SSI Event Analysis A Team Approach to Preventing Surgical Site Infections Vicki Sweeney, RN, CIC Methodist Hospital Henderson, KY SSI Event Reporting Template SSI Event Reporting Template developed by: Shelby Lassiter, RN, BSN, CPHQ, CIC
North Carolina Quality Center www.ncqualitycenter.org Surgical Site Infections (SSI) According to CDC, 2-5% of patients who undergo surgical procedures will develop an SSI. SSI increases patient days and cost and can potentially lead to increased morbidity. Team Efforts to Prevent SSI
In order to prevent SSI, a team effort is indicated. No longer is the Infection Preventionist the only person to evaluate and initiate strategies to decrease the risk of SSI. More hospitals are taking a team approach to reviewing the process and learning better ways to prevent harm. Event Analysis There are many methods of performing event analysis. Chart Review Post op screening via surgeon or patient questionnaires
Microbiology review * Team evaluation and analysis Teamwork is essential in targeting ZERO Surgical Site Infections (SSI) Team Event Analysis Team event analysis includes staff from: Infection Prevention Pre-op OR PACU Post-op Surgeon
Other individuals as indicated; Team Event Analysis Performing an SSI event analysis allows the team to identify opportunities to prevent SSI that may not be identified by just performing a chart review, such as: Traffic patterns in the OR room Where the surgical clipping is taking place. Preop or in OR Any instruments/equipment where IUSS (Immediate use steam sterilization) was performed Temperature and Humidity issues in OR room Illness among staff, staff shortages, training,
Initial Identification of Patient with SSI Identify patient as having an SSI based on NHSN Definitions Notify members of team that an SSI has been identified Send out SSI Event Analysis Tool to
each area for completion of their section. Schedule time to meet to review and discuss findings (within 7-10 days) SSI Defect Analysis Tool Section 1-Pre-op Phase Ht., Wt., BMI Where is patient living prior to admission? Location and date pre-op teaching done Was patient instructed in the following: Pre-op shower/bath Not to shave operative area for 72 hours prior to surgery? To avoid smoking/tobacco use as far in advance as possible To report any signs/symptoms of infections pre-op to surgeon?
How to properly use CHG cloths? If diabetic, importance of glucose control peri-operatively? Importance of hand hygiene for self, visitors and hospital staff? Was pre-op MRSA/S. aureus surveillance testing performed per protocol? Was skin assessed pre-op for boil or other skin lesions/rashes? Were abnormal pre-op assessment labs reported to surgeon? Listing of pre-op medications Pre-op HA1c (if diabetic) Highest pre-op glucose How was skin prepped? Shaved? Clipped? No hair removal? Any social or language barriers identified? SSI Defect Analysis Tool: Section 2 OR and PACU
Date of Surgery including day of the week Type of Surgery Surgeon(s) Was surgery Emergent? Urgent? Elective Was Foley inserted in OR for surgery ASA Score and Wound Class Incision cut times: Start and Close Pre-op Antibiotics: Type and Dose (If cut time 3 hours, was antibiotic re-dosed)? EBL or any blood/blood products given in OR? Tourniquet Time (if used) OR Room Number Date last room air exchange measured prior to date of surgery with number of air exchanges Any problems with maintaining appropriate humidity and temperature in OR room on date of surgery?
Any issues with equipment? Any breaches in sterile field/protocol? Any technical difficulties during case? Anything flashed sterilized for case? Patient lowest temp., lowest SaO2, Highest glucose level in OR and PACU What skin prep solution was used prior to surgery? Maximum number of people documented as being in room during case. Vendors? Students? SSI Defect Analysis Tool: Section 3 Post Op Area(s) List all locations for patient post-operatively Any antibiotics given post-op? List date antibiotics stopped Date of 1st dressing change 1st dressing changed by whom?
