The document describes a project to reduce surgical site infections at a large Florida hospital. An interdisciplinary team conducted a gap analysis and implemented standardized protocols across preoperative, intraoperative, and postoperative care based on evidence-based research. Changes included new patient cleansing and shower kits, antibiotic protocols, OR cleaning processes, and follow up calls. As a result, the hospital's surgical site infection rate dropped significantly from 1.94% to under 1% within one year of implementing the new protocols. Keys to the project's success included executive support, physician collaboration, technology improvements, standardization of work, and industrial engineering principles.
1. Reducing Surgical Site Infections
A standardized and evidence-based approach
Sheena M. Butts
Industrial Engineer
2. • Full service health system
• 851 bed, not for profit medical center
• 5th largest hospital in the state of Florida
• Busiest single-site Emergency Department in
the state, approximately 200,000 visits per
year
• Approximately 1400 surgical cases per month
4. Opportunity Statement
• A multi-phase process improvement effort to
reduce Surgical Site Infections was initiated
in October 2013. The goal of the project is to
reduce and sustain near zero surgical site
infections. As a result, standardized
improvement efforts were implemented
across the preoperative, intraoperative, and
postoperative phases of care
5. Objectives:
• Reduce and sustain near zero surgical site
infections
• Implement standard evidence-based clinical
pathways through the preoperative,
intraoperative, and postoperative phases
• Improve patient experience
6. Project Team:
• Interdisciplinary Project Team
– Senior Chief Quality and Informatics Officer
– Chief Academic Officer
– Chief of Surgery
– IT Analysts
– Nursing Leadership
– Director of Quality
– Patient Safety Officer
– Infection Prevention Manager
– Pharmacists
– Industrial Engineer
7. Method:
• The project team completed a three month
gap analysis and utilized evidence based
research, workflow analyses, data analyses,
and root cause analyses to determine a set
of standards to reduce surgical site
infections
8. Design: Preoperative
• Washing Kits and Patient Shower sequence with
Hibiclens (CHG)
• Standardized Pre & Post Operative Instructions
• Clipping Process to be completed outside of OR for
qualifying cases
• MRSA Alert
• Trial of Total Hip and Knee Surgeries with 3M Nose to
Toes Kits
• Prophylactic Antibiotics ordering and workflow redesign
to ensure appropriate antibiotic choice, dose, and
timing
• Nursing and Physician documentation changed to reflect
and track process changes
9. Design: Intraoperative
• CHG prep
• OR room temperature and humidity levels monitored
with TempTrack
• Antibiotic Re-dosing Alert
• Positive Patient Identification Protocol & Positive
Medication Identification (PPID & PMID)
• Surgical Scrub Attire Policy
• Appropriate Wound Classification
• Standard OR room cleaning process (including 3M Clean
Trace monitoring)
10. Design: Postoperative
• Postoperative Prophylactic Antibiotic Administration Alert
(1 hour prior)
• Follow-up phone call (like to automate)
• Surgical Site Infection (SSI) letter to surgeon
15. Keys to Success
Executive Leadership Support
DYAD collaboration between surgical
services leadership and physician leadership
Technology and System Improvements
Industrial Engineering Principles
Standard Work
Cleansing and SSI Prevention Education Developed for patients. Prior education was not standardized across providers, was difficult to read or way too many pages of information. Did not include evidence-based washing with hibiclens process. New instructions are easy to read, only 1 page front and back- Before surgery and After Surgery and talks about important SSI prevention education that often gets missed such as making sure the patient has clean sheets and uses clean towels, etc…
Clipping instructions developed for clinicians to complete outside of the OR
Walk through process. Prior process was to administer antibiotic at cut-time or after cut-time which did not allow for adequate tissue perfusion time.
NHSN: National Healthcare Safety Network. Our SSI infections are reported to this site. All classes of cases (clean, dirty, clean-contaminate, etc..) are counted and this is representative of all procedure types that our tracked through the network. Our results indicate that we have reduced our surgical site infection rate. This successful projects demonstrates that changes can be made across the health system to standardize and implement evidence-based processes for all providers in order to decrease surgical site infections.
Of note, the team completed a statistical analysis of our 3M Nose to Toes trial for MRSA decolonization and determined to discontinue use as the evidence for efficacy was not evident after a 6 month trial period.
Executive Level support helps to ensure that we have the support needed from all departments in order to complete the implementations
DYAD partnerships with physicians allows us to have at least one physician leader on the project team and they are responsible for helping to drive any process changes affecting their practice through with their colleagues
Automation of workflow, triggers and alerts, documentation changes and other IT solutions were implemented to help support many of the implementation process changes
Utilization of engineering principles to eliminate waste, improve flow, error-proof, and improve quality
Development of standard work so that all clinicians, surgeons, staff members are following the same Surgical Site Infection prevention practices
