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New approaches in the fight against SSI
New approaches in the fight against SSI Checklists, comprehensive process improvement and new clinical interventions are being piloted in major projects across the country to find better solutions for preventing surgical site infections
By Carina Stanton Senior News Editor espite rigorous efforts to implement clinical interventions throughout the perioperative process to prevent surgical site infections, these dangerous and costly health care-acquired infections still occur.
D
New funding and collaborative efforts from several leading health care organizations are focused on testing and sharing new methods for preventing surgical site infection (SSI) that address not only the evidence-based clinical interventions that are known to protect patients from SSI, but also the behavioral practices that support less chances for SSI to occur. These organizations, including the Institute for Healthcare Improvement (IHI), Johns Hopkins’ Armstrong Institute for Patient Safety and Quality, and the Joint Commission Center for Transforming Health Care, are each leading pilot projects for SSI reduction and expect to have results to share later this year. Project JOINTS IHI’s Project JOINTS (Joining Organizations IN Tackling SSIs), which is supported by a grant from the U.S. Department of Health and Human services, is preparing to launch the second cohort of states for the project, according to Diane Jacobsen, MPH, CPHQ, director, Institute for Healthcare Improvement and content director for Project JOINTS. Participant states for the first cohort of Project JOINTS include Arkansas, Colorado, Michigan, New York and Tennessee. doi: 10.1016/S0001-2092(11)01376-7
© AORN, Inc, 2012
Following recommended practices for skin preparation, such as preparing the surgical site with an antibacterial agent can reduce the risk of surgical site infection.
Each site participating in this project is working to implement IHI’s Enhanced Surgical Site Infection (SSI) Bundle of interventions designed to reduce the risk of surgical site infections in patients undergoing hip and knee arthroplasty. Jacobsen explained that the Project JOINTS Enhanced SSI Prevention Bundle includes specific actions that are taken in addition to measures required by the Centers for Medicare & Medicaid (CMS) Surgical Care Improvement Project (SCIP). These specific Enhanced Surgical Bundle elements include: 1. Patient bathing or showering with chlorhexadine for at least 3 days prior to surgery 2. Preoperative skin prep with a long-acting ssi Continued on C8 January 2012 Vol 95 No 1 • AORN Connections | C1
ssi Continued from C1
antiseptic agent in combination with alcohol 3. Pre-surgical nasal screening of patients for Staphylococcus aureus followed by decolonization of Staphylococcus aureus carriers It’s no surprise to Jacobsen that team engagement among nurses, surgeons and executive staff members has been a critical piece to successful implementation of IHI’s Enhanced SSI Prevention Bundle among hospitals participating in this study’s first cohort. She said these first cohort participants will share success strategies for promoting this team engagement and other elements of the Enhanced SSI Prevention Bundle with second cohort participants. “We expect the adoption of this bundle will be improved with the second cohort because of this knowledge sharing,” Jacobsen noted. Johns Hopkins’ Armstrong Institute project to reduce surgical site infections Another SSI research project just getting underway is through Johns Hopkins’ Armstrong Institute for Patient Safety and Quality. Led by Armstrong Institute Director Peter Pronovost, MD, PhD, the project is funded by a $10 million grant from the Agency for Healthcare Research and Quality and is slated to include 10 states with 10 hospitals from each state participating in the study. The project is using data from American College of Surgeon’s National Surgical Quality Improvement Program® (NSQIP). Pronovost previously led a successful Armstrong Institute project targeted to reduce central line associated blood-stream infections in ICU patients. Two important elements of that project—an
Team engagement and the use of a surgical checklist with evidence-based interventions can be powerful weapons in the fight to prevent surgical site infection. C8 | AORN Connections
incident specific checklist that supports evidencebased interventions and focused culture change that addresses safety behaviors—have been modified and are being tested for this new SSI project targeted for colon surgery, according to Pronovost. As with the blood-stream infection prevention project, the project will use a new concept known as clinical communities, a system of developing patient safety and quality improvement programs from the ground up, Pronovost explained. “We see that quality improvement projects are wiser and will work better when created by clinicians, rather than being done to clinicians,” he said. In order to do this, project participants are given a summary of the evidence-based practices for preventing SSI in colon surgery and then the clinicians develop their