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

Reducing SSI Description

Description the QI Activity

VGH has a number of established practices to reduce SSI. These include: nasal decolonization for cardiac surgery patients, clippers for hair removal, a hand hygiene campaign, a hyperglycemia protocol, and a smoking cessation program.

The new processes included tightening antibiotic times and antibiotic re-dosing during the operation and active warming of the patient once off cardiac bypass machine. New dressing products and protocol for the surgical and harvest site were also implemented.

Antimicrobial Prophylaxis

Our Anti-microbial Stewardship team met with our group to share the latest research from the Medical Letter guideline 2012 and ASHP guidelines 2013. This was the basis for our pre printed; pre- operative orders, which were updated to reflect new standards. An audit demonstrated inconsistency with the prophylactic antibiotic dose, which was not weight—related and was not accurately charted when it was infused. Since January 2013, we have been utilizing the custom fields to track antibiotic compliance and are finding that every month the interval improves. Over 80% of patient with operations greater than 4 hours are receiving an antibiotic re-dose in the OR. The time an antibiotic is finished infusing is now mandated by the hospital to be recorded on the operation log. The accuracy has improved the quality of our data collected.

The provincial standard for end time prophylactic antibiotic infusion is 60 minutes prior to skin incision. At our site, the cardiac surgery team is using 30 minutes as the goal time for infusion of antibiotics. Claude Laflamme shared information that a 30 minute infusion completion time for prophylactic antibiotic is better at reducing SSI than 60 minutes. (Alexander et. al., Updated Recommendations for Control of Surgical Site Infections; Annals of Surgery, 2011; 1082-1093. 2011 Lippincott Williams & Wilkins)

The rate of antibiotic re-dosing improved when pharmacy started to send a pre-mixed dose to the operating room with the patient. This was a cue for the anesthetist to infuse the drug at the appropriate time.

Normothermia

The issue of normothermia was addressed with Claude Laflamme. He recommended that pre warming of cardiac patients was not indicated as their body temperature is cooled once on the cardiac surgery bypass machine. He did recommend that active warming start once the patient is off the bypass machine to help with the prevention of SSI. The anesthetists have been recording the patient’s temperature on the anesthesia record and efforts are being made to have the patient enter cardiac surgery intensive care unit (CSICU) with a core temperature greater than 36 degrees Celsius.

Wound Care

Recommendations are to leave the skin preparation solution on the skin for a minimum of 6 hours and to leave the dressing undisturbed for 48-72 hours.

The team met with our hospital wound care specialist for advice on a dressing that would be used on the surgical incision. A silicone based dressing reduced skin tears and was able to be on for 72 hours. This would help ensure that the skin preparation solution would remain under the dressing. The surgeons and unit manager approved the new dressing product. The representative from the company producing the dressing came and spoke with the staff and provided education resources. The nurse practitioner and nurse educators disseminated the information to the frontline staff. Mepilex Border, which is a silicon dressing, is put on the sternum incision by the operating room staff. This dressing is left on until post operative day 3. Once in the CSICU a compression dressing, Coban 2, is applied over the mepore dressing at the harvest site(s). The nurse practitioner worked with the operating room staff to help implement this practice change. This practice change is embedded in the pre printed post operative order set.

The nurse practitioner conducted patient interviews to decide if the new dressings were beneficial to patients. She found there were fewer skin tears when the dressing was removed and patients were comfortable with the new dressings.

The nurse educators and nurse practitioner were instrumental in educating, and communicating to the staff with regard to the new dressing products and techniques. The new standard of care is embedded in the pre-printed post operative orders.

Our group made up the acronym CLEAN to reflect our best practice bundle.

Date project initiated: October 2012.

C Clean Hands
Chlorhexidine Pre-Op wash X 2; night before surgery and morning of surgery
Nasal De-Colonization Project
Clippers for hair removal
L Leave Dressing on 72 hours post op; Compression wrap to harvest site and Silicone based dressing to sternum
Leave Pink Chlorhexidine preparation Solution on 6 hours post op
E Engage Patients and Staff on Best practices for prevention of SSIs
A Appropriate Antibiotic Use: Pre-op timing/Intraop timing/Post op timing (Prophylactic antibiotic timing: 30 minutes before skin incision; Re-Dose intra- op as appropriate with ORs > 4 hours; Post op duration X 24 hours)
N Normothermia (36 C to 38 C) (Pre/Intra/Post OP)
Normal blood glucose range <10 mmol/L
Nutritious Meals
No Smoking