At this point in the safety program, this may seem like old news to you. Reduction of surgical site infections after implementation of a bundle of care. Surgical Site Infection (SSI)—Colorectal ADDENDUM 2 August 2016 Set aims, goals and timelines for practice changes and performance. Tell them, as often and in as many ways as possible. Pre-Operative Surgical Site Marking. Preventing Surgical Site Infections Care Bundle Key Recommendations for Practice Pre-Op… 1.Avoid hair removal at the surgical site. Wick EC, Hobson DB, Bennett JL, et al. This module covered developing an implementation plan for your SSI prevention bundle. Tap into things that folks value: that feeling of doing something important, something meaningful, that voices are heard, and that they are appreciated for the work they do. Now we will discuss how to translate evidence into bedside practice. Image: Calculating the barrier priority score for each barrier uses a table with space to record following information: Barrier, Likelihood score, Severity score, and Barrier priority score. Facilitator Notes (Word, 6.71 MB), Internet Citation: Implementing Your Surgical Site Infection Prevention Bundle: Slide Presentation. Acknowledge and celebrate your success. Five categories of education opportunities listed and described in boxes: inservices, forums, orientation, evidence, and boards. This powerful message and data are an opportunity to engage senior executives as well as the frontline staff. Antibiotic redosing and weight-based dosing. Find creative ways to communicate. One indicates a barrier is unlikely to occur; five indicates a barrier is very likely to occur. If hair must be removed use single patient use clippers and not razors. Teach your team(s) about your intervention. Post baseline infection rates and number of patients impacted by surgical site infections. ACOG practice bulletin No. Joint Commission Surgical Site Infection Prevention Checklist Rockville, MD 20857 Customize your briefing and debriefing based on local defects. You will learn to identify and address local barriers to implementing your SSI prevention bundle with the Barrier Identification and Mitigation tool. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. The BIM tool covers a series of questions focused on three categories: clinician, environment, and guideline. Never underestimate the value of an engaged senior executive. Customize the tools to meet the needs of your area. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. 1. Temperature in pre-op area prior to going to OR. Moving staff from compliant to engaged is key to a successful intervention. These can change over time but are based on the results of a local investigation: five or seven things to focus on. They should represent local wisdom and local defects—what’s going on in one hospital will differ from what is happening in another. Also, educate staff on the science of improving patient safety. Why don’t physicians follow clinical practice guidelines? JAMA Surg 2014 ; 149 : 1045 – 1052 . Surgical site infections (SSIs) are a frequent complication of surgical care and are associated with significant morbidity, mortality, and cost. Available until 1/25/17. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. Image: Stacked arrows labeled Engage, Educate, Execute, and Evaluate. How often is a barrier expected to occur? Abstract this information from the patient’s chart and present it to the team. Determine how well your effort has improved care processes and outcomes. It unites staff members with a common goal, puts a face to the numbers, and most importantly, is EASY to do.”. Pronovost PJ, Goeschel CA, Marsteller JA, et al. Wash the patient … New clinical building impact; Plan to teach sonographers how to use an alternate device in some cases to alleviate burden in short-term; long-term fix under review. Please click on the section headings to begin. Increasing numbers of patients also undergo … Successful strategies include watching frontline staff perform the interventions. First column reads Factors. Strategies will depend on YOUR stakeholders. To evaluate the impact of a surgical site infection (SSI) prevention bundle on SSI rates after hysterectomy for benign and malignant indications at an urban academic medical center. Be prepared to provide data that show the compliance with intervention, or how many patients are not receiving therapies A, B, and C. Is it clear who’s responsible for providing therapy A, B, or C? Dig deeper into what the SCIP measures represent within your organization to make sure patients receive evidence-based therapies. Second example of an equipment defect: Ultrasound was needed in another room, repeated calls during critical part of case. Activity: Identify roles for your ideal BIM Team. Based on the recorded evidence, the team was able to advocate for expanding the fleet. Crolla RM, van der Laan L, Veen EJ, et al. Create a large pool of supporters within your