own approach to implementation. Pronovost stressed that clinician engagement is just the beginning of success with this project, which also requires robust measurement of outcomes, a checklist of best practices and culture change to support sustained implementation of the checklist and best practices. “When we look at the checklists developed for the bloodstream project, 99% of the checklists were the same in the different facilities, but it was that 1% shaped by unique cultural elements that made the checklist work,” he explained. Surgical Site Infection Project: Joint Commission Center for Transforming Healthcare A combined approach that addresses systematic quality improvement and change management through Robust Process Improvement™ (RPI) is being used to drive the Joint Commission Center for Transforming Healthcare’s Surgical Site Infection Project, with a specific focus on colorectal surgery. This RPI methodology builds off of Lean Six Sigma quality improvement methods, but also uses change management methodologies and tools for high reliability that provide a more holistic approach, according to Siew Lee Grand-Clément, RN, MSN, CPHQ, Center project lead and black belt for RPI. This SSI project also uses data from the American College of Surgeon’s NSQIP, because this clinical data set is highly regarded by surgeons and clinicians, and, more importantly, the rigor in
ensuring consistent and accurate data collection provides the improvement teams the ability to capture the reality of the pre- and postimprovement states on each of the participating hospitals, Grand-Clément said. She added, “We are glad to see the movement of using data in a meaningful way to drive outcomes by other NSQIP hospitals and collaboratives like the Armstrong Institute.” As part of this project, team members observe surgical cases where the process is used to document what they see, some even using videotape, Grand-Clément explained. “We have found that engaging the front-line health care workers and walking through their process with them, known as Gemba-walk in Lean terms, to test the process, observe barriers and brainstorm solutions, is key to change management and improvement implementation ,” she stressed.
process risk points, such as the surgical team member roles and interactions during the surgical closing process. Perioperative nurses should take note of these observations and think about ways they can contribute to reducing surgical site infection, said Ramona Conner, MSN, RN, CNOR, AORN manager of standards and recommended practices. “We are anxious to see the results of these studies and will look to this evidence in supporting our recommendations.” Implementing sustainable change Conner stressed the importance of perioperative nurses and all other members of the surgical team being active participants in changes to reduce and prevent surgical site infections. “If the perioperative nurse or any other member of the surgical team is not involved in affecting the change it won’t happen, or if it does happen, it won’t be sustainable,” she stressed.
The biggest driver of change is believing it’s possible. –Peter Pronovost, MD, PhD
As project leader, Grant-Clément also has a bird’s-eye view of the progress with all participants. “We have found that different people at the same juncture face the same barriers, so by pulling the right people together from different sites, they can share their strategies to overcome the barriers and brainstorm solutions together.” Observations and learning While results for each study are not expected to be shared until later this year, some initial findings from the projects are becoming evident, such as safer approaches for skin preparation and the value of team work. For example, within the Armstrong Institute study, Pronovost said project participants are finding errors associated with incorrect practices for skin preparation at the surgical site. Within the Joint Commission project, Grand-Clément said, the collaborative has learned the importance of using the team approach in orchestrating each improvement detail to address the identified © AORN, Inc, 2012
Pronovost said AORN members play an important role in collaborating with surgeons and other members of the surgical team to build upon collective wisdom in order to improve outcomes. “Sustainable change will only happen if it’s going on deeply in the organization. This is hard work and no one can do it alone,” Pronovost stressed, adding that “The biggest driver of change is believing it’s possible.” Additional resources Project JOINTS www.ihi.org/offerings/Initiatives/ProjectJOINTS/ Pages/default.aspx Armstrong Institute for Patient Safety and Quality www.hopkinsmedicine.org/armstrong_institute/ Surgical Site Infections project: Joint Commission Center for Transforming Healthcare www.centerfortransforminghealthcare.org/ projects/detail.aspx?Project=4 January 2012 Vol 95 No 1 • AORN Connections | C9
By Carina Stanton Senior News Editor espite rigorous efforts to implement clinical interventions throughout the perioperative process to prevent surgical site infections, these dangerous and costly health care-acquired infections still occur.
