Working Towards Eliminating Surgical Site InfectionsJason Parkvold RN, BSN and Diane McDougall RN BA, BSN

SUNRISE HEALTH REGION

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Faculty/Presenter DisclosureFaculty: Jason Parkvold RN, BSN and Diane McDougall RN BA, BSN

Relationships with commercial interest: • Warming Devices for trial (3M)• Dressings for Trail (Convatec)

Disclosure of Commercial Support• This program has received in-kind support from [3M Canada] in the form of

[Educational training and warming equipment for trial]

• This program has received in-kind support from [Convatec] in the form of [Educational training and two boxes of dressings for the trial]

Potential for Conflict(s) of Interest: • [3M Canada and Convatec][developed/licenses/distributes/benefits from the

sale of] a product that will be discussed in this program: [Bear Hugger Warmers and AQUACEL Surgical Dressings]

Mitigating Potential Bias• No financial incentive has been provided to either of the presenters. Only the

equipment or supplies used during the trial were provided to the health region by either company. Contracts are in place to purchase any supplies found beneficial after the trials ended.

Who are we?•We are a medium sized health provider in Eastern Saskatchewan.•We service a population of approximately 60,000 people within the health region. •We also provide surgical services to a large area of Western Manitoba.

Why did Sunrise undertake this the Surgical Site Infection (SSI) project

• We set out to reduce the issues of time and suffering that patients endure with a post surgical infection. • As well we wanted to look at

ways to reduce the unnecessary use of health region resources to treat people who develop a Surgical Site Infections by stopping them from occurring.

How do you Identify the issues?

• We used the Canadian Patient Safety Institute SSI bundle.• SSI indicators that were being used to identify infections Provincially,

Nationally and Internationally. • Set up surveillance standards based on the criteria found in this

research. • Talked with Staff and Physicians.

Where did we begin?

• We picked the two high risk surgeries noted in the literature that we perform. Colorectal surgery and Caesarian Sections. • We did a 6 month retrospective data

analysis of all of these surgeries from 2010 so that we could have a baseline to compare our ongoing surgical data. • We began monthly auditing of all

cases in these two surgical categories.

What did we find?• We found trends that needed work:• Inter-operative temperatures were being

recorded infrequently and many of our patients were hypothermic after surgery• Rates of infection were higher in our clean

(little or no bacterial contamination) surgical cases than our dirty (Moderate to High contamination ) surgical cases• We rarely gave patients prophylactic

antibiotics within the hour prior to the initial cut being performed

What did this lead us to do?• We first focused on our temperature

readings• We instituted a policy that stated any

surgery over 30 minutes would require an inter-operative temperature to be taken.• We provided the surgical team with

esophageal temperature probes• With the data from these successes we

were then able to assess that approximately 20-25 percent of our patients were hypothermic in any given quarter of the year.

• We then looked at what we were doing to keep these patients warm• We gave warmed fluids• Covered them with warmed

blankets• The temperature of the theaters

is very difficult to regulate so it tends to vary through out the year depending on the external temperature• We had a warming blanket

placed on the table under the patient’s back

• None of these interventions was enough to stop 20-25% of our patient population from coming out of the theater cold• We looked at what other systems

were available to help us keep the patients warm• We found that the current company

whose equipment we had in the theater made a total body warming device “Bear Paws units”• We decided to trial it to see what

kind of difference it would make

25

75

Hypothermic Patients Throughout the Surgical Pro-

cedure

HypothermicNormothermic

•We ran a trial on 30 clients•We used our normal

temperature monitoring protocol on all of these clients• These clients could be

warmed prior to surgery, while surgery occurred and post surgery

• What we found was that 90% of clients maintained normal body temperature 36-38 degrees • Of the 10% that did not maintain

normal body temperature only one client was hypothermic through out the inter-operative period• All clients (100%) prior to

leaving recovery had returned to the normal body temperature range

10

90

Normothermia during the Surgical Procedure

HypothermiaNormothermic

Antibiotics within 60 minutes

• We also focused in on timely antibiotic administration• This was noted to be an issue

and was the focus of one of our first Mistake Proofing Projects• What was found was that we

were providing antibiotic prophylaxis to our surgical patients within 60 minutes to less than 30% of our patients

30

70

Prophylactic Antibiotics

Within 60 MinutesOutside 60 Minutes

Why was this?