organization. Image: Arm outstretched and holding a stick with carrots hanging from the stick. What are the local barriers to implementation? The BIM tool helps to identify and prioritize barriers. Often, in spite of efforts to communicate infection rates, frontline staff may still lack awareness of the rates. The last step of the TriP methodology is to ensure that all patients are receiving the evidence-based therapy. Staff will not find value in the briefing process unless the time they put into it helps them do their job or helps their patients. Share with your staff the issues identified last month or last quarter, the issues resolved, and any issues in progress and the status. Same form used in all operating room departments, such as–. Image: Education Examples. Action: Check type of case; possible preference card update. This compendium summarizes the literature on effective strategies to engage senior leaders and staff, to execute an implementation plan within a certain environment, and evaluating that effort. How do you think the next patient will be harmed? Other ideas involve posts in the break room, posts in the restrooms, and treats to celebrate successes. The last of the 4 Es is to evaluate. Talk to frontline staff to identify how they would reduce surgical site infections. Providers need to know the rationale for the given practice. ACS NSQIP–American College of Surgeons National Surgical Quality Improvement Program. The second A is attitudes or agreement. The CDC estimates that 50% of all SSIs are preventable. Measure your performance. CDC Definitions of Surgical Site Infections • SSI – occurs within 30 days after the procedure (or within 1 year if an implant) – has at least one of the following: • purulent drainage from the incision • organisms isolated from an aseptic culture of the incisional fluid or tissue • … In summary, briefings and debriefings provide an evidence-based strategy to standardize care and create independent checks. How can you standardize work to make it easier for providers to do the right thing? Content: Illustrations: Patrick Sullivan, MD Cheryl Castleberry, RN BS Satyen Tripathi, MA CMI. Highlight staff members that ensure patients receive the evidence-based therapies. Image: Photo of colorectal surgery set of tools. What supplies and equipment are available/used? It takes a lot of effort, and there’s a role for everyone in this work. The model used in translating evidence into practice was first developed as part of a statewide intensive care unit program. Generally, staff members have far less exposure to priorities than expected. How valuable do you think the frontline providers found briefing with a long form listing issues that did not change? Develop an implementation plan for your surgical site infection (SSI) prevention bundle. This additional step in the ordering system encourages consistent care. Engaging a senior executive requires a different strategy than engaging a surgeon or a nursing colleague to participate. Select “Supplemental tools” under “Applying CUSP To Promote Safe Surgery” and “Surgical Complication Prevention.”. Briefing and debriefing was reintroduced with a new tool and feedback process. Briefing and debriefing work. Close the loop to solve defects at the system level. They know your patients. How will you know when progress is made on each effort? Bandari J. Telephone: (301) 427-1364, Implementing Your Surgical Site Infection Prevention Bundle: Facilitator Notes, https://www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-fac-notes.html, AHRQ Publishing and Communications Guidelines, Healthcare Cost and Utilization Project (HCUP), Quality Indicator Tools for Data Analytics, United States Health Information Knowledgebase, Funding Opportunities Announcement Guidance, AHRQ Informed Consent & Authorization Toolkit for Minimal Risk Research, Public Access to Federally Funded Research, Grant Application, Review & Award Process, Study Sections for Scientific Peer Review, Getting Recognition for Your AHRQ-Funded Study, AHRQ Research Summit on Diagnostic Safety, AHRQ Research Summit on Learning Health Systems, Comprehensive Unit-based Safety Program (CUSP), Improving Your Laboratory Testing Process, Safe Transitions Across Ambulatory Settings, U.S. Department of Health & Human Services. AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. The principles of safe design apply to BOTH technical tasks and teamwork. The development of the Surgical Care Improvement Program (SCIP) measures represents an effort in which surgical experts identified salient interventions to prevent SSIs. Identify and address local barriers to implementing your SSI prevention bundle. These defects can escalate problems faced during the case and prioritize finding a solution. A framework for improvement. To learn more about Science of Safety, watch this informative 23-minute video: http://www.ahrq.gov/hai/cusp/modules/understand/index.html. One strategy is to audit the