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July 12, 2018
Deb Campbell, RN-BC, MSN, CPHQ, CCRN Alumna
K-HIIN Infection Prevention Improvement Advisor
Ky Hospital Improvement Innovation Network
Minimal review to tie this content to last webinar◦ Choosing what to measure
Describe process measures related to
◦ SSI
*Remember, the goal is not to discuss specific
interventions in detail, but rather monitoring and feedback as prevention mechanisms !!
Quality Directors
Surgical Services staff
Nurse leaders
WOCNs
Environmental Services
Pharmacists
Others?
QI and environmental control expertise
Antibiotic choices/duration/timing
Wound care
Reliable Implementation-The difference between a great policy and actual best practice at the bedside consistently every day every time for every patient
I found an article from 2004 containing some of the recommendations that we still find unreliably performed today!
Surveillance is the best way to ensure appropriate compliance.
◦ A sample is:
A few of many
Part of a whole
◦ A good sample is something else!
Avoid bias! (Weekends, nights)
Choosing process measures ◦ Top 10 checklist
◦ Change package/toolkit
◦ EBP articles/research
◦ RCA from last 1-5 SSIs
◦ Trigger tools/chart reviews
◦ Ask the staff
Narrow focus◦ Most frequent procedures v. most problem prone*
◦ Gap analysis--- might be surprised!
Ultimately, process measures depend on yourinterventions
Most often reported breaches- IC Today 2013◦ HH #1
◦ Attire
◦ Sterile field management
◦ Traffic control
◦ Environmental hygiene
◦ Sterile Processing (e.g., flash sterilization, other)
◦ Skin prep
◦ Other (normothermia, items brought in to OR)
Have we made progress? (2017)◦ Rank order is slightly different!
What will you find?
Remember the cross-cutting interventions for HAIs-HH and environmental disinfection
Today we will use a different lens when thinking of “broad brush” interventions.
◦ Pre-operative processes
◦ Environmental hygiene
◦ Intra-operative processes
◦ Post-operative processes
Advantages◦ Aligns process measure data collection with
education/best practice literature
◦ Captures several/many interventions that have been shown to improve outcomes without ranking them
◦ Simplifies sharing feedback- “all or nothing” concept
Example◦ Of the 100 pre-op patients that we audited, 80 met
all elements of the SSI bundle =80%.
What is the disadvantage?
Smoking cessation
Optimize nutritional status*
Blood glucose control for diabetic patients
Weight loss
Avoid pre-op day hospitalizations**
Reduction alcohol/drug use◦ 50% at least, ISCR
Dental exam/cleaning
Patient education
# patients tobacco free 12 weeks prior to surgery/# patients who received a TKR.
# patients with normal HgbA1c/# patients who underwent any elective surgery.
# TKR pts within 10% of recommended BMI/
#TKR procedures
# pts with dental exam/
# elective procedures
# pts with serum albumin
WNL/# procedures
Pre-op bathing/showering (cloths/liquid?)
Nasal decolonization practices (plus oral rinse?)
◦ Mupiricin
◦ Povidone iodine
◦ Alcohol
Appropriate hair removal◦ Clippers v. razors
◦ Location: Pre-op area v. OR
Skin prep (CHG/alcohol- immediacy and persistence of activity) Technique matters!
Appropriate antibiotic prophylaxis as indicated
SCIP measures related to antibiotics
# patients who received CHG shower/bath per instructions/# non-emergent surgeries
# pts with clipped hair removal in the pre-op area < 2 hours prior to cut time/ # pts who required hair removal
# pts completing decolonization process/# TJR procedures (or all procedures)
# correctly prepped pts/# preps observed
Cleaning AND disinfecting rooms* ◦ Wipe down horizontal surfaces prior to first case of
the day!
◦ Between cases v. end of day cleaning
◦ Technology, e.g., UV
Instrument cleaning/sterilization◦ SPD training (certification?)
