All surgery carries risk, but the risk of infection is far greater than it should be. Today, an estimated two to five percent of surgical patients in the US develop infections. The cost in both human and economic terms is significant: surgical site infections (SSIs) increase the length of stay in the hospital by an average of 7.5 days, at an estimated cost of $130 million to $845 million per year in the US.
The good news is that by using evidence-based processes of care and redesigning systems to reduce risk factors, the incidence of SSI can be dramatically reduced. Just ask the OR staff at OSF St. Joseph’s Medical Center, a mid-size hospital in Bloomington, Illinois, USA, and part of the OSF Healthcare System.
By implementing a combination of strategies to reduce infection, OSF St. Joseph’s Medical Center has not only significantly reduced — or virtually eliminated — perioperative adverse events and surgical site infections on the pilot population, which they intended, but they’ve also reaped a few surprise benefits, such as reduced post-surgical nausea and reduced use of post-surgery pain medications.
“We have a long history of working with IHI to improve care,” says Kathy Haig, RN, Director of Quality Resource Management and St. Joseph’s Patient Safety Officer. “We participated in a Collaborative to reduce adverse drug events, and achieved our goal of a tenfold reduction. We participated in a Patient Safety Collaborative, and made great strides there as well. So joining the Collaborative to improve surgical safety was a natural next step for us.”
Through this Collaborative on Reducing Surgical Site Infections (SSI), staff at OSF learned an important fundamental lesson about improving surgical safety. “You cannot make one small change, or two small changes,” says Haig. “You have to be willing to embrace a series of changes if you want to make noticeable improvement that is sustainable.”
At OSF, Haig says they identified a pilot population for the changes staff would test: all patients undergoing surgery for CABG, total hip replacements, total knee replacements, abdominal hysterectomy, vaginal hysterectomy, laminectomy, cervical neuro procedures and appendectomies. The range of the pilot population was 61 to 90 patients per month.
The collection of steps designed to reduce SSI work together to reduce the incidence of infection and postoperative complications. These steps, used in addition to basic prevention strategies, include:
Antibiotics: What and When
An estimated 40 to 60 percent of SSIs can be prevented through proper use of prophylactic antibiotics. Changing the system to support the consistently appropriate administration of antibiotics prior to surgery is a critical step in reducing the incidence of SSI.
“We worked hard to develop a surgical prophylaxis protocol,” says Haig. “Once it was approved by our Medical Executive Committee, it became the default procedure if a prophylaxis antibiotic isn’t ordered. The protocol is different depending on the type of procedure, and we have re-dosing guidelines if the procedure lasts more than four hours.” As a result of the protocol, says Haig, appropriate use of prophylactic antibiotics increased from 86 percent to 97 percent.
Equally important as the type and dose of antibiotics is the timing. “It has to be given within 60 minutes of the incision,” explains Haig. This is harder than it may seem, given the series of steps that precede surgery. “We did multiple tests of change to support this goal,” says Haig. In the end, what works best at OSF is a process in which the pre-admission nurse gives the orders for the antibiotic to the pharmacy the night before surgery so the medication is delivered to the OR first thing in the morning. A pre-op holding nurse gives 1cc to the patient to test for allergic reactions, and the rest of the dose is taped to the patient, and given by OR staff when the patient arrives in the OR.
No Shaving
Because shaving introduces tiny nicks that can harbor bacteria, the preferred method of hair removal prior to surgery is clippers. Changing ingrained habits can be difficult. At OSF, a sly but effective approach — based on science, Haig hastens to add — helped to eliminate the use of razors. “We have learned about human factors principles, things like designing systems that take advantage of people’s natural habits and inclinations.” Haig says that after they identified the preferred type of clippers (which had been tested by another hospital in the OSF system), “we gradually moved the razors to more inconvenient locations, and made the clippers easily available. Now the razors are gone and the clippers are used housewide.”
Glucose Control
Studies show that higher blood sugar levels are associated with higher rates of infection and mortality because high glucose compromises white cells’ ability to fight infection. While there is still some debate about what glucose levels are the most beneficial for surgical patients, there is growing agreement that controlling blood sugar is beneficial. “We looked at several existing protocols,” says Haig, “and they differed in their control range. One was tight, one was loose, and one was in the middle. That’s the one we decided to use.”
