Lakeland Regional Health is an 851-bed not-for-profit hospital in Florida with over 1400 surgical cases per month. To reduce surgical site infections, they initiated a multi-phase process improvement project in 2013 involving executive leadership, physicians, nurses, and industrial engineers. They implemented standardized protocols for pre-operative, intra-operative, and post-operative care based on evidence and data analysis. This included protocols for patient showering/prepping, antibiotic administration, and monitoring temperatures in operating rooms. As a result, their surgical site infection rates decreased from over 2% to under 1% from October 2013 to August 2015, demonstrating the effectiveness of standardized, evidence-based practices.

1. Together, our Promise is.
YOUR HEALTH.
PURPOSE
DESIGN
SMART LEAN
SETTING
METHOD
RESULTS & IMPLICATIONS
REDUCING SURGICAL SITE
INFECTIONS:
A standardized and evidence-based
approach
Sheena M. Butts, CSSBB, Industrial Engineer
OBJECTIVES PARTICIPANTS
Lakeland Regional Health is a full service medical center and health
system. As an 851 bed, not for profit medical center, Lakeland
Regional Health (LRH) is the fifth largest hospital in the state of
Florida and also operates the busiest single-site Emergency
Department in the state. LRH has an average surgical case volume of
over 1400 cases per month.
KEYS TO SUCCESS
 Executive Leadership Support
 DYAD collaboration between surgical services leadership and
physicians
 Technology and System Improvements
 Industrial Engineering Principles
 SMART LEAN Methodology
 Standard Work
Lakeland Regional Health (LRH) is committed to continuous
improvement and 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.
Timothy Regan, MD, COQ; Graham F. Greene, MD,CAO, FACS,FRCP;
Margie Voyles, RN, MS; Carrie Ogilvie, RN, MSN; Jewels Stark, RN,
BSN, MS, MBA; Michelle Hunt, BSMT, ASCP, CIC; Pam Troxell, RN, MSN,
CNOR, CIC; Mary Beth Perry, RN, MSN CPAN; Cateria Davis, RN, BSN;
Cheryle Smith, RN, MSN; Diane Campbell, RN, MSN, CSSBB; Wanda
McManus, RN, BSN, CPHQ, CPPS; Belinda Freer, RN; Jessica Cobian,
PharmD, BCPS; Ever Glendenning, RN, BSN,CPAN; Derek Cyr, CPHIMS;
Sheena Butts, IE, CSSBB
• Reduce and sustain near zero surgical site infections
• Improve patient experience
• Implement standard evidence-based clinical pathways
through the preoperative, intraoperative, and
postoperative phases
The preoperative standardizations include; a uniform shower chlorohexidine
sequence, standardized pre and post-operative instructions, standardized
clipping protocol (outside the operating room for qualifying cases), trial of 3M
SAGE Noes to Toes kit for Total Hip and Total Knee cases, electronic MRSA alert,
revised prophylactic antibiotic ordering and administration protocols, and
nursing and physician document changes to reflect standardizations.
Intraoperative standardizations include; CHG prep, automated operating room
temperature and humidity monitoring, appropriate wound classification, revised
surgical scrub attire policy, antibiotic re-dosing alert, positive patient and
medication identification, and standard room cleaning and monitoring. The
post-operative standardizations include; post-operative antibiotic administration
alert, Surgical Site Infection letter provided to surgeons, and an automated
follow-up phone call.
A multi-phase process improvement effort was initiated in October
2013. The project team consisted of executive, physician, quality,
surgical services, industrial engineering, information technology, and
infection prevention leadership. 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.
2.5
1.94
2.14
2.26
1.84
1.22
1.11
1.63
1.83
1.1
0.89
0
0.5
1
1.5
2
2.5
3
Oct
2014
Nov
2014
Dec
2014
Jan
2015
Feb
2015
Mar
2015
Apr
2015
May
2015
Jun
2015
Jul
2015
Aug
2015
NHSN SSI Rate
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. Above graph shows SSI results
reported to National Healthcare Safety Network.
Preoperative Phase Intraoperative Phase Postoperative Phase
• 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 Noes 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
• 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)
• Postoperative Prophylactic Antibiotic
Administration Alert (1 hour prior)
• Automated Follow-up phone call
• Surgical Site Infection (SSI) letter to
surgeon