◦ Reduce, eliminate flash sterilization
◦ Staff handling in the OR
Non-critical items- careful disinfection**
Pressure gradient, humidity and temp of OR ◦ Vertical laminar, filtered airflow (studies)
◦ Air exchanges (at least 20/hr)
# correct items on rounding checklist/total # items on checklist
# instances of flash sterilization-goal of 0*
# times temp, humidity or pressure gradient ranges breached- goal of 0*
# correctly cleaned ORs/# observed ◦ Track # and what type of errors occur
# microbiological samples acceptable/# samples collected/tested?? **
Antibiotic timing-2017 had virtually no
Staff hand antisepsis process*
Surgical attire – (what and how donned)◦ Hair and arm covering
◦ Hospital laundered scrubs only (changed v. covered)
◦ Jewelry, nails
Monitoring of sterile field/aseptic technique**◦ Traffic decreased/doors closed
◦ “Sterile Conscience”
Culture◦ Checklists done right! (2014 study)
◦ “Stop the line”
Oxygen supplementation
Antibiotic impregnated sutures (triclosan*)◦ Weaker comment regarding consideration of
antimicrobial impregnated dressings
Judicious fluid administration
Patient normothermia**◦ Warm blankets
◦ Forced air
◦ Socks and hats
◦ Warm fluids
Safe injection practices-1 needle, 1 syringe, 1 patient, 1 time
SCIP measures*, e.g. # pts with temps WNL throughout peri-operative period/# surgeries
Average # times door opened from cut to close –use a specific surgery type to start
# of times hand antisepsis done per policy/# observations of process
# observations with all surgical attire per policy/# observations
# observations with continuous sterile field monitoring/# observations
# time-outs done correctly/ time-outs observed
Room
Overall cleanliness
Table
Floor
Supplies
Nurse’s desk
Traffic Control
Appropriate attire
Appropriate staff
Room doors closed
Anesthesia Carts
Clean
Medications secure
Immediate Use Sterilization
QC complete
Log complete
Supply areas
Clean
No expired items
Proper storage
Sterile Processing
Proper attire
Separation of clean & dirty
Traffic control
Early Progressive Mobility
Judicious pain med/sedation*
Timely device removals**
Wound care◦ Sterile technique for dressing changes
◦ No betadine- impairs wound healing
◦ Translucent dressing to allow visualization?
◦ Project Joint (non-adhering layer, absorptive layer, occlusive layer) for 24-48 hours
Optimal nutrition
Patient education
HH compliance PACU/post-op unit
# pts with local/block for pain*/# procedures
# pts who met progressive mobility goals daily/# post-op pts
# pts receiving recommended calorie/protein intake/# post-op pts
# correctly performed dressing changes/# observed
#clean, occlusive dressings at 24 hours/#observed
# pts successfully educated about post op care using teachback/ # procedures
Cardiac surgeries◦ APIC Guide for Prevention of Mediastinitis
Monitor unplanned returns to OR*
Orthopedic surgeries◦ Project Joint
Avoidance of closed suction drainage systems
Use of occlusive dressings
Irrigation practices? (low v. high)
GI surgeries◦ Separate closing trays and PPE
◦ Oral and Bowel prep protocols
Oral abx
Wisconsin Supplement**
SSI prevention is a team sport*Physicians
OR staff
Pre-op and PACU staffs
Sterile processing staff
EVS staff
Engineering staff
Educators
Dietitians
WOCNs
Post-op nursing unit staff
Materiel Management department
Patients and families
May be the hardest area to achieve this!Territoriality
Heirachical
Time pressure, stress
High degree of expertise*
Us v. them (IPs)
Hardwire the teamSurgical Care Committee/PI team component
Infection Control or Quality Committee sub-committee
Special project team (short term, PI cycles) e.g.ERAS
PFAC subcommittee
Social events- team building!
All or nothing- can work great for bundles ◦ Example – In May, we had 180 surgical patients.
110 met all bundle elements. 110/180 = 61%
Drilling down- Of the 70 who did not, 50 patients did not perform their CHG shower/bath. 130/180 did = 72%
What happened?
◦ Of the 50, 40 were
noted to have not
received the CHG
at a PAT visit.
100% v. incremental goals
Use competition◦ Compete against your past performance
◦ Compare services/departments/disciplines
Celebrate success!
Share it- not just the numbers/not just on dashboards and at meetings!!
What issues are you seeing? Use for training and re-training!
Regular agenda item to keep topic top of mind to get resources needed
Discover (and work to overcome) barriers!! Unacceptable hand
antisepsis product
Lack of knowledge of
hazards around door
closure and OR traffic
Outcomes matter, but processes drive them!
PLEASE let us help if this is new for you or you would just like a second opinion or advice from someone outside your everyday work flow!!
502-992-4383
Process measure webinar # 9
C. diff/MRSA process measures
Thursday, August 16, at 11am ET (10am CT)