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Acute Myocardial Infarction	Medication Reconciliation (ADE)
Boards on Board	Pressure Ulcers
Catheter-Associated UTI	Rapid Response Teams
Central Line Infections	Surgical Complications
Congestive Heart Failure	Surgical Safety Checklist
High-Alert Medications	Surgical Site Infections
MRSA	Ventilator-Associated Pneumonia

Use this table to quickly find a mentor for the prevention of Surgical Site Infections with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: April 2002
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531

Additional Information:

Baystate Medical Center has been successful in reducing our surgical infection rate as well as decreasing the incidence of post-operative adverse events.  Since incorporating known infection prevention measures (appropriate antibiotic timing, selection and duration, clipping, maintaining normothermia and glycemic control) BMC has observed the lowest infection rates since monitoring was initiated.  Through use of a multipronged approach, we have been able to identify patients at risk for post-op complications (MI/VTE) and provide early preventative interventions.  Lastly, the use of the "potentially preventable" review model has helped to direct opportunities/areas for process improvement.  Use of modalities such as CPOE (Computerized Physician Order Entry), CPGs, real time cues/prompts, standardization of care, ongoing performance monitoring/feedback and engaging clinical champions in leading the process review, change and ownership has supported our success.  We now particpate in NSQIP and use MedMined to determine the impact of HAIs.

We achieved top 10th decile performance in PY 1 of the HQID (CMS/Premier Hospital Quality Incentive Demonstration) for CABG.  We were the MA representative hospital for CMS SSIPP project in 2002-2003 and were cited as an outstanding performer.  Additionally we have been MASSPro's partner in the state wide rollout of SIP now SCIP.  High rates of process interventions (such as but not limited to antibiotic timing, selection and duration, clipping and use of beta blockers - consistently at > 95%) are consistently in place through use of the 3 tier design system.  Our surgical infection rate has consistently been well below the national rate and our rates of post op cardiac events and PE/DVT are below our comparative benchmark.

Our performance continues to be recognized as a top 1% SCIP hospital in MA and a top 10% SCIP hospital nationally by Why Not the Best and Premier HQID project.

See graphs of their results.

Mentor designation - 1/31/06
Information updated - 2/24/10

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Butler Memorial Hospital – Butler, PA
Availability Status: Available to answer requests
Licensed Beds: 234
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: August 2004
Mentor Contact Name: Diane Wilson
Mentor Contact Email: dlw.nur@butlerhealthsystem.org
Mentor Contact Phone: 724-284-4862

Additional Information:

• Conducted rapid small tests of change enabling Butler Memorial Hospital to eliminate conflicting pre-op orders from surgeons and provide on time pre-op antibiotics.
• Anesthesia personnel has the primary responsibility for administering antibiotics.
• Standardized peri-operative antibiotic prophylaxis by procedure and weight adjustment.

Increased on-time pre-op antibiotics from 57% to 96% (process measurement) and decreased Class I SSI from, 2.3% to 1.0%, and Class II SSI from 2.7% to 1.0%.

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Cincinnati Children's Hospital Medical Center – Cincinnati, OH
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 451
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: September 2003
Mentor Contact Name: Uma Kotagal, MD, Vice President for Quality and Transformation
Mentor Contact Email: uma.kotagal@cchmc.org
Mentor Contact Phone: 513-636-0178

Additional Information:

First focus was on antibiotic timing within 0 - 60 minutes prior to incision for high risk populations processed preoperatively through same day surgery.  Initial compliance was at 70%.  Children are put to sleep prior to IV insertion, so completing the IV start and the antibiotic after intubation and prior to incision is a challenge.

Revised entire antibiotic process from ordering to administration building in high reliability concepts through use of the FMEA process. 

Began issuing daily compliance data with follow-up of failures in March 2005.  In July 2005, Anesthesia compensation was tied to compliance.  Currently at or above 95% which has been sustained.  Added orange "Preop Antibiotic" bracelets in September 2005 and then all processes to include inpatients in December 2005. 

