Kigali surgery innovation hackathon 2018

1. Nichole Starr, MD, MPH | nichole@lifebox.org
Clean Cut Fellow - Ethiopia| Lifebox Foundation
General Surgery Resident| University of California, San Francisco
CLEAN CUT:
SSI Prevention through Process
Mapping and Quality Improvement
Kigali Hackathon
12.7.2018

2. WHAT IS LIFEBOX?
1.Checklist Implementation
2.Safe Anesthesia: Pulse Oximetry Training &
Distribution
3.Clean Cut - Surgical Infection Prevention
Training
Tools
Partnerships
Sustainable solutions for improving anesthesia &
surgery

3.  Pulse Oximeter Distribution and Training
 1,129 pulse oximeters since 2011
 9 workshops held for anesthesia providers throughout Ethiopia
 Next steps: distribution of 30 pulse oximeters via Ethiopian Society of Anesthesiologists

4. • Mortality from common operations is 4-20 times
higher in LMICs than high income countries –
largely due to SSI
• SSI is leading cause of hospital-acquired
infection in Sub-Saharan Africa
• Surgical populations – SSI
Tanzania – 35.6%
Ethiopia – 14.8-21.1%
Nigeria – 22.9%
• Risk reduction with improved adherence to
infection prevention standards
WHY SURGICAL SITE INFECTIONS
(SSIS)?

5. • Appropriate use of surgical safety checklist can improve patient outcomes
• The surgical checklist highlights basic infection prevention standards:
• Low to no-cost interventions can improve compliance with basic infection prevention
standards
CHECKLIST IN INFECTION
PREVENTION
Proper Antibiotic
Prophylaxis
60’
Use of Sterile
Instruments
Standardized
Gauze Counts
Surgical Safety Checklist
Use & Communication

6. Infection
prevention
standards
Process
Mapping Identify gaps
Adherence to
standards
↓ SSIs
Safe
Surger
y
Safe
Surger
y
Quantitative
Measurements
Develop local
solutions
&
CLEAN CUT OVERVIEW

7. STUDY MEASUREMENTS
Adherence to Infection
Prevention Standards
Appropriate Skin
Preparation
Maintenance of
Sterile Field
Confirmation of
Instrument Sterility
Antibiotic
Prophylaxis
Gauze Counts Surgical Safety
Checklist
60’
Primary Outcome
• SSI
Secondary Outcomes
• Hospital length of stay
• Other infectious
complications
• Urinary tract infection,
pneumonia,
endometritis, etc
• Reoperation
• Disposition on discharge
Patient Outcomes

8. 8
Right Drug
Right Route
& Dose
Right time
Correct
Prophylaxis

9. Antibiotics
(Abx)
Ordered
Intern
Patient
afford
Abx?
Yes
No
Abx
transferred to
ward
Abx type &
delivery time
documented?
Patient arrives
in OT
Induction
Position
patient
Skin
prepped
Study Measurement
Patient
Requires
Surgery
Skin
Incision
Yes
No
What is the
primary reason?
Appropriate Abx
given local
resistance? Yes
No
What is the
primary reason?
OPERATINGTHEATERWARD
Process?
Prepare
patient for
surgery
Abx in
stock?
“Sign In”
Surgery
“Timeout”
PHARMACY
What is the
primary reason?
Yes
No
Ward Intern
Confirm Abx
given
Confirm Abx
administration
time
Confirm type
of Abx given
ANTIBIOTIC (ABX) DELIVERY PROCESS MAP
Abx
administered
in ward?
What is the
primary reason?
No
Yes
Abx
administered
before
induction?
What is the
primary reason?
Yes
No
OT Nurse/ Anesthesia
Anesthesia
28%  49%

10. DISCUSSION & PROCESS CHANGE
Surgical Staff Meet Monthly:
-Review process data
-Review patient outcomes
-Brainstorm solutions that work in
their setting

11. MAJOR PROCESS IMPROVEMENTS
Improved
Checklist Use
Proper
Handling
of Clean and
Dirty
Linens
Sterile
Indicator
Use
Fewer Holes
in Gowns &
Drapes

12. ADHERENCE RESULTS – 5 SITES
Category Infection Prevention Adherence Measure
Baseline
Total (%)
n = 368
Follow-Up
Total (%)
n = 1521
p-value
Skin Preparation Surgeon performed proper hand decontamination 310 (84.2%) 1506 (99.0%) <0.0001
Gown and Drape
Integrity
Sterility indicator in gown/drape pack 52 (14.1%) 983 (64.6%) <0.0001
Gowns/Drapes dry prior to start of operation or replaced 245 (66.6%) 1502 (98.8%)
<0.0001
Instrument
Sterility
Sterility indicator inside the instrument tray 134 (36.4%) 1023 (67.3%) <0.0001
Instruments dry prior to start of operation or replaced 244 (66.3%) 1480 (97.3%) <0.0001
Antibiotics
Antibiotics prior to incision (Inpatient ward + OR) 318 (86.4%) 1376 (90.5%) 0.006
Antibiotics given in OR 104 (45.0%) 738 (49.5%) 0.205
Gauze
Pre-Incision gauze count 297 (80.7%) 1450 (95.3%) <0.0001
Final gauze count 288 (78.3%) 1440 (94.7%) <0.0001
Surgical Safety
Checklist
Time Out Performed 224 (60.9%) 1173 (77.1%) <0.0001

13. PATIENT OUTCOMES: HOSPITAL 3

14. SafersurgeryLifebox
Foundation
@SaferSurgery
THANK YOU!
Contact Information:
Nichole.Starr@ucsf.edu
nichole@lifebox.org