next 10 patients. Can you think of budget-friendly extrinsic motivators? Image: Chart shows significant drop in SSI rate at Johns Hopkins Hospital as reported through NSQIP from third quarter 2009 through the fourth quarter of 2013. Henrickson SE, Wadhera RK, Elbardissi AW, et al. Your data collection does not have to be sophisticated. Are the necessary supplies and equipment available? Post infection rates and the number of patients affected by SSIs to bulletin boards. The BIM tool was introduced to systematically identify and address the barriers to eliminating surgical site infections. Document a number (e.g., 10 patients in the last quarter) to make it real for staff. IMPLEMENTING A SURGICAL INFECTION PREVENTION PRACTICE 9 and by using evidenced based practices, the journey to higher quality care with overall decreased costs may be within reach. Ensure all patient receive the intervention. How do clinicians know they are following the guideline? Influence of a total joint infection control bundle on surgical site infection rates. Assume a recent audit shows that only 16 percent of your surgical patients are receiving proper antibiotics redosing. If the provider does not agree with the antibiotic selection, that would be OK. Yet an auditing of medical records shows that the correct dosage is not delivered; appropriate redosing does not happen. Use the 4 Es to lead change: engage, educate, execute, and evaluate. How can the BIM process empower and motivate staff? According to datafrom AHRQ, more than 10 million patients undergo surgical procedures as inpatients each year, accounting for over one-fourth of all hospital stays. Share stories about how SSIs affected the patient’s life, his or her children, family, and their job. Key stakeholders in the surgical arena are critical to a successful safety program for surgery. The practices were divided into bundle elements that reflected preoperative, intraoperative, and postoperative care. Essential to report progress to your team: Track your surgical site infection rates and detect trends. What do you think we can do to prevent it? This module is about implementing your surgical site infection (SSI) prevention bundle. We talked about identifying and addressing local barriers that hinder the implementation of your bundle. Newer guidelines from a … Reduce communication breakdowns and OR delays. Use the SSI Investigation tool to determine progress in implementing your SSI prevention bundle with patients. Extrinsic motivation refers to external rewards or incentives attached to the work. The debriefing process raised awareness and accountability for the delivery of care and provided a forum to share the expectations within the surgical unit. Include the type of issue, the stakeholders, details about the defect, and the action plan. Rockville, MD 20857 Use briefing time to identify defects. The BIM tool walks through a series of questions focused on three categories. Include the components of your local bundle. It entails the personal satisfaction of performing a job well, exceeding your own expectations, or perhaps feeling a part of something larger. 11 Surgical site infection prevention is the responsibility of both the patient and the health care providers. Briefings and debriefings standardize care, reduce complexity and create redundancy. Prioritize this important and challenging task. Make sure the frontline providers have visibility of these efforts. As a group, assign a likelihood score for each barrier. To learn more about Science of Safety, watch this 23-minute video: https://www.ahrq.gov/hai/cusp/videos/04a-science-safety/index.html. Reduce procedure and miscommunication-related disruptions and nursing time spent in core. This module will help you develop an implementation plan for your SSI prevention bundle. That’s the basis for the SSI prevention bundle: focus on the elements in the bundle, as those are the evidence-based practices that will need to be applied into practice. Let’s take another look at it. But nationally, improving compliance with SCIP measures has not translated into reductions in SSIs. Does the clinician believe that following the guideline will reduce infection rates? Objective. Your team would rate this barrier with a lower severity score than a barrier of broken warming equipment. Image: Briefing tool: Original briefing form used in all Hopkins operating room departments. Other evaluation methods involve evidence-based auditing and SSI investigation tools, or tracking process measures. It shows the significant drop in surgical site infections achieved in colorectal surgeries at Johns Hopkins Hospital. Form a subgroup of your SSI prevention team. If your goal is to ensure that all providers perform appropriate preoperative skin preparation, then provide multiple opportunities for sharing and discussing the guidelines. For instance, a physician may not have read the literature for maintaining normothermia. Expect many barriers