Next area of work is preoperative skin prep.  In process of eliminating shaving in favor of clipping only when necessary, standardizing skin prep solution to CHG and implementing CHG wipe in Same Day Surgery or pre-op holding. 

Surgical Site Infection Rate for Class I and II infections in 2003 was around 1.0 per 100 procedures.  Rate for first quarter of 2006 is 0.4 per 100 procedures. 

[5/12/06]

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Henry Ford Hospital – Detroit, MI
Availability Status: Available to answer requests
Licensed Beds: 904
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: May 2002
Mentor Contact Name: Jack Jordan
Mentor Contact Email: jjordan1@hfhs.org
Mentor Contact Phone: 313-874-3925

Additional Information:

Efforts to improve surgical infection rates at Henry Ford Hospital were launched in 2002 with a surgical infection prevention collaborative sponsored by CMS.  A 10-member team (physicians, pharmacists, nurses, etc) was assembled to review and the CMS proposals. 

Over the next three months a number of changes were initiated:

• Assigning responsibility for antibiotic administration to the anesthesiologist.
• Changing policies around antibiotic discontinuation. 
• Removing all razors from the preoperative areas.
• Converting all skin preparation to chlorhexidine. 
• Improving glucose control in the surgical ICU and the OR. 

One outgrowth of the surgical infection reduction program was the launch of a hospital-wide program to improve glucose control.  As a result:

• A steady improvement in glucose control for all patients resulting in a significant improvement in overall infection rates.

• The rate of glucose readings above 250 has been reduced by 85% in the ICUs.

• The rate of hypoglycemia continues to be the same as when the program began.

The highly successful tight glucose control program at Henry Ford Hospital was recognized as a finalist for the Codman award from JCAHO in 2005.

The effort led to:

• A more than 50% reduction in surgical site infection rates including a 19-month period with no vascular surgery infections. 

• A steady improvement in glucose control for all patients resulting in a significant improvement in overall infection rates.

• The rate of glucose readings above 250 has been reduced by 85% in the ICUs.

• The rate of hypoglycemia continues to be the same as when the program began.

[1/31/06]

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The Indiana Heart Hospital – Indianapolis, IN
Availability Status: Available to answer requests
Licensed Beds: 56
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: February 2002
Mentor Contact Name: Cleo Ann Burgard
Mentor Contact Email: cburgard@ecommunity.com
Mentor Contact Phone: 317-621-5329

Additional Information:

This intervention is spread throughout our five Network hospitals:  Community Hospital Anderson, Community Hospital East, Community Hospital North, Community Hospital South, and the Indiana Heart Hospital

• A multidisciplinary team successfully implemented the surgical infection prevention measures for cardiovascular surgery utilizing FOCUS PDCA and Rapid Cycle Process Improvement strategies
• Collaboratively standardized and redesigned surgical processes to produce evidenced-based best practices
• Implementation of the "Surgical Bundle" has allowed us to identify process owners, assign responsibilities and reduce variation
• Use of an electronic medical record at the Indiana Heart Hospital has reduced variation, standardized care and improved compliance with the practice measures
• Tight glycemic control in patients undergoing cardiovascular surgery has subsequently allowed us to identify patients with undiagnosed diabetes that otherwise would not be identified during their hospitalization, and the ability to initiate treatment and follow up for their disease
• We maintained "Green Light" (> 90% compliance) performance in the majority of surgical bundle measures for 2005
• Reduced the overall cardiovascular surgery sternal wound infection rate by 50% in the first year and have maintained the rate below the NNIS mean

[2/14/06]

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Northwestern Memorial Hospital – Chicago, IL
Availability Status: Available to answer requests
Licensed Beds: 811
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2004
Mentor Contact Name: Bob Costello
Mentor Contact Email: rcostell@nmh.org
Mentor Contact Phone: 312-926-4714

Additional Information:

• Implemented a new process to improve the timely and appropriate delivery of prophylactic antibiotics to all surgical patients.  This process change standardized the use of antibiotics.

