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SSI INTEREST GROUP: HOSPITAL WEBINAR #1
February 23, 2016
HOUSEKEEPING ITEMS
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Webcast will be recorded.
2
BACKGROUND
SSI Interest Group idea was developed by
Mary Shanks
• Coordinated with OAHHS and OHA
• Hold a series of webinars to share hospital
experience
• All Oregon hospitals invited
Goal to further share best practices with PfP
hospitals on 04/29/16
3
GROUND RULES
This is a ‘safe table’ format
• The focus is on patient safety
• Participants encouraged to openly share to
collaborate and educate their peers
• Be respectful of sensitive info/data that you may
hear
4
RESOURCES
HRET-HEN.org
SSI Top Ten Checklist:
• http://www.hret-hen.org/topics/ssi/13-14/2014-
SSIChecklist.pdf
HRET SSI Change Package
• http://www.hret-hen.org/topics/ssi/13-14/2014-
SSIChangePackage508.pdf
5
INTRODUCTIONS
Facilitator:
• Mary Shanks, Infection Preventionist, Kaiser Westside
Medical Center
Today’s speakers:
• Mary Shanks, Infection Preventionist, Kaiser Westside
Medical Center
• Susan Diskin, Infection Preventionist, Legacy Good
Samaritan Medical Center
• Annette Stefan, Infection Preventionist, Providence St.
Vincent Medical Center
• Julie Koch, Infection Preventionist, Salem Health
6
SSI INTEREST GROUP: MARY SHANKS
KAISER WESTSIDE MEDICAL CENTER
February 23, 2016
KAISER WESTSIDE MEDICAL
CENTER
Opened in August 2013: • Community hospital
• Licensed 122 beds
• 10 ORs
• Total Joint Program
• Approx 1900 Total Joint procedures/yr- 800 hips,
1100 knees
• 14 Orthopedic surgeons
8
DECREASING SSI RISK
Current efforts in place to decrease risk • Preop clinic visit- each patient screened medically
including dental clearance before approved for
surgery. Each patient receives education, attends
class either in person or online, CHG cloths for pre-op
bathing.
• Pre-admission clinics: each patient seen by MD/NP,
MRSA screening done up to 1-2 months prior to
surgery
• Care coordination- discharge planning
9
10
DATA
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
Qtr 3 2013 Qtr 4 2013 Qtr 1 2014 Qtr 2 2014 Qtr 3 2014 Qtr 4 2014 Qtr 1 2015 Qtr 2 2015 Qtr 3 2015 Qtr 4 2016
Rat
e
WMC Total Knee Infections by Quarter 2013-2015
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
Qtr 3 2013 Qtr 4 2013 Qtr 1 2014 Qtr 2 2014 Qtr 3 2014 Qtr 4 2014 Qtr 1 2015 Qtr 2 2015 Qtr 3 2015 Qtr 4 2015
Rat
e
WMC Total Hip Infections by Quarter 2013-2015
Superficial infections are included
ACTIONS TAKEN
Formation of TJ SSI review team
• Interdisciplinary- meet monthly to review
• Care coordination, wound care, orthopedics, ID, IP,
pharmacy, anesthesia, clinic, nursing, OR staff,QM,
Therapy, SPD manager
Consultant to evaluate SPD processes • High risk area
• Management turnover
Site visit to KP facility in N Cal • Teams, 24/7 OR
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SUMMARY
Changes made:
New warming devices in ORs
Mepilex antimicrobial dressings
CHG bath by staff in SPA
Increased staffing in SPD, lighting
Next:
• Measure OR times?
• Increased testing of instruments with ATP
12
What advice do you have for me?
13
QUESTIONS?
2/25/2016 14 Oregon Association of Hospitals & Health Systems
THANK YOU
www.oahhs.org
Mary Shanks, RN, MSN, CIC Coordinator
Kaiser Permanente Infection Prevention and Control
2875 NW Stucki Hillsboro, OR 97124
971-310-4720 (office)
SSI INTEREST GROUP: HOSPITAL PRESENTATION SUSAN DISKIN
LEGACY GOOD SAMARITAN MEDICAL CENTER
February 23, 2016
LEGACY GOOD SAMARITAN
MEDICAL CENTER
17
KEY SERVICES
Total Joint and Spine Programs
Robotic Surgery
Bariatric Surgery/Weight Loss Program
Hip Fracture Service
Cardiac Service Line
Cardiac Rehabilitation
Women’s Services
Cancer Institute
Emergency Department
Primary Stroke Center
Kern ICU
Inpatient Rehabilitation
Renal Transplant
Bloodless Surgery and Medicine Program
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Total Hip, Knee & Shoulder Programs
2010 2016
Developed a Steering Committee lead by surgeon champion: All Surgeons Physician’s assistants Office staff Director of Surgery CAO Surgery managers Unit Leaders Performance improvement
team: hospital based work group – drive the changes.