and find as many as possible. The process did not include followup on the comments. Develop new relationships with other experts and clinicians. Providers want to do the right thing, but it may be too hard to do the right thing. Tapping into the wisdom of the frontline staff is powerful on a number of levels. While this approach has pros and cons, it identifies opportunities for improvement. Include frontline staff members. For instance, if warming equipment is available, but down the hall, someone on the care team can retrieve the device. One successful strategy is to talk to the frontline staff. All new interventions must share why the change is required, you must share the evidence for buy-in. Global guidelines on the prevention of surgical site infection. Facilitator Notes (Word, 6.71 MB), Internet Citation: Implementing Your Surgical Site Infection Prevention Bundle: Facilitator Notes. Second section of the BIM tool. Action: Contacted ultrasound manager Bob about getting another device. Identify and address local barriers to implementing your SSI prevention bundle. This is an exceedingly powerful opportunity to engage your staff. The most common types of inpatient surgical procedures include cesarean section, orthopedic procedures (hip and knee replacement, hip fracture repair), neurosurgical procedures (spinal fusion and laminectomy), and intraabdominal procedures (cholecystectomy and colorectal resections). Customize the tools to meet the local needs of your clinical setting. Ask them about the obstacles that impede compliance with the intervention. Tip: The BIM tool can be found on the AHRQ Web site at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/bim.docx (Word, 1.73 MB). Likelihood Score multiplied by the Severity Score equals the Barrier Priority Score. How often does the clinician do everything right? Dive deeper into SCIP measures to identify local defects. Fornwalt L, Ennis D, Stibich M ... and using a surgical safety checklist—can help high performing hospitals and health care providers move beyond SCIP to ensure that they provide the best care possible to their surgical patients and decrease the rate of SSI Prevention of Surgical Site Infections Following Major Gynecologic Surgery Bundle Complete Resource Listing December 2017. Mortality rates drop also if briefings are done well. Frequently or rarely? Guideline for the Prevention of Surgical Site Infection (1999) Page last reviewed: November 5, 2015 Content source: Centers for Disease Control and Prevention , National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) , Division of Healthcare Quality Promotion (DHQP) WHO: Global Guidelines for the Prevention of Surgical Site Infections These guidelines from the World Health Organization aim to provide evidence-based recommendations for interventions to decrease the risk of surgical site infections. Step Three—After identifying the barriers, list them. However, the provider would then need to provide additional information for the requested selection. Vary the content of the bundle based on your local defects. It also provides a framework for developing an action plan for addressing barriers. Be vigilant. Images: Stacked arrows labeled with Engage, Educate, Execute, and Evaluate: Internal, psychological rewards that derive from the work itself. People may say “we don’t have time” or “we don’t have money.” Initial quality efforts rarely have the luxury of protected time or extra funding to accomplish the goals. Track performance over time. Rank the barriers from high to low scores; tackle the high scores (16 and above) first, then address the low scores (15 and below). Covered in detail in a later module, the audit tools help you measure compliance. Each surgical unit may need to address different defects. The first ever Global guidelines for the prevention of surgical site infection (SSI) were published on 3 November 2016, then updated in some parts and published in a new edition in December 2018. Have the frontline staff walk the targeted process to identify defects. Think broadly. Efficacy of protocol implementation on incidence of wound infection in colorectal operations. Surgical site infection (SSI) continues to represent a significant portion of healthcare-associated infections because of their impact on morbidity, mortality, and cost of care. One option is to track SSI rates over time to identify trends, an outcome measure. Share these data points with the senior leadership. Consider next translating that bundle into practice. There are opportunities to understand what motivates our staff, both intrinsic and extrinsic. Integrate a well-developed middle-level management quality improvement group with frontline staff. It is essential to adapt tools to the local environment. Currently, our organization, has a high rate of surgical site infections (SSI) … Say: They will identify potential barriers. Video segments are located at: https://www.ahrq.gov/hai/cusp/modules/understand/index.html. Why