Description: Description of team: An interdisciplinary team consisting of Perioperative Leadership, Infection Prevention, Patient Safety, Anesthesia, Pharmacy, Perioperative Nurses, Frontline Nurses, and Surgeons were brought together to create a Surgical Site Infection (SSI) Committee. Preparation and planning: The SSI Committee identified increase in standardized infection ratio (SIR) for total joint surgeries at the end of calendar year 2017. Observations in preoperative, postoperative, and operating room of total joint cases were performed by Infection Prevention, Patient Safety, and Perioperative Leadership and brought back to the SSI Committee to assess opportunities for improvement. No singular opportunity was most prevalent or identified as a root cause to the increase in SSIs and the Committee decided to research joint replacement bundles to standardize care and reduce variation for joint replacement patients.
Assessment: After reviewing literature for best practice, many bundle elements were identified to reduce infection, but no singular joint bundle was readily adaptable for the practice setting. Review of SSI cases also identified opportunity to include care provided outside of the hospital and the decision was made to include the clinic setting in to the bundle. Along with the bundle, patient education, preoperative testing, and preoperative readiness provided by orthopedic clinics was standardized to improve clarity for patients and workflow for the Pre-Registration area. Wound culturing technique in local nursing homes, primary care clinics, and the local Emergency Department was also identified as an opportunity. Calendar year 2017 SIR for knee joint replacement procedures (KRPO) was 2.203, while calendar year 2017 SIR for hip joint replacement procedures (HPRO) was 1.163. The rise impacted fiscal year 2018 rates ending with a KPRO SIR of 2.142 and HPRO SIR of 4.236. Implementation: The bundle was created to follow the patient from the decision point for a joint replacement to discharge from the hospital. Each element was agreed upon by the member of the team representing their discipline and they were expected to champion the bundle as a finished product. The bundle was audited via checklist form, broken down by department, and which member of the team should document identified elements. Audit results were reported to the SSI Committee to evaluate adherence and outcomes. Infection Prevention worked with Marketing and Surgeons to standardize patient education, preoperative testing, and preparation. Wound Care and Infection Prevention educated and demonstrated proper wound culturing technique in Nursing Homes, Primary Care Clinics, and the Emergency Department, providing feedback when contaminated wound cultures were identified. Outcomes: KPRO experienced a SIR decrease from 0.933 for 6 months prior to implementation, to 0.00 for six months after implementation; and HPRO experienced a SIR decrease from 3.705 for 6 months prior to implementation, to 0.00 for six months after implementation. Implementation improved FY 19 SIRS ending with a KPRO SIR of 1.366 and HPRO SIR 1.081. Implications for perioperative nursing: Standardization and evidenced based checklists improve patient safety by decreasing mental burden on members of the healthcare team. While not all bundle elements are nursing driven, perioperative nurses serve a vital role ensuring compliance and keeping our patients safe. Interdisciplinary teamwork involving frontline nurses in best practices results in ownership of the process and improved patient outcomes.
Co-Authors: Amelia Payne, Cayla Wallace, Thomas Alsop