That protocol, approved by the surgeons and a clinical specialist specializing in diabetes, calls for keeping surgical patients’ glucose levels between 100 and 140. “We started using insulin drips on open heart diabetic patients post-operatively in the ICU. It does add work for the nurses who are already busy, so we had to educate them on the importance of this step.” Now, says Haig, they have broadened the effort to apply it to another population of patients — diabetics with a blood sugar of more than 150.
Oxygen Tension
Maintaining high levels of inspired oxygen post-operatively has been shown to help reduce the risk of SSI. At OSF, all post-surgical patients are fitted with a non-rebreather mask for an hour in the PACU, which increases their inspired oxygen to more than 80 percent. There have been unexpected side benefits from this process, says Haig.
“We began to notice that there was much less nausea in the PACU, so much so that our neurosurgeons have made use of the non-rebreather mask a part of their standing orders,” she said. “We also noticed that we use fewer pain medications, which is better for patients and also reduces costs.”
Normothermia
Keeping patients warm during surgery is not about their comfort; it is about their safety. Increasing the body temperature to between 36 and 38 degrees Celsius (96.8 degrees Fahrenheit) increases circulation and brings white blood cells to the compromised area to fight infection. “It is a way of getting the body’s own defenses to work a little harder,” says Haig.
Warming the patient involves a combination of steps: keeping the OR itself warm (perhaps warmer than staff would like), using warming blankets or hot air blankets, and heating IV and irrigation fluids. Someone also must be designated to monitor the patient’s temperature regularly throughout the procedure.
At OSF, says Haig, “we did all those things. In our pilot population, we went from about 84 percent at 36 degrees or above, to 97 percent.”
Going Above and Beyond
OSF is steeped in a culture of improvement, thanks to strong leadership from the top, says Haig. “Leadership support is the most important element in changing staff attitudes about improvement,” says Haig. “I cannot say enough about Ken Natzke, our CEO, Larry Wills, our Senior Assistant Administrator of Hospital Operations, Paul Pedersen, our Medical Director and Deb Smith, our Assistant Administrator of Patient Services in terms of their total commitment to quality. I can go to them with an idea that three years ago would have seemed crazy. Today, they say yes, let’s try it.”
The team members and staff involved in the SSI Collaborative are another key to success, says Haig. “Their persistence as well as their willingness to learn and change has made all the difference in the world in reaching our goals.” Because this is a culture that energizes staff to keep moving forward, they went beyond the SSI steps they learned in the Collaborative and worked on additional ways to improve outcomes for surgery patients.
“We tested a DVT prophylaxis protocol to prevent blood clots,” says Haig, “and after some tweaking we implemented it.” The protocol calls for a nurse to perform a scored risk assessment upon admission and notify the physician about the patient’s score; the physician then orders the appropriate intervention if indicated. Interventions can be as simple as a compression device, or an anticoagulant, or a combination of things. “We have a lot of geriatric patients with poor circulation and multiple co-morbidities,” says Haig. “Before, some surgical patients would have standing orders for DVT prophylaxis, but now we have incorporated it for everyone. We are measuring about 85 to 90 percent compliance.” Tested initially on both medical and surgical patients, the protocol is now in place for all patients hospital-wide.
They also developed and introduced a beta-blocker protocol, which calls for the evaluation of all surgical patients for risk of myocardial infarction (MI). When the preadmission screening indicates that a patient meets the criteria, anesthesia staff is notified and they, or the patient’s primary care physician, order a beta-blocker, which is either introduced several days prior to surgery, or given by IV just before the procedure begins. “We only had one peri-op MI in the year after we introduced the new protocol,” says Haig.
A one-stop preadmission process, a wrong-site surgery protocol, team resource management training, the list of improvement efforts at St. Joseph’s seems endless. And that, says Haig, is just the point. “You’re never finished,” she says. “Each and every day we are more aware of what we can do better. Quality and safety are strategic objectives. Our mission, ‘…serving with the greatest care and love’ is not just a saying, but a way of life."