• Later the team implemented a new process to better coordinate the timing of prophylaxis administration.

Successful Implementation Strategies
(1) Multidisciplinary team
(2) Standardized antibiotic recommendations
(3) Standardized order sets/protocol
(4) Compliance scorecards for surgeons
(5) Hospital Support (i.e. resources, leadership and commitment)

• Compliance with aggregate SSI guidelines: >60% (Aggregate measure includes Compliance with Timeliness, Compliance with Appropriateness and Compliance with Discontinuation)

• Compliance with timely initiation of prophylactic antibiotics for surgical patients has improved from 77% to 92% over the past year.

[1/31/06]

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OSF St. Joseph Medical Center – Bloomington, IL
Availability Status: Available to answer requests
Licensed Beds: 145
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: October 2003
Mentor Contact Name: Kathy Haig
Mentor Contact Email: kathy.m.haig@osfhealthcare.org
Mentor Contact Phone: 309-662-3311 ext. 1347

Additional Information:

OSF St. Joseph Medical Center has implemented many of the interventions in the IHI surgical change package.  A team effort from leadership, front line staff, surgeons and anesthesiologists have promoted a safety surgical setting through reduction of surgical site infections, DVT and perioperative MI's.  Changes include surgical prophylactic antibiotic default orders, a process to insure administration of the prophylactic antibiotic within one hour of incision, elimination of razors, processes to insure normothermia and increased FiO2 above 80%, DVT assessment and intervention protocol, and a perioperative beta blocker protocol.  Neurosurgeons have added a non-rebreather to their standing orders as benefits of less nausea and vomiting and need for narcotic pain control were realized in the general surgical patients with this intervention.

Selection of the appropriate surgical prophylactic antibiotic averaged 96% for FY2005.  Administration of the antibiotic within one hour of the incision averaged 93% for FY2005.  Infections on Class 1 procedures decreased from 16 in 2004 to 4 in 2005.  Only 2 periop MI's have been identified in each 2004 and 2005 since implementation of the periop beta blocker protocol.  DVT's were reduced 15% in total Inpatients with a Secondary Diagnosis of DVT and Total Inpatient Readmissions with a Primary Diagnosis of DVT decreased by 71%.

[1/31/06]

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Our Lady of Lourdes Memorial Hospital– Binghamton, NY
Availability Status: Unavailable to answer requests
Licensed Beds: 267
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: November 2004
Mentor Contact Name:
Mentor Contact Email: 
Mentor Contact Phone:

Additional Information:

The numbers of days between SSIs in Total Joint patients were an average of 2.5 days in October, 2004.  As of October 31, 2005 the days between SSIs were 141 days.

Total Joint volumes have increased 57%, the Press Ganey patient satisfaction scores have been at the 90th percentile since opening the Joint Academy (dedicated total joint unit) in April 2005, and Nursing Satisfaction, as demonstrated by the National Database of Nursing Quality Indicators, Nursing satisfaction survey is 61.88 - > 60 = high satisfaction.

Indicator	October 2004	October 2005
Appropriate antibiotic	100%	100%
Appropriate hair removal	100%	100%
Antibiotic administered within 0-60 minutes of incision	45%	82%
Antibiotic discontinued within 24 hours of end of surgery	49%	91%
Length of stay	10/1/04 – 11/30/04 Total Hip Replacement – 4.23                Total Knee Replacement – 4.27	10/1/05 – 11/30/05 Total Hip Replacement – 3.24 Total Knee Replacement – 3.14

[1/31/06]

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Palmetto Health Richland – Columbia, SC
Availability Status: Available to answer requests
Staffed Beds: 649
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: August 2007
Mentor Contact Name: Ursula B. Callan, MSN, RN, CCRN  Director-Center for Nursing Excellence and Clinical Outcomes
Mentor Contact Email: ursula.callan@palmettohealth.org
Mentor Contact Phone: 803-434-8740

Additional Information:

At Palmetto Health Heart Hospital (Columbia, South Carolina, USA), a 124-bed, free-standing facility and a division of a 649-bed regional referral center, we have eliminated deep sternal wound infections for over 30 months.  The Palmetto Health Heart Hospital developed and implemented a tight glycemic control in the pre-, peri- and post-operative period of the cardiac surgery (CS) patient based on the Portland Protocol.