• Well it was a combination of issues• Different standing order sets

from our surgeon’s• The use of multiple antibiotics

prior to surgery• No consistent method of

informing the unit preparing the patient of the time patient would enter the theater

What did we do?

•We standardized order sets for Colorectal and C-Section procedures for all surgeons•We tried multiple PDSAs on the best method of communicating when patient will be entering theater•We started using surgical pause to ensure antibiotic started prior to incision

• We did multiple sets of staff and physician education on why it was important to have the antibiotics delivered within 60 minutes• We had pharmacy research

appropriate drug administration rates for the staff so that they could meet the time requirements with multiple drugs• As of Dec 2013 our rate of

appropriate antibiotic prophylaxis is now 93% and we continue to look at ways to improve this number.

93

7

Propholactic Antibiotic Rate

Within 60 MinutesOutside 60 Minutes

Wound Management • Our final improvement process has

been to trial alternate dressings for our C-Section patients• The reason for this is that a C-Section

should never be a dirty procedure• This surgical category consistently

had our highest rate of Surgical infections• The majority of these infections were

superficial infections

• Looking at the indicators for this procedure it became clear that two indicators showed up on the majority of the SSI cases• The indicators were weight

above 70 KG and removal of dressing within 24 hours• As well most of these cases were

discharged home within 48 hours of the procedure occurring

• Since most of the infections occurred within 7-10 days of the procedure what could we do?• Our current practice at the time

was to apply a standard dressing and generally remove it at 24 hours• This wound would then be

cleaned and have a dressing spray applied• The patient would then generally

be discharged home

• A search of the current literature was done as well as discussions with other health regions around the province• What was found was that there

was no set protocol for wound management within the literature let alone the province• Through the search of the

literature what was found was a dressing that allowed good mobility, was waterproof and provided a physical barrier

How could we change this process?

• We could look for a dressing that stayed intact for a longer time period• One that was an active barrier to

bacteria and waterproof so that it would allow the patients to have an active lifestyle once discharged• A trial of the “Aquacel” dressing

was planned

• One surgeon trialed the dressing while the other two Obstetricians decided to maintain their current practice• They provided us with wonderful groups to compare the results• In the trial group we had 15 surgeries. Out of this group we had 1

infection and this dressing we had difficulties getting proper adhesion of the dressing.• In the current practice group we had 17 surgeries and 3 infections.

1

14

Trial Patients

InfectionsTotal Cases

3

14

Current Practice

InfectionsTotal Cases

• The difference in the rate between the two surgical groups was 62% more surgical infections for the current practice. • Since running this trial we have had a second Obstetrician and a

locum Obstetrician start using this dressing. • As well we have had interest in our General Surgery program in

starting to use this dressing in our abdominal cases with an open incision.

What has been the impact of these changes?• We have had comments from patients:• “I have never before came out of surgery and been warm”• “I couldn’t even tell where my incision was as there was no redness

along the spot where they cut”• “ The dressing allowed me to shower when ever I wanted to once I

got home”

• Staff comments:• “The dressings are easy to use”• “The warming device is easy to control and can be turned off once

patient maintains normal temperature in the recovery period”• “I am seeing good wound bed healing in my office on follow up visits”• System improvements:• Noted reduction of C-Section infections in the quarter the dressing

trial was conducted

Cost savings for treatment of each one of those infections:• The reduction of at least one

antibiotic prescription• The reduction of at least one

Physician/Outpatient visit• Not needing Home Care Services

providing wound care• Not incurring a readmission

and/or a possible further OR procedure

• 2 Dollars – 380 Dollars Per Prescription• 33.20 Dollars – 230 Dollars Per

visit• 20 Dollars – 300 Dollars Per visit• 418 Dollars – 1319 Dollars Per

bed day (not including treatments)• All Costs are ranges: actual cost

will vary

Sooner Safer Smarter – Patient First :

• Saving to the patient:• No Extra lost work time for the patients due to an infection after

surgery• No costly trips for additional health care services• No additional stress about the ongoing healing process

Questions?Contact Me:

Jason ParkvoldSunrise Health Region

Clinical Improvement Facilitator

jason.parkvold@shr.sk.ca

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