Senior/System Leader:
Robert Stern, MD, Vice President of Medical Affairs
Clinical Champion:
Gerald Dorff, MD, Infectious Disease
Specialist Day-to-Day Leader:
Barbara Rogness, RN, BSN, Patient Care Coordinator
Support Team:
Karen Miller, RN, MSN, Director of Quality Improvement
Mary Conklin, RN, BSN, MBA, Outcomes-Based Care Management
Mary Luzinski, RN, BSN, MS, Infection Control Practitioner
Gayle Land, RN, BSN, Infection Control Practitioner
Elaine Curz, Data Specialist
Jamie Winner, PharmD, Clinical Specialist Infectious Disease

Initial improvement efforts will focus on the three antibiotic measures with goals of 100 percent for appropriate antibiotic choice, zero to one hour timing of the prophylactic antibiotic, and discontinuation of antibiotic prophylaxis 24 hours after the start of surgery.

The pilot population includes cardiac surgical cases, thoracic surgical cases, total hip/knee replacements, colon/small bowel surgical cases, vascular bypass, and abdominal aortic aneurysms.

Within one month of starting this project, we intend to have 100 percent of our appropriate pilot population experience appropriate body temperature and oxygen tension during the time of surgery. We also expect 100 percent of our cardiac cases will have proper glucose maintenance while in the operating room and for 48 hours post-operatively. By the end of April 2002, 100 percent of our surgical patients requiring hair removal will have it done by clipping.

It is our intent to spread the successful redesigned processes to all adult surgical inpatients requiring prophylaxis by January 2003.

• Number of surgical cases between surgical site infections (Goal: double the number of cases)
• Percent of surgical cases with on-time prophylactic antibiotic administration (Goal: 100 percent)
• Percent of surgical cases with appropriate selection of prophylactic antibiotic (Goal: 100 percent)
• Percent of surgical patients who received prophylactic antibiotics whose antibiotics were discontinued within 24 hours after surgery (Goal: 100 percent)
• Percent of patients with hyperglycemia undergoing cardiac surgery with intra-operative glucose control (Goal: 100 percent)
• Percent of patients with intra-operative normothermia (Goal: 100 percent)
• Percent of surgical patients provided supplemental oxygen (O2) intra-operatively (Goal: 100 percent)

Appropriate Antibiotics
Administration of prophylactic antibiotics beginning 0 to 1 hour prior to surgical incision decreases the risk of surgical infection. Identifying a group of appropriate prophylactic antibiotics that should be administered to patients undergoing surgery leads to decreased infection rates. Discontinuing prophylactic antibiotics within 24 hours after surgery prevents resistant strains of bacteria without increasing infection rates and reduces costs.

Examples of some of our key PDSA cycles for this prevention strategy are:

• Designated responsibility and accountability for preoperative prophylactic antibiotic administration to anesthesia.
• Standardized administration process to send all prophylactic antibiotics to the Holding Area.
• Assisted pharmacy in the development of guidelines for prophylactic antibiotic use.
• Followed through with the approval of the surgical prophylaxis guidelines through the hospital Pharmacy and Therapeutics and Medical Executive Committees.
• Administered prophylactic antibiotics according to adopted guidelines by updating pre- and post-operative standing order sets.
• Adopted a process for hospital pharmacists to intervene when the guidelines are not followed. This was to assist us while the process of updating all existing order sets takes place.
• Created visible reminder of the guidelines is placed on each chart in the Holding Area.
• Laminated pocket sized cards of the guidelines were given to all anesthesiologists, all participating surgeons, and attached to all anesthesia carts. Extras were made available in the surgical lounge.
• Educated Operating Room staff regarding the importance and reasoning of antibiotic timing.
• Provided feedback on prophylaxis compliance and infection rate data monthly by sharing our Senior Leader reports.

Normothermia
Surgical patients with core temperatures of > 36 degrees C / 96.8 degrees F are less likely to get an infection.

Examples of some of the key PDSA cycles for this prevention strategy are:

• Designated responsibility and accountability for thermoregulation to anesthesia. Provided clinical research data on the physiology behind this measure as a means of education for the Anesthesia group.
• Provided profiled anesthesia data to demonstrate progress toward attaining our goal.
• Provided forehead temperature strips on the anesthesia carts for use on the regional anesthesia cases.
• Increased overall awareness of standard use of forced air warmers, warm blankets, and ambient room temperature as options to assist with attaining normothermia.

Oxygen Tension
Providing surgical patients with supplemental oxygen (O2) has been shown to decrease infection.

Examples of some of the key PDSA cycles for this prevention strategy are:

• Administered protocol for supplemental oxygen (O2) which is defined as (a) intra-operative FIO2 >80 percent in the intubated patient or a non-rebreathing face mask at >12 L/min fresh gas flow in the non-intubated patient.
• Provided available clinical research to the Anesthesia Department to facilitate acceptance and buy-in.
• Revised the Anesthesia record to include an area for documentation of FIO2 by the Anesthesia Department Chair.
• Provided profiled anesthesia data to demonstrate progress toward goal attainment.

Blood Glucose Control
Maintenance of recommended blood glucose levels in patients with diabetes as well as in hyperglycemic patients has been linked with improved outcomes such as decreased rates of infection and decreased mortality.