2012 2014
Disease specific accreditation from Joint Commission
Initiated Project Joints – IHI guidelines
Launched Pre-op
Bathing with Hibiclens
Total Joint Class mandatory or back-up is a visit to pre-admit with nurse 1-2 weeks
before surgery
MRSA/MSSA screening and decolonization process initiated
Wound closure and
dressing evaluated and standardized
Multiple surgery initiatives begun and reinforced
2013 2015 2011
Pre-Operative Bathing with Chlorhexidine
Soap Patients receive two 4 oz. bottles of Hibiclens at the pre-op total joint
education class, and instruction with teach-back on doing 5 showers before
surgery.
Use of Project Joints template – created an instructional handout with
Hibiclens
Audit tool created – Short Stay Unit evaluates bathing compliance
MRSA/MSSA screening and decolonization Patients are swabbed at joint class. Those who are unable to attend class
are seen in PAS 1-2 weeks prior to surgery.
Swabs run by PCR results faxed to the surgeon’s office patients
notified if positive and educated ensure RX of mupirocin completed.
Audit tool created - Short Stay Unit measures compliance
19
OTHER PERFORMANCE IMPROVEMENT
MEASURES
20
Surgery initiatives:
Limit and eliminate OR traffic >notice on the room, stock “what if” items
Restrict vendor access
Gown, gloves, mask for prep
Full barrier for foley insertion
Glucose monitoring
Clean closure > new, separate tray
Dedicated team
SSI drilldowns with team
Learnings brought to Steering committee
Wound Closure Dermabond Dermabond Prineo
Glucose Initiatives: If CBG is greater than 130, anesthesia is called. If diabetic, then insulin infusion protocol initiated with titration to SQ post
operatively If elevated CBG and negative for Diabetes diagnosis, IV insulin Inpatients: CBG monitored for 24 hours and if still elevated after 24 hours
attending notified
Dressing Management Silver dressing used in some cases Prevena used in high BMI cases
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[VALUE]
[VALUE]
[VALUE]
[VALUE] 0
1.48
1.11
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
2012 2013 2014 2015
SIR
Good Samaritan Medical Center - Standardized Infection Ratio Data trend (2012 - 2015)
HIPS 1 3 1 1* KNEES 0 2 2 0
WHY PROJECT JOINTS?
22
Provides structured approach to program and SSI
prevention
Patient Education was in place – what more can we
do?
Formal launch in March 2012
Steering Committee/Surgeon champion
Project Coordinator to maintain elements
Pre-operative bathing with chlorhexidine
MRSA/MSSA screening and decolonization
KEY POINTS/SUMMARY
Involve leadership and surgeons
Involve the patient from start to end
Prevent chances for failure
Have to invest:
Financials – Cost of swabbing patients for 1 year = ~ $25,000
Cost of ONE joint SSI = ~$25,000 (NSQIP ROI)
23
What advice do you have for me?
24
QUESTIONS?
2/25/2016 25 Oregon Association of Hospitals & Health Systems
THANK YOU
www.oahhs.org
Susan Stockert-Diskin BSN, RN, CIC Infection Prevention and Control
Legacy Good Samaritan Medical Center 1015 NW 22nd Ave. Portland, OR 97210
Phone: (503) 413-7365 [email protected]
SSI INTEREST GROUP: HOSPITAL PRESENTATION ANNETTE STEFAN
PROVIDENCE ST VINCENT MEDICAL CENTER
February 23, 2016
PROVIDENCE ST. VINCENT MEDICAL CENTER
Community-based teaching hospital: 523
beds • Centers of Excellence:
• Providence Heart & Vascular Institute – 683 cases 2015 includes on /off pump, VAD, valves, CABG
• Providence Brain and Spine Institute
• 5 Operating Rooms: Main OR, CVOR, L&D,
Pediatric OR, Outpatient Eye Surgery • Premature to geriatric care with NICU, PICU;
Adult Critical Care including ICU, CICU and NCCU
• 2014: total surgeries 16,230 (excluding L&D)
• 1,546 total joint procedures (HPRO/KPRO)
28
STERILE PROCESSING
Blip of HPRO SSI Nov/Dec 2014
• Lost FTE, end of year total joint surge, late tray
delivery, bio-burden in processed instruments
• IUSS mainly in joint trays, ~ 8%
• Prep of instruments in OR not occurring, arrive
in decontamination with dried material
• Antiquated washer/disinfectors
• Insufficient EVS serving decon/clean side of
SPD
29
DECREASING SSI RISK- CURRENT
EFFORTS
• Pre-operatively: already in place – Total Joint Class – required for elective procedures
– Optimize co-morbids: Hgb A1c, BMI, skin conditions