This initiative has been so successful, the lessons learned have been translated to several other patient populations including pacer/defibrillator implants, other cardiac surgeries and the Medical ICU.  The reduced mortality and morbidity have resulted in an expanded house-wide diabetes education team. 

Palmetto Health Heart Hospital has reached and sustained zero Deep Sternal Wound Infections for over 30 months!

Palmetto Health Heart Hospital has reached and sustained post operative mean blood glucoses below the target goal of 130mg/dl since September 2006 in both our Cardiovascular Intensive Care and Cardiovascular Telemetry patient populations.

Palmetto Health Heart Hospital has achieved 100% on all CMS Appropriate Care Measures for CABG from August 2007 to August 2008 with the exception of April 2008 where we experienced a drop to 93.75% related to a missed opportunity for one patient with antibiotic given 1 hour prior to surgery.

[2/23/09]

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Porter Hospital – Middlebury, VT
Availability Status: Available to answer requests
Licensed Beds: 45
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: October 2004
Mentor Contact Name: Patricia A. Jannene, Vice President Patient Care Services
Mentor Contact Email: PJannene@portermedical.org
Mentor Contact Phone: 802-388-4759

Additional Information:

1. Removed razors
2. Instituted temporal artery thermometers
3. Educated surgeons on evidence based literature supporting our measures
4. Incorporated the surgical staff in our active team
5. Changed timing of antibiotic in the pre-op area and by anesthesia
6. Continuous feedback with graphic display of information monthly

Porter Hospital has had no surgical site infections since 10/04 in our target population - we are 412 cases since the last post-op infection.

Porter Hospital has had maintained a 95-100% with appropriate antibiotic choice, 100% with the appropriate hair removal, 100% with pre-procedural briefing and a zero infection rate.

[1/31/06]

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River's Edge Hospital & Clinic – St. Peter, MN
Availability Status: Available to answer requests
Licensed Beds: 22
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Benjamin W. Chaska, MD, MBA, CPE, FACPE, Chief Medical Officer and Patient Safety Officer
Mentor Contact Email: bchaska@riversedgehealth.org
Mentor Contact Phone: 507-934-8416

Additional Information:

Adaptation: Surgical site infection prophylaxis.  Use of clippers throughout the hospital including the ED, Med-Surg, OB and OR.  Initiation of normothermia protocol for all surgical patients.

Actions Taken:
• Adopted the use of clippers for proper hair removal throughout the hospital.
• Implemented use of Bair Paws gowns and Bair Hugger blankets to warm all surgical patients.
• Normothermia protocol used on all surgical patients with continued improvement.

Surgical site infections have declined by 50%.
Surgical Site infections have declined from 20.4/1000 in 2004 to 7.0 to 10/1000 in 2005 to 2009.

Mentor designation - 1/31/06
Information updated - 2/22/10

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Sequoia Hospital – Redwood City, CA
Availability Status: Available to answer requests
Licensed Beds: 421
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: March 2002
Mentor Contact Name: Joanne Jeffords, VP, Mission and Quality
Mentor Contact Email: joanne.jeffords@chw.edu
Mentor Contact Phone: 650-367-5855

Additional Information:

• While participating in the QIO/CMS SIPs Collaborative, implemented the SSI key components of care in the Cardiac population
• Engaged the support of an interdisciplinary team
• All razors were removed from the OR after literature was given to MDs to support clippers.  They were also given pictures of patients that had razor burns.  Team physician champion, neurosurgeon, was first to change over to clippers.
• Administration of IV antibiotics was examined and changes implemented to ensure antibiotics were infused one hour prior to cut time.  This was best accomplished with Anesthesia administering the antibiotic.  An area was placed on the anesthesia record to allow for documentation of antibiotic administration.
• Endocrinologist educated MDs and RNs about importance of glycemic control.  Glycemic control tightened in the post op cardiac patient.
• In May 2005, Sequoia was awarded "Best Practice for Hyperglycemia Control" in the CHW system.
• Changes made to pre-printed cardiac surgery and vascular surgery order sets.  These changes reflected compliance: physician would have to handwrite changes if they wished to make changes.
• Orthopedics have adopted changes to their practice.
• Currently spreading SSI reduction standards to the Colorectal and Gynecologic surgeries.
• In the Cardiac population from 2002 until 2005 there have been 4 deep sternal wounds, giving us a rate of 0.2%, compared to the STS standard of 2.7%.
• Greater than 95% of post operative cardiac patients have glucose control in the post-operative period.
• 100% of hair removal is done with clippers on all surgical patients.
• 100% of Cardiac surgery patients received appropriate antibiotic, on time and discontinued on time in latest audit (May - December 2005)

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South Shore Hospital – South Weymouth, MA
Availability Status: Available to answer requests
Licensed Beds: 395
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: April 2003
Mentor Contact Name: John Stevenson, MD
Mentor Contact Email: john_stevenson@sshosp.org
Mentor Contact Phone: 781-624-8996

Additional Information:

South Shore Hospital has implemented systems to improve the appropriate use of antibiotics (selection, timing and discontinuation) and appropriate hair removal.

Through the use of standing guidelines for antibiotic selection by case type, administration by the Department of Anesthesia in the OR and use of a reminder in the pre-procedure time out, we were able to move compliance with on-time administration and appropriate antibiotic selection to consistently greater than 98%.

We spread the initiative to all surgical case types appropriate for prophylactic antibiotics, including spread to outpatient procedures.  Within 6 months, we had achieved and have maintained compliance of greater than 95% for on-time antibiotics and antibiotic selection for outpatient procedures.

We are currently addressing perioperative temperature management and timely removal of urinary catheter through nursing and physician education to increase awareness and improve documentation.

Data on percent of Patients with Appropriate Hair Removal: 
FY 09 = 98%

Data on percent of Surgical Cases with Appropriate Selection of Prophylactic Antibiotic: 
FY 09 = 98.7%

Data on percent of Surgical Cases with On-time Prophylactic Antibiotic Administration:
FY 09 = 98.8%

FY 09 -   Class 1 SSI = 0.4%
             Class 2 SSI = 0.4%
FY 05 -   Class 1 SWI = 0.6%
             Class 2 SWI = 0.5%

Mentor designation - 6/2/06
Information updated - 3/16/10

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Texas Children's Hospital – Houston, TX
[Pediatric Mentor]

Availability Status: Available to answer requests
Licensed Beds: 462
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2005
Mentor Contact Name: Carrie Smith
Mentor Contact Email: casmith@texaschildrenshospital.org
Mentor Contact Phone: 832-824-1314

Additional Information:

• Texas Children's Hospital brought all of the members of each of the teams together for meetings by service line to gain consensus.
• A trigger was developed and antibiotics are initiated by anesthesiologists after last line placement at the time the patient is turned over to the circulator for positioning.
• A sticker was created to place on the drapes to remind the anesthesiologists of when the redose times are.
• Razors were removed from the OR rooms.
• For initation of antibiotics within 60 minutes of incision, our baseline data was 67%.  We have maintained a 97% average for the past 6 months.
• For redosing antibiotics for procedures greater than 4 hours, our baseline was 38%.   We have maintained a 93% average for the past 6 months.
• For discontinuation of antibiotics, our baseline was 70%.  We have maintained a 99% average for the past 6 months.
• For appropriate hair removal, our baseline was 11%.  We have maintained a 99% average for the past 6 months.
• For the procedures that participated in this collaborative we have reduced the Surgical Site Infection rate by 46%.

[12/22/07]