developed for the summit showing a patient who experienced a postoperative SSI.
A separate team focused on improving culture. Standardized procedures and processes were established for antibiotic timing; appropriate surgical prep and hair removal; hand hygiene; communication, including briefings, debriefings, and time-outs; OR attire; and use of chlorhexidine gluconate wipes. (See specific steps in story below.) Teams collected data for each intervention, charted observations and audits of the processes, communicated findings, and modified procedures as needed.
From 2006 through 2012, KSMC reduced SSIs by 45%. The program involved multiple initiatives to reduce SSIs from the Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases Society of America (IDSA) and the Institute for Healthcare Improvement (IHI) "Plus" Measures Toolkit, and the Surgical Care Improvement Project (SCIP).
Members of the infection control staff have targeted measures embedded in the medical record that automatically create a report when any one of the targeted measures are triggered. These triggers include antibiotics ordered within 30 days of the procedure, wound cultures ordered within 30 days of the procedure, and diagnosis of a wound infection documented within the health record. The triggers identify cases to be reviewed by the infection control specialist.
Data were captured in a comprehensive Quality Dashboard Report, which was shared widely throughout the facility, including frontline staff, surgeons, and administrative leaders for the OR. A quality consultant was hired for compliance and reporting, and an education consultant was hired for preparation and simulation training, for a total personnel cost of $71,640. Other costs included a poster board for the Oregon Nursing Quality and Research Consortium for $100; facilities, audiovisual, and food for the Surgical Summit at $19,645; summit supplies and printing expenses (copies and badges) at $1,200; and "Pathway to Zero" poster boards at each facility for $250, for a total of $21,195.
Preventing SSIs is one of the 10 focus areas of the Centers for Medicare & Medicaid Services' Partnership for Patients. (For more information, go to http://partnershipforpatients.cms.gov. )
Pathway to reduce SSIs focused on 12 areas
The "Pathways to Zero SSIs" at Kaiser Sunnyside Medical Center in Clackamas, OR, included these activities:
• Appropriate attire for the OR.
Emphasis included: elimination of cloth skullcaps and requirement of disposable hospital-provided caps; hospital-laundered scrubs only and changed daily; elimination of exposed jewelry; and scrubs and attire in the operating room must cover all exposed skin. Staff fill out a Surgical Glitch Form Report when an event occurs, and they send the form to a quality consultant, according to Donna J. Berning, RN, MS, CPHQ, regional nurse consultant, surgical services for Kaiser in Clackamas. OR Attire Compliance Audits are completed at each facility and sent to the consultant for monitoring. (The Debriefing Glitch Form Report Categories, Surgical Glitch Form Report, and Surgical Team Glitch-Form Checklist are included with the online issue of Same-Day Surgery. If you need assistance, contact customer service at firstname.lastname@example.org or(800) 688-2421.)
• Hand hygiene.
Re-education focused on the importance of hand hygiene in the perioperative arena. A "Self Efficacy" tool was developed by the Regional Surgical Services Unit-Based Team. (A copy is included with the online issue.) Each facility manager distributed 20 random audits to staff members to be completed over the final four hours of their shift. Audits were sent to the quality consultant to monitor and reported to the SSI Prevention Committee. Defects were addressed.
• Appropriate hair removal.
Clipping was transferred to the Surgical Prep Unit and eliminated in the OR with the exception of select cases. Twenty cases were randomly audited per month/per site by the quality consultant and reported to the SSI Prevention Committee. Defects were addressed.
• Surgical skin prep.
Single agent preps were eliminated. ChloraPrep was selected as the standard prep for all operations except for select cases. All OR nurses were educated and required to demonstrate competency. Twenty randomly selected cases were audited per month/per site by the quality consultant and reported to the SSI Prevention Committee. Defects were identified, and surgeons were contacted if the first-choice prep was not used.
• Preop antiseptic bathing — CHG wipes.
