Quality in the Operating Room Begins with SSI Reduction and Elimination

By Karin Lillis

One weapon in the armament against surgical site infections (SSIs) is the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP), an essential tool to helping hospitals reduce the rate of SSIs and other complications that arise during and after patient procedures, says Clifford Ko, MD, MS, MSHS, FACS, director of the Division of Research and Optimal Patient Care at the American College of Surgeons (ACS). Ko will deliver the keynote address, “Achieving Quality Improvement in Patient Care,” at the OR Manager conference to be held Oct. 7-9, 2015 in Nashville, Tenn.

The NSQIP is a nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in the private sector that provides tools, training and data to help hospitals maintain excellence in patient care.

“NSQIP provides extremely accurate 30-day outcomes," Ko says. "All of our data collectors undergo training and yearly testing, and they know the definitions of the variables they collect. Also, the all of the data are audited. We audit data by going to the hospital, or the hospital sends it to us. We verify accuracy against the original record. Additionally, NSQIP hospitals have to follow their patients for 30 days. If more than 5 percent are not followed within that time period, we do not use the data."

He says NSQIP gives a much truer and accurate rate of SSIs: "The main benefit NSQIP participants gain is access to benchmark and risk-adjusted data. They’re getting the best data to know how they’re doing. Without data, we all think we’re doing great-but the story is often a little different.“

“We know that the system works," Ko adds. "As we looked at it longitudinally, there were statistical improvements over eight years of the process or using the data to be a foundation for improvement. The first great example is the program itself. Eighty percent of 700 participating hospitals are getting better. There are a lot of individual examples of hospitals of all sizes improving. It goes back to the ones that look at the data, standardize, innovate and have great teamwork and culture.”

The NSQIP website provides case studies of successful facilities. For example, Mayo Clinic Rochester Methodist Hospital in Minnesota reported a significant decrease in the number of SSIs tied to colorectal surgeries. In a one year period, the hospital reported an increase in the average rate of such SSIs from 7.05 percent to 10.1 percent. Although the hospital reported its numbers were in line with other NSQIP-participating organizations, the facility sought to reduce the rate of colorectal SSIs by 50 percent, over the course of a year. At the time, the hospital estimated its surgeons performed more than 2,300 colectomies a year. Mayo Clinic Rochester Methodist Hospital also has two operating suites and two post-op nursing units dedicated to colorectal surgery (NSQIP, 2013).

Hospital leadership employed the DMAIC Method (define, measure, analyze, improve, control) as it laid out its quality improvement process (NSQIP, 2013). That SSI reduction effort included interventions across the episode of care, multidisciplinary collaboration, engaging staff, patients and families, standardizing as many processes as possible; and frequent feedback and communication.

“The hospital’s multidisciplinary team met to review the existing literature on SSI prevention as well as develop a detailed value stream map of the entire surgical episode. The hospital optimized its processes to ensure that it had very high compliance with those best practices strongly supported in the literature,” the case study notes (NSQIP, 2013).

“Furthermore, other practices that may have had less support in the literature but made sense from a workflow and/or economic perspective where also incorporated into its bundle. The overall goal was to institute process steps that would be performed at a very high level of compliance across the continuum of care.”

Ultimately the hospital’s overall SSI rate among colorectal surgery patients declined to 4.3 percent (NSQIP, 2013).

“Teams have to get better and learn how to innovate-teamwork and culture are essential to have, in that there is leadership and communication,” Ko says. “With the data, comes standardization, new and better ways of doing things, and communication and trust.”

Successful SSI reduction initiatives, he notes, must have commitment from hospital executives, division chiefs, managers and front-line leaders and staff. “They have to crave that data and use it in the best way possible. You have to be willing to try new methods, look at things from different points of view. Resiliency and support are crucial.”

He adds, “Knowing what your organization’s strengths and weaknesses are will be important. Is it a large or small organization? Is the culture filled with silos, or is the organization a place where great communication and dedication to excellence are walking in step? If a place is well-organized, a program like this will be terrific. If there is suboptimal organization and communication, at least being aware of these shortcomings will help improve communication around a program like this.”

Ko continues, “One question that I ask wherever I go is, how do you measure your quality? How do you measure how good you are? If you want to get better, how do you get better? Ask the C-suite and chief of surgery, the infection control and OR manager and frontline staff-surgeons, nurses, etc. Do you get the same answer from these levels? If you do, the infrastructure is there. If you get very different opportunities, there is a huge opportunity for change and growth there.”

Reference: American College of Surgeons. (2013). Case studies. Available at https://www.facs.org/~/media/files/quality%20programs/nsqip/mayocliniccasestudy.ashx.

OR Quality Roundtable

ICT asked manufacturers, "What is your best advice to operative and clinical personnel to help them avoid adverse events, complications and infections in the operative environment?" Here are participants' responses:

With several recent infectious disease outbreaks, the healthcare industry is seeing an increased focus on personal protective equipment (PPE) to keep employees and patients safe from harmful exposure. It all starts with education. Proper education-on the dangers of not using PPE and the impact of PPE on worker safety and health-is key to keeping employees safe and preventing the spread of disease. Clinicians must know why they need to use each specific type of PPE for their job, so they can feel confident that the PPE they are being asked to use is reliable in performing its intended function.
In addition to properly educating healthcare employees, and ensuring their effective usage of PPE, planning is key. Planning should identify the types of PPE needed, as well as the quantity levels. Hospitals should consider stocking PPE that can be consumed in daily operations, as much as possible, to ensure the stock is consumed on a first in, first out (FIFO) basis. For example, try not to purchase a unique item that does not have current or alternative use in your facility. This will help eliminate scrapping stock due to expiration dates.
Decisions regarding when to use PPE, and what type to use, should be determined by CDC recommendations for standard precautions, previously called universal precautions, and expanded isolation precautions. According to the CDC, standard precautions assume blood and body fluid of any patient could be infectious and recommends PPE and other infection control practices to prevent transmission in any healthcare setting. In addition, according to the CDC, expanded precautions include contact precautions, droplet precautions and airborne infection isolation. PPE kits that contain a variety of PPE, based on Standard or Expanded Precaution types, can increase efficiency and convenience to the staff.
-- Rosie Squeo, RN, BSN, MA, CWCMS, senior consultant for clinical operations, Cardinal Health, and Jim Bach, vice president of inventory management, medical segment, Cardinal Health

Effective reprocessing of surgical instruments begins in the operating room. Unfortunately, at many facilities, the necessary steps are not taken in the OR. Instead, instruments are shipped back to sterile processing without any point of use cleaning steps being taken. The attitude often is, "it is the job of the people downstairs!"
We all know this-once organics dry, particularly protein, they are significantly more difficult to remove. Cleaning grooves, gears, pulleys, springs, hinges, etc. are already a challenge. Let blood, for example, thoroughly dry in those places and the task becomes almost impossible. So what should be done?
-The cleaning of instruments should begin during the surgical procedure. Instruments should be wiped clean with sterile water and non-linting wipe/sponge. Those with lumens need to be flushed with sterile water. Instruments also should not be used for the remainder of a procedure, but kept moist using sterile water, never saline.
-The cleaning of instruments should continue post procedure at the point of use.
A non-linting wipe/sponge moistened with water should be used to wipe gross soil, and lumens should be flushed with water. Assembled instruments should be disassembled. Also, instruments must be separated and placed in a leak-proof, puncture-resistant container marked with a biohazard symbol. Ringed instruments should be placed arranged in single layers or placed on stringers, and box locks should be opened.
-Instruments should be kept moist in the transport container to prevent organics from drying. Accomplish this by:
Covering with a low-linting water-soaked towel.
Placing in a package designed to maintain humid conditions.
Using a spray foam or gel product intended for this purpose.
Effective reprocessing of begins in the OR. Following these steps (including those in the device IFU) are key to accomplishing the ultimate goal: instruments that are safe and ready to use on the next patient.
-- Ralph J. Basile, vice president of marketing, Healthmark Industries