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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!!

dcampbell@kyha.com

502-992-4383

Process measure webinar # 9

C. diff/MRSA process measures

Thursday, August 16, at 11am ET (10am CT)