D
New funding and collaborative efforts from several leading health care organizations are focused on testing and sharing new methods for preventing surgical site infection (SSI) that address not only the evidence-based clinical interventions that are known to protect patients from SSI, but also the behavioral practices that support less chances for SSI to occur. These organizations, including the Institute for Healthcare Improvement (IHI), Johns Hopkins’ Armstrong Institute for Patient Safety and Quality, and the Joint Commission Center for Transforming Health Care, are each leading pilot projects for SSI reduction and expect to have results to share later this year. Project JOINTS IHI’s Project JOINTS (Joining Organizations IN Tackling SSIs), which is supported by a grant from the U.S. Department of Health and Human services, is preparing to launch the second cohort of states for the project, according to Diane Jacobsen, MPH, CPHQ, director, Institute for Healthcare Improvement and content director for Project JOINTS. Participant states for the first cohort of Project JOINTS include Arkansas, Colorado, Michigan, New York and Tennessee. doi: 10.1016/S0001-2092(11)01376-7
© AORN, Inc, 2012
Following recommended practices for skin preparation, such as preparing the surgical site with an antibacterial agent can reduce the risk of surgical site infection.
Each site participating in this project is working to implement IHI’s Enhanced Surgical Site Infection (SSI) Bundle of interventions designed to reduce the risk of surgical site infections in patients undergoing hip and knee arthroplasty. Jacobsen explained that the Project JOINTS Enhanced SSI Prevention Bundle includes specific actions that are taken in addition to measures required by the Centers for Medicare & Medicaid (CMS) Surgical Care Improvement Project (SCIP). These specific Enhanced Surgical Bundle elements include: 1. Patient bathing or showering with chlorhexadine for at least 3 days prior to surgery 2. Preoperative skin prep with a long-acting ssi Continued on C8 January 2012 Vol 95 No 1 • AORN Connections | C1
ssi Continued from C1
antiseptic agent in combination with alcohol 3. Pre-surgical nasal screening of patients for Staphylococcus aureus followed by decolonization of Staphylococcus aureus carriers It’s no surprise to Jacobsen that team engagement among nurses, surgeons and executive staff members has been a critical piece to successful implementation of IHI’s Enhanced SSI Prevention Bundle among hospitals participating in this study’s first cohort. She said these first cohort participants will share success strategies for promoting this team engagement and other elements of the Enhanced SSI Prevention Bundle with second cohort participants. “We expect the adoption of this bundle will be improved with the second cohort because of this knowledge sharing,” Jacobsen noted. Johns Hopkins’ Armstrong Institute project to reduce surgical site infections Another SSI research project just getting underway is through Johns Hopkins’ Armstrong Institute for Patient Safety and Quality. Led by Armstrong Institute Director Peter Pronovost, MD, PhD, the project is funded by a $10 million grant from the Agency for Healthcare Research and Quality and is slated to include 10 states with 10 hospitals from each state participating in the study. The project is using data from American College of Surgeon’s National Surgical Quality Improvement Program® (NSQIP). Pronovost previously led a successful Armstrong Institute project targeted to reduce central line associated blood-stream infections in ICU patients. Two important elements of that project—an
Team engagement and the use of a surgical checklist with evidence-based interventions can be powerful weapons in the fight to prevent surgical site infection. C8 | AORN Connections
incident specific checklist that supports evidencebased interventions and focused culture change that addresses safety behaviors—have been modified and are being tested for this new SSI project targeted for colon surgery, according to Pronovost. As with the blood-stream infection prevention project, the project will use a new concept known as clinical communities, a system of developing patient safety and quality improvement programs from the ground up, Pronovost explained. “We see that quality improvement projects are wiser and will work better when created by clinicians, rather than being done to clinicians,” he said. In order to do this, project participants are given a summary of the evidence-based practices for preventing SSI in colon surgery and then the clinicians develop their own approach to implementation. Pronovost stressed that clinician engagement is just the beginning of success with this project, which also requires robust