American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Reducing SSI Rates by Introducing the CLEAN program at a British Columbia Collaborative Hospital

Vancouver Costal Health - Vancouver General Hospital

April 16, 2014

Vancouver General Hospital joined American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) in 2011. Since then Vancouver General Hospital reviewed their ACS NSQIP data and set a goal to reduce the cardiac SSI rate from 7% to 2% by January 30, 2014. To do so, the hospital reviewed available literature including the ACS NSQIP Best Practices Case Studies and Guidelines and instituted a program called CLEAN, an acronym reflecting the hospital’s best practice bundle.

What Was Done?

Problem Addressed

Global Problem

Surgical site infections (SSI) are a major contributor of postoperative morbidity among surgical patients. This potentially preventable adverse outcome impacts the patient’s experience and increases the overall cost of treating the patient.

Identification of Local Problem

Vancouver General Hospital’s NSQIP raw rate for cardiac surgery SSI’s was twice as high as rates from other NSQIP-comparable cardiac hospitals. A multidisciplinary team was formed and set the goal to reduce the Vancouver General Hospital Cardiac Surgery SSI rate from 7% to 2% by January 30, 2014 as measured by the ACS NSQIP database.

How Was the QI Activity Put in Place

Context of the QI Activity

British Columbia’s (BC) population is roughly 4.6 million people. Currently, there are 5 sites in BC that perform cardiac surgery and two of these hospitals are located in Vancouver. Vancouver General Hospital is an academic teaching hospital, with more than 800 beds; roughly 75 cardiac surgeries are performed a month. In 2011 the province of British Columbia provided funding for more than 20 hospitals to join ACS NSQIP. Vancouver General Hospital signed onto ACS NSQIP at that time. Participation in ACS NSQIP provided the reliable benchmarked data that motivated hospital QI work.

Planning and Development Process

The cardiac quality improvement team was formed in the fall of 2012. At this time, the working group reviewed the NSQIP data and other sources of outcome data to identify the project they wanted to focus on.

Our most important step was identifying and meeting with all the various departments that the patient interacts with during their surgical journey. The team includes ward nurse champions, an infection control practitioner, nurse practitioner, anesthetists, surgeons, quality coordinators, pharmacy, nursing leaders and educators from the Operating Room, Perioperative Unit and Surgical Units. The team meets monthly and meeting minutes and action items are reviewed for follow up, and are communicated to the entire group.

The inclusion of the affected groups early on in the decision making was felt to have a major impact on the acceptance of the process. We did not meet any resistance to implementing our changes to best practice.

The group reviewed the available literature for SSI prevention practices which included the best practices outlined by NSQIP and Health Canada. We were fortunate to have a guest speaker present on SSI prevention. Dr. Claude Laflamme presented at our surgical grand rounds. He is the director of Cardiac Anesthesia at Sunnybrook Hospital in Toronto, and a contributing author to Safer Health Care Now; Prevention of SSI from Health Canada. He highlighted the latest research to back the best practices outlined.

Audits of current practice assessed the standard of care provided, and identified areas of opportunity. This included care of the surgical site, normothermia, and prophylactic antibiotic timing. Our audit of two weeks of surgical cases (27 charts), showed that:

  • There was no standard of care for the surgical dressing. A bed bath would be done in the first 6 hours post operation to remove any visible skin preparation solution which was pink. If the dressing was soiled, it would be removed and a new dressing applied. The practice included removing the dressing on day 2, and keeping the incision exposed to air unless it was draining fluid.
  • The majority of the patients arrived in CSICU below 36 degrees.
  • The time the prophylactic antibiotic was infused was documented on the anesthesia record 60 % of the time; the exact time was recorded less than 40% of the time on the intra operative record or medication record. This meant the times were approximated.
  • Prophylactic antibiotics were administered within 30 minutes of skin incision 7% of the time, within 60 minutes 44% of the time, and greater than 60 minutes 49%.
  • For surgeries over 4 hours, a re-dose of the antibiotic was administered less than 20% of the time.