– PAC: CHG shower x2, mupirocin for nasal Staph carriers,
Do’s/Don’ts before surgery
– CHG cloth to surgical site in SSU
• After Intra-Op observations by IP: • Standardized surgical prep to ChloraPrep
• Surgeon’s asked to stop wiping prep off with lPA
• Absolutely no personnel changes while capsule is
open
• No entry/exit sign on door to OR during procedure
30
RISK REDUCTION – CURRENT
EFFORTS Intra-op (cont)
• Surgical attire: cover jackets, shoes, including
vendors, anesthesiology
• Vendor presence only when requested by
surgeon and only one
• Culture of mutual accountability, being the wing
man for each other
• Personal electronics policy
• Reinstituted sterile soak basin to keep
instruments moist in the OR
31
RISK REDUCTION-CURRENT EFFORTS
Post op:
• Year 2014, 50% of HPRO SSI r/t hemi-
arthroplasty, readmitted from SNF
• Total Joint Program, Fracture Team & Marquis
collaborated to share practices to reduce post-
op complications, increase efficiencies for SNF
• Additional dressings, etc. sent with patient on
discharge to SNF
• Implemented May, 2015
• 1 re-admission HPRO SSI last half 2015
32
DATA
33
IMMEDIATE USE STEAM
STERILIZATION
34
ACTIONS TAKEN
IP in the OR
IP/ID attended Ortho division mtgs until
resolution of SSI spike
Enzymatic spray to instruments in OR
Monetary investment: SPD FTE, equipment
• Retraining of SPD personnel
• Audits of sterile trays
Corporate: contract revision - tray delivery,
number of trays available, weight of trays
35
KEY POINTS
Be sure you understand what is happening
in your facility; dig, dig, and dig some more
Involve your Director of Infection Prevention
and Quality Specialist in all aspects
Attention to details: pre, intra, post-
procedure
Trace instrumentation processing
Question IUSS usage; what types of trays
are consistently “flashed”?
36
SUMMARY
Look at complex processes and procedures in fine
detail
It takes a village: bring all stakeholders to the table
• Ensure best practices in place/easy for front line
to follow
Seek executive level support when needed
Follow up on action items until firmly in place, then
at re-assessment at regular intervals
37
What advice do you have for me?
38
QUESTIONS?
2/25/2016 39 Oregon Association of Hospitals & Health Systems
THANK YOU
www.oahhs.org
Annette Stefan, BSN, RN, CIC Infection Preventionist
Providence St. Vincent Medical Center 9205 SW Barnes Rd. Portland, OR 07225
503-216-3013 [email protected]
SSI INTEREST GROUP: HOSPITAL PRESENTATION JULIE KOCH
SALEM HEALTH
February 23, 2016
SALEM HOSPITAL
Regional Medical Center • Marion County – 320,000 people
• Polk County over Willamette River
• 454 licensed beds
• Busiest ED in the state of Oregon
• 13-25% Hispanic
• Types of surgery: • Orthopedic/Neurosurgery
• Cardiac
• Bariatric
• General
• OB/GYN
• ENT
• Endoscopy
42
DATA
SSI SIR
43
1.24
0.91
0.31
0.44
0.00
0.50
0.00
0.50
1.00
1.50
HPRO KPRO CBGB COLO HYST LAM
SSI SIRs by Procedure Code
2013Q1 thru 2015Q3
ORTHO DATA
HPRO SIR
44
1.04
0.47
2.70
0.86
1.97
0.34
0.72
2.17 2.08
0.93
0.56
0.00
0.50
1.00
1.50
2.00
2.50
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2013 2014 2015
HPRO SIR 2013Q1 thru 2015Q3
Four Step Problem Solving
45
TESTS OF CHANGE
Pre-operatively • MRSA/MSSA Screening
• Decolonization protocol
• % of patients having joint replacement surgery
that receive reinforcement of teaching points
during pre-op call
• % of vancomycin administered >59 minutes and
<120 minutes prior to incision time
Operative • # times door to OR opens during a total joint
replacement surgery
46
TESTS OF CHANGE
Post-operative • Standard work for OR Cleaning
• Zone cleaning in OR
• UV Light Ortho rooms at terminal clean
Other Issues • Dressings?
• Warmer?
• Vacuum Outlets - ATP
47
RECENT CLUSTER
2 HPRO/ 2 KPRO within 1 week in January
Deep Dive
• Multidisciplinary
• Line Listing all variables
No Smoking Gun
Other
• Vaccum
48
SUMMARY
Use a horizontal approach
Go to the Gemba
Multi-disciplinary
Minimize variation
49
What advice do you have for me?
50
QUESTIONS?
2/25/2016 51 Oregon Association of Hospitals & Health Systems
THANK YOU
www.oahhs.org
Julie Koch, RN, MSN, CIC Manager – Infection Prevention & Employee Health Salem Health 503-561-2606 [email protected]