Was sterile technique used to change dressing? Type of dressing applied with first dressing changed Was urinary catheter in after leaving PACU? If so, list date discontinued Any wound drains post-op? If yes, list date drains removed. Lowest temperature for 1st 24 hours post-PACU Lowest SaO2 for 1st 24 hours post-PACU Highest glucose level for 1st 24 hours post-PACU and highest glucose for POD 2 Did patient return to OR during index procedure admission? If so, when? Any social or language barriers identified? Any post-operative events that were out of the ordinary? SSI Defect Analysis Tool:
Section 4 Infection Prevention Number of days between surgery and first signs/symptoms of infection Was patient readmitted? Signs and symptoms of infection at time of presentation Cultures taken? Date and organism identified. MDRO? Type of SSI: SIP, DIP, Organ Space Risk Factors present pre-index procedure: Diabetes Hyperglycemia w/o formal diagnosis of DM Immunosuppressive medication or diagnosis Tobacco use (smoker, chewer, dipper, etc.) Untreated remote infection (s) pre-op Positive pre-op MRSA screening or past history of MRSA Did patient develop any infections other than SSI post-operatively?
Identify which staff were notified with date SSI Defect Analysis Tool: Section 5 Contributing Factors (All areas to complete) Answer questions as accurately as possible, elaborating as needed. If any issues are identified, try to determine why they occurred, asking Why at least five times to drill down to root cause. Communication Was verbal and written communication during hands off clear, accurate, clinically relevant and goal directed? At time of transfer onto unit? At time of transfer to another unit if applicable? At time of discharge to receiving facility or to patient/family if going home?
Looking back on the case now, were there any opportunities to prepare the patient better for discharge? Was staff comfortable expressing concern about patient safety issues? To management? To physician? Did attending physician provide clear instructions to the team? To patient and family/significant other? ANTIBIOTICS, INCISION CARE AND INFORMATION AVAILABILITY Was there a clear protocol for pre-op antibiotics to be administered in a timely manner? Was antibiotic protocol based on current evidence-based medical science?
Weight based? When was the antibiotic protocol last reviewed? Was there a clear protocol for incision care and dressing application/removal/changes? If so, was it followed? Was dressing change protocol based on current evidence-based medical science? When was the policy last reviewed? Were test results available in a timely manner to help make care decisions? Were test results accurate? Did computer system(s)/software generate any errors? Did the computer system(s) software malfunction? Was there any user error in use of computer system(s)/software? TRAINING AND EDUCATION FACTORS Was surgeon knowledgeable, skilled, and competent?
Were there any observed surgical technique issues? Were other team members (including vendors in OR) knowledgeable, skilled, and competent? Did surgeon and team follow established protocols? Did team members seek supervision or help appropriately? CAREGIVER FACTORS Were any caregivers observed to be fatigued during care/surgery? What was staffing like on the unit during the patients stay? Did the caregivers outlook/perception of own professional role impact on this outcome? (e.g. ego
issues, fear of confrontation, etc.) Was physical or mental health of any caregiver a factor in this outcome? ENVIRONMENTAL FACTORS Was there any construction or remodeling of any type going on in the area during this patients stay in your area? If so, describe: Were there any housekeeping issues during this patients stay that may have impacted the outcome? What are cleaning protocols for an occupied bed in your area? For room cleaning between patients? Was there adequate equipment and was it in good working order?
What are the equipment cleaning protocols in your area and how is cleaning between patients assured? How did workload impact care during this patients admission on your unit? Any other organizational factor(s) you can think of that may SSI Defect Analysis Tool: Sect. 6--ANALYSIS SSI Defect Analysis Tool: Section 6 - Analysis Review data collected and list below the contributing factors to this SSI. Rate each factor on its importance to this event and future events. Contributing Factors Importance to
Importance to future current event 1(low) events 1(low) to 5 to 5 (high) (high) INTERVENTIONS ACTION PLAN STRENGTH OF INTERVENTIONS Strength of Interventions Weaker Actions
Intermediate Actions Double check Checklists/Cognitive aide