SSI SERHA Charter

Safer Health Care Now SSI (Surgical Site Infection Prevention)

DRAFT PDSA: Plan Do Study Act

Project Name: Safer Healthcare Now SSI (Surgical Site Infection Prevention) Act Plan

Team Leader: Nurse Manager PACU/Perioperative Clinic/Surgery Admissions Study Do Team Members: Nurse Manager, OR RN, OR RN, OR Clinical Resource Nurse, OR RN, Perioperative Clinic/Surgery Admissions Anaesthesiologist Administrative Director, Surgery Program Infection Control RN

E Purpose of Project: R A  To improve quality of care delivered to patients during surgery by reducing the risk of Surgical Site Infections T

A  To increase the reliability and predictability of performing three components of care: optimal use of prophylactic antibiotics; appropriate hair H removal; and normothermia. W

E  To spread improvements from the test populations to all surgical populations W G N

I Goal Statements:

Y Achieve 95% or higher in implementing the 4 components of care for patients undergoing surgical procedures: R

T  Prophylactic antibiotic administration within 60 minutes prior to surgical incision O T

I  Prophylactic antibiotic discontinued within 24 hours after surgery end time L

P  Appropriate clipping pre-operatively as close to incision time as possible (not razor shaving) 0 M  Maintain normothermia (36 C) peri-operatively for patients undergoing colorectal surgery O C C A ? H S

Surgical Procedure: ______?

T Measures: Status: Date Aims: N

E 1. % surgical pts. with 1. 1. Achieve

M prophylactic antibiotic 95% or E

V administration within higher O

R 60 mins. prior to P incision M I 2. % surgical pts. 2. 2. Achieve N A

whose prophylactic 95% or S I

antibiotic(s) were higher E discontinued within 24 G

N hrs. after surgery end A

H time (48 hrs. for cardiac C surgery) A 3. % surgical pts. with 3. 3. Achieve W

O hair clipped or no hair 95% or N

K removal higher

E 4. % colorectal surgical 4. 4. Achieve W pts. with Temps =>360C 95% or L L

I post-operatively higher W

T Ideas for Change: A H W

S Prophylactic Abx. Timing and Discontinuation: E  Designate responsibility for pre-op prophylactic Abx. Administration (Circulating Nurse/Anesthesia/Hold Room RN) connected to key point in G

N process A

H  Standardize administration process to occur with commonly performed activity within 1 hr. prior to incision (2 hrs. for vancomycin) C

E  Develop system where Abx. is hanging at head of pts. bed ready for administration W  Ensure systematic documentation of Abx. Administration on every pt. chart (stamp on peri-operative record) N

A  Provide feedback on prophylaxis compliance data monthly C

E  Involve pharmacy, infection control & infectious disease staff for their input & involvement K

A  Standardized departmental standing orders specifying antibiotic, timing, dose and discontinuation M T

A Hair Removal: H

T  Perform hair removal when necessary with clippers right before surgery (Surgery Admissions or OR) L

L  Remove all razors from the OR I

W  Use reminders (signs, posters) N I

L Normothermia (Colo-rectal Surgery):

S  Offer Warm blankets, etc in Surgery Admissions and Holding Room to limit heat loss in pts. prior to operative procedure; keep at 36 C

R  Standardize use of warming devices to ensure pt. temp 36 C perioperatively E

V  Standardize temperature monitoring method intraoperatively

O  Provide devices & protocol for consistent measurement of pt. temp R P  Allow surgical staff to control room temp M I

?  Use warmed forced-air blankets during surgery and in PACU T

N  Use warmed IV fluids E  Use warming blankets under pts. on the operating table M  Use hats and booties on pts. perioperatively

Roles & Responsibilities of Team Members:

Team Leader – Overall leadership of team  Facilitating and keeping track of PDSAs, measurement data  Communication link with team and others  Assist with reporting

Team Members: Work with TL and team to facilitate cycles and communication with stakeholders Participate in process to collect measurement data.

OR RNs: Assist with test cycles, measures and reporting

Anesthesiologist: Liaison with anesthetists and communication link with team and others Input to ideas for change and clinical process

Perioperative Clinic/Surgery Admission RN: Assist with data collection, interpretation and input

Meeting Schedule: Standard monthly meetings Safer Healthcare Now website & conference calls – www.saferhealthcarenow.ca

Author: Beth Kennedy Date: September 2006