Pre-bathing with Chlorhexidine (CHG)-impregnated cloths was used for all procedures involving a skin incision. CHG wipes were distributed in the PreOp Clinic or physician's office. Patients were instructed to use the wipes the evening before and the morning of the procedure. Twenty randomly selected cases were audited per month in inpatient operations by the quality consultant for compliance and reported to the SSI Prevention Committee. Defects were identified and addressed.
"Don't forget about culture," says Dana Trocino, RN, CIC, regional infection prevention manager at Kaiser in Clackamas, OR.
A cultural assessment was conducted, followed by additional evaluations and administration of a Safety Attitudes Questionnaire (SAQ) sponsored by the Kaiser regional senior leaders. Kaiser leaders contracted with Pascal Metrics in Washington, DC, to supply a standardized questionnaire and summary of the results, Berning says. (See contact information in resource at end of this story.) Categories in the survey include teamwork, job satisfaction, safety, perceptions of management, stress recognition, and working conditions. Kaiser places the lower metrics on a dashboard with goals for improvement, and each unit-based team creates its own projects to achieve the goal, she says. "The what' is clearly defined," Berning says. "The how' each team achieves it is within the team itself."
A Culture Committee was formed and included the director of outpatient surgical services, the regional COO for surgical services, regional chief quality & patient safety officer, assistant chief of staff, surgeon champions, and director of inpatient surgical services. This team focused on strengthening the role of the surgeon as a leader. Simulation-based training was developed as part of a collaborative project with Baylor University Dallas. Four key behaviors were emphasized for the surgeon to demonstrate to level the hierarchy in the OR and establish the surgeon as the role model for safety in the OR. (See box below.)
• SCIP infection measures.
The Surgical Care Improvement Project (SCIP) was developed by the Centers for Medicare & Medicaid Services and implemented in 2006. The infection-related SCIP measures include remove hair with clippers, appropriate antibiotics, prophylactic antibiotics IV in appropriate time, discontinue antibiotics within 24 hours, maintain perioperative normothermia, and remove foley catheter by second postop day. These processes were monitored monthly, and defects were addressed. Failures also were discussed individually with surgeons.
• OR environment.
Multidisciplinary teams included representatives of environmental services and engineering and facilities, as well as an OR education consultant. The consultant provided education and simulation training in the following: decreasing OR traffic once final timeout has occurred, consistently practicing 18 Association of periOperative Registered Nurses (AORN) standards, recognizing when standards of practice are not being met, and being empowered to speak up if they see or hear something that causes concern or break in recommended practice.
• Glucose monitoring.
All surgical patients have their glucose levels checked in the holding area and one hour after incision. Any patient with a level greater than 140mg/dL is started on an insulin infusion. A glycemic control team, made up of pharmacists and internists trained in perioperative glucose control, assume management of the infusions, ensure proper transitions off the drips, and maintain a glucose level between 80ml and180mg/dL.
• Postoperative antiseptic dressing.
Postoperative dressings were standardized (for operations with a closed incision) to a silver impregnated dressing (Acticoat) or antimicrobial gauze (AMD, polyhexamethylene biguanide coated).
• Bariatric surgery/antibiotic dosing by weight.
SCIP measure was expanded so that they can be best described as antibiotic management. Appropriate weight-based dosing and re-dosing based on duration of the case and the half-life of the antibiotic was addressed. Standard protocols were developed for the anesthesia team reflecting these factors. Randomly selected cases were monitored by the Infection Control Department for compliance. Defects were discussed with surgeons.
• Isolation precautions within the perioperative arena.
Perioperative staff members were educated regarding isolation for patients in contact precautions. Color headers were added to the electronic record indicating isolation precautions as an alert. Staff place patient safety reports on all near-misses or actual incidences for quality staff to track and trend and for the Infection Control Department to monitor and follow-up with education as needed.
• Pascal Metrics, 1025 Thomas Jefferson St. NW, Suite 420 East, Washington, DC 20007. Phone: (202) 333-9090. Fax: (202) 280-1250. Web: http://www.pascalmetrics.com. E-mail: email@example.com.