Examples of some of the key PDSA cycles for this prevention strategy are:

• Implemented use of a standardized treatment protocol to maintain serum glucose less than 200 mg/dL in patients undergoing cardiac surgery.
• Attached standardized protocol to all cardiac postoperative order sets. This includes glucose testing for all patients, not being dependent on a previous diagnosis of diabetes.
• Educated the ICU and cardiac surgical floor in the research behind this measure and in use of the protocol.
• Standardized the process for cardiac surgical patients to have a glucose checked with the first set of blood gasses drawn in surgery.
• Revised the Anesthesia record to include a place for glucose documentation by the Anesthesia Department Chair.
• Provided the surgeons and Anesthesia Department with clinical research to facilitate attainment of the goal and recognize the importance of a hyperglycemic state vs. a diagnosis of diabetes.
• Developed glucose protocol for use with general surgical patients. We are confident this protocol will facilitate maintenance of blood glucose levels below 200 mg/dL. We are in the process of getting approval through the Pharmacy and Therapeutics Committee for use house wide.
• Developed a self-learning tool and competency to educate all nurses about the clinical reasons to control hyperglycemia.

Note: We have seen the use of insulin drips postoperatively on general surgical patients increase in the last few months. We are encouraged that the message is getting out there. We are anxious to have our newly developed protocol standardize this process throughout he hospital.

Avoid Shaving Operative Site
Clipping instead of shaving results in decreased infection rates.

Examples of some of the key PDSA cycles for this prevention strategy are:

• Removed all razors from operating room.
• Placed razors in the automated dispensing unit to enable identification of users.
• Utilized the SIP Newsletter to get the message and the rationale to all surgery staff.
• Explained our rationale to any doctor who requested a razor, giving the clinical research behind this decision.
• Educated the Operating Room staff in wet techniques of clipper use.
• Performed hair removal with clippers right before surgery by either Holding Area or Surgery staff.
• Switched to using clippers in the Cardiac Diagnostic Unit and Cardiac Catheterization Lab.
• Developed a flyer to send to all patients pre-operatively instructing them not to shave the surgical site for 72 hours prior to surgery.

Note: This process changed for the pilot population as well as for all surgical cases at the time it was implemented. We are in the process of attempting to trial a hair vacuum to resolve the issue of hair being left on the surgical field. This has been a complaint from some surgeons since the start. Our only means of data collection for this measure is by documentation of razor use through the ADU machine. To date, 34 razors have been taken from the ADU machine since April 23, 2002. Twelve of these were for neurosurgery for which we have made an exception. We feel this has been a very successful change as only 22 surgical cases have been shaved rather than clipped. This number includes all surgical cases done at SJRMC since April 23, 2002.

Basic Prevention
The US Centers for Disease Control has several recommendations for basic prevention (category 1A recommendations):

• No prior infections
• 15 air changes/hour in OR
• Keep OR doors closed
• Use sterile instruments
• Stop tobacco use prior to surgery
• Wear a mask
• Shower with antiseptic soap
• Cover hair
• Prep skin with appropriate agent
• Wear sterile gloves

SJRMC has done the following PDSA cycles related to this area:

• Sent a flyer to all patients pre-operatively instructing them to shower with a CHG product the night before surgery.
• Gave information on smoking cessation to all patients who currently smoke or have quit within the last year. Counseling services are available to all who request it.
• Changed the policy so nurses can write a nursing care order for patients to receive counseling services related to smoking cessation.
• Initiated the use of Avagard waterless scrub in the main surgery area, Labor and Delivery rooms, C-section rooms, and the circumcision rooms.
• Re-evaluated the entire sterilization process and educational programs.
• Implemented a process for the pre-operative use of Bactroban.

Note: We are presently switching to a CHG product for all IV and central line insertions and site care. We are planning to go forward and change to CHG skin preps in the Operating and Labor and Delivery Rooms in the near future.

• SJRMC has implemented processes that guide the selection of appropriate prophylactic antibiotics and assure they are given in the optimal time frame to minimize the risk of infection.
• SJRMC has converted from shaving to clipping hair at surgical sites, another measure that has been demonstrated to reduce surgical risk.
• SJRMC is developing more aggressive treatment protocols for elevated blood sugar in order to diminish the potential for infection.
• SJRMC has focused a great deal of attention on maintaining normal body temperature during the entire surgery process.
• SJRMC has focused attention on providing patients with supplemental oxygenation during surgery.

These processes will increase the quality of care while reducing antibiotic costs and the risk of antibiotic resistance. It is also expected that the redesigned processes will reduce the cost of care by ultimately reducing the number of infections. We are working on a process to measure the financial impact the changes have made at SJRMC.

While all our goals of 100 percent have not been attained, we have made significant improvements in all areas as compared to the status prior to the project. We intend to continue our improvement efforts with the intent of attaining our original goals of 100 percent.

Spread of Changes
The work of SJRMC is currently being spread to all adult surgical inpatients as of January 1, 2003. This has introduced significant redesign of processes in many areas of the hospital. Other Covenant Healthcare Hospitals have already attended a presentation by the SJRMC team where we shared information from our interventions as well as rapid cycle PDSA process. We plan on serving as a resource to them as they go through this process. Our knowledge of the rapid cycle PDSA process has already proven valuable in a number of areas of the hospital as various departments and committees look at making changes and process improvements.