isn’t each patient receiving the correct antibiotic, the correct dosage, and the correct redosage at the correct time (or therapy A, B, C, D, and E?). Second column allows space to record results. Image: BIM Action Plan table, with space to record: selected actions, performance measures, leader, and followup date. Step One—Form a subset of your CUSP or SSI prevention team. Are there too many steps? Ensure all patients receive the intervention. The majority of SSIs are largely preventable and evidence-based strategies have been available for years and implemented in … Briefings and debriefings have been linked to reductions in communication breakdowns, operating room delays, communication-related disruptions, nursing time spent away from the patient’s bedside, operating room traffic, and SSIs. (ability). Post team members’ names and pictures and team successes. A walk-through encourages direct participation and observation and allows frontline staff to contribute their wisdom. Consider the potential application of emerging evidence within the organization. One team encouraged people to tell the team story to a coworker. It was used in the national central-line associated blood stream infection prevention program. Activity: List several examples of both intrinsic and extrinsic motivators. Obstet Gynecol 2009;113:1180- 1189. The 4 Es model (engage, educate, execute, and evaluate) will guide your change efforts. Tip: The higher the Barrier Priority Score for a barrier, the more critical it is to eliminate or decrease the effects of that barrier. Use the Barrier Identification and Mitigation (BIM) tool. Tip: The BIM tool (Word, 1.73 MB) can be found on the AHRQ Web site. First example of an instrument defect: Wrong tray; got a medium, but needed major 1 & 2. What does the clinician currently do (or not do)? *Note: Use of brand names is for identification only and does not imply endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. READINESS Antibiotic Prophylaxis for Gynecologic Procedures. Regardless of outcome or process measures data, post your progress in the unit and discuss during staff meetings. The surgical site infection reduction bundle consisted of 15 processes throughout the surgical encounter, including preoperative, intraoperative, postoperative, and postdismissal elements . Who are the strategic partners you need to engage in your organization? Methods: A SSI bundle for cesareans was introduced in our hospital in April 2014 to reduce the SSI rate. Principles of safe system design, a feature of high-reliability organizations, focus on systems rather than individuals. The first column reads: Guideline, Data collection mode (check one): The next columns provide space to record the Investigator and the Shift. Use both types of motivators to engage staff members. No single SSI prevention bundle exists. Intervention bundles were developed in the mid-1990s to improve the care of mechanically ventilated patients. Are they aware, in agreement, and/or able to comply? Briefings and debriefings provide a proven effective strategy to standardize care and create independent checks. Educate care providers on risk factors for SSI and prevention with an emphasis on bundle elements and evidence-based best practices. Give staff opportunities to shine and showcase their work to senior leaders and throughout the organization or the community. An NHSN Operative Procedure is a procedure • that is included in the ICD-10-PCS and/or CPT NHSN operative procedure code mapping And • Is the proper equipment available to maintain normothermia? How does the current administrative support affect adherence? Provide a framework for developing an action plan. First column reads Factors. Prioritize educating staff on the expectations. How can the BIM process empower and motivate staff? Under the heading Factors is a subheading for Clinician and several categories and questions: Does the clinician know how to comply with the guideline? surgical procedure-specific etc. It takes a village to make this work happen. 3 Preoperative components were used for elective procedures; peri- and postoperative components were recommended for all procedures (). 104. While the direct method is used as the gold standard Agency for Healthcare Research and Quality, Rockville, MD. Again as a group, assign a severity score that represents the probability that the barrier, if encountered, would lead to guideline nonadherence. Involve surgeons both on staff and with privileges, anesthesiologists, nurse anesthetists, circulating nurses, scrub nurses, perioperative nurses, and operating room technicians. If the devices are all damaged, it is highly unlikely that the care team can comply with the intervention. Did you share enough of the evidence to garner buy-in? To sign up for updates or to access your subscriberpreferences, please enter your email address below. Consider the potential application of emerging evidence within the organization. Implementing standardized operating room briefings and debriefings at a large regional medical center. Content last reviewed October 2020. These metrics go beyond the current SCIP measures. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. To determine the barrier priority score, multiply the likelihood score and the severity score. If that coworker could answer a question or two about the team or intervention at a staff meeting, both received a small prize. Use the audit tool to present SSI cases to leadership, staff, and the infection control community. Use the questions in the Staff Safety Assessment. Do providers agree with this recommendation? Entice the staff: tell them that no matter the results, they will get to present at a meeting with leadership; they will share their work and insights. Conflict with colorectal surgical instrument set. Slide 2: Learning Objectives. Depending on how the evidence is acquired or shared, providers may not agree that the given evidence applies to her or his patient. The provider would retain autonomy. The infection preventionist (IP) has an important role in SSI prevention beyond SSI surveillance. Step Two—Using the BIM tool, walk through the potential barriers with stakeholders. Invite all stakeholders to observe or participate in the walk-through. Identify and focus on the defects in your surgical unit. After the debriefing, close the loop to solve any defects at the system level. Joint Commission Surgical Site Infection Prevention Checklist. Keep a log of the comments from the debriefing tool. Your data become the evidence to motivate staff to change their practice. Specific care bundles include bundles for the prevention of central line-associated bloodstream infections (CLABSI), bundle for the prevention of catheter-associated urinary tract infections (CAUTI), bundle for the prevention of ventilator-associated pneumonia (VAP), and bundle for the prevention of surgical site infection. Customize tool based on your department’s specific needs. Win the hearts and minds of your team(s). Find out whether staff members know about or understand their surgical site infection rates. How-to Guide: Prevent Surgical Site Infections. Think broadly within the 4 Es when mapping out how to forge key partnerships. The evidence does not currently support an association between performance in SCIP measures and successful reduction of SSIs. Staff members need to know if their efforts are making a difference. (Available at www.ihi.org). Bundles are dynamic and can evolve over time. Following columns provide space to record Barriers and Potential Actions. External rewards or incentives attached to the work. Do the clinicians know the guidelines and how to comply with them in the organization? Nundy S, Mukherjee A, Sexton JB, et al. Find creative yet consistent messaging to communicate with your staff. Financial incentives are not necessary. Hedrick TL, Heckman JA, Smith RL, et al. Resources are limited, and addressing many things at once is not feasible. Investigate as many SSIs as possible, but there is no right number to review. So what options do you have if you can’t offer time or financial incentives? Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. Second, involve the frontline staff and recognize them for their contributions. A surgical safety checklist to reduce morbidity and mortality in a global population. Slide Presentation (PowerPoint, 1.87 MB) If the patient is sensitive or 2. Briefing and debriefing tools must be customized to address your local defects and goals. Acknowledge and celebrate your successes. How do you think the next patient will develop a surgical site infection. Pre-Operative Cabana MD, Rand CS, Powe NR, et al. Frustrated MD stopped the procedure for the other OR and waited 15 minutes for the equipment to be returned. In the Compendium, it’s not just about the right antibiotic, the right timing, and the right choice, but it’s also about making sure that we have the right dose of antibiotic and the right redosing schedule for the antibiotic. Three categories listing issues that did not change and debriefings provide a surgical site infection prevention bundle checklist effective strategy to standardize care and independent... Module, the stakeholders, details about the obstacles that impede compliance with measures...: Revised briefing tool customized for the requested selection, Smith RL, et al settings! 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Be followup on the action item a good job tool was introduced to systematically identify address! Circles labeled with the three steps of the surgical setting into the of... Clinician, environment, and action plan for your ideal BIM team, perhaps a of! Or how they would reduce surgical site marking approach used to develop a site., Wadhera RK, Elbardissi AW, et al prioritize barriers, frontline staff and recognize them their!
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