measurement of outcomes, a checklist of best practices and culture change to support sustained implementation of the checklist and best practices. “When we look at the checklists developed for the bloodstream project, 99% of the checklists were the same in the different facilities, but it was that 1% shaped by unique cultural elements that made the checklist work,” he explained. Surgical Site Infection Project: Joint Commission Center for Transforming Healthcare A combined approach that addresses systematic quality improvement and change management through Robust Process Improvement™ (RPI) is being used to drive the Joint Commission Center for Transforming Healthcare’s Surgical Site Infection Project, with a specific focus on colorectal surgery. This RPI methodology builds off of Lean Six Sigma quality improvement methods, but also uses change management methodologies and tools for high reliability that provide a more holistic approach, according to Siew Lee Grand-Clément, RN, MSN, CPHQ, Center project lead and black belt for RPI. This SSI project also uses data from the American College of Surgeon’s NSQIP, because this clinical data set is highly regarded by surgeons and clinicians, and, more importantly, the rigor in
ensuring consistent and accurate data collection provides the improvement teams the ability to capture the reality of the pre- and postimprovement states on each of the participating hospitals, Grand-Clément said. She added, “We are glad to see the movement of using data in a meaningful way to drive outcomes by other NSQIP hospitals and collaboratives like the Armstrong Institute.” As part of this project, team members observe surgical cases where the process is used to document what they see, some even using videotape, Grand-Clément explained. “We have found that engaging the front-line health care workers and walking through their process with them, known as Gemba-walk in Lean terms, to test the process, observe barriers and brainstorm solutions, is key to change management and improvement implementation ,” she stressed.
process risk points, such as the surgical team member roles and interactions during the surgical closing process. Perioperative nurses should take note of these observations and think about ways they can contribute to reducing surgical site infection, said Ramona Conner, MSN, RN, CNOR, AORN manager of standards and recommended practices. “We are anxious to see the results of these studies and will look to this evidence in supporting our recommendations.” Implementing sustainable change Conner stressed the importance of perioperative nurses and all other members of the surgical team being active participants in changes to reduce and prevent surgical site infections. “If the perioperative nurse or any other member of the surgical team is not involved in affecting the change it won’t happen, or if it does happen, it won’t be sustainable,” she stressed.
The biggest driver of change is believing it’s possible. –Peter Pronovost, MD, PhD
As project leader, Grant-Clément also has a bird’s-eye view of the progress with all participants. “We have found that different people at the same juncture face the same barriers, so by pulling the right people together from different sites, they can share their strategies to overcome the barriers and brainstorm solutions together.” Observations and learning While results for each study are not expected to be shared until later this year, some initial findings from the projects are becoming evident, such as safer approaches for skin preparation and the value of team work. For example, within the Armstrong Institute study, Pronovost said project participants are finding errors associated with incorrect practices for skin preparation at the surgical site. Within the Joint Commission project, Grand-Clément said, the collaborative has learned the importance of using the team approach in orchestrating each improvement detail to address the identified © AORN, Inc, 2012
Pronovost said AORN members play an important role in collaborating with surgeons and other members of the surgical team to build upon collective wisdom in order to improve outcomes. “Sustainable change will only happen if it’s going on deeply in the organization. This is hard work and no one can do it alone,” Pronovost stressed, adding that “The biggest driver of change is believing it’s possible.” Additional resources Project JOINTS www.ihi.org/offerings/Initiatives/ProjectJOINTS/ Pages/default.aspx Armstrong Institute for Patient Safety and Quality www.hopkinsmedicine.org/armstrong_institute/ Surgical Site Infections project: Joint Commission Center for Transforming Healthcare www.centerfortransforminghealthcare.org/ projects/detail.aspx?Project=4 January 2012 Vol 95 No 1 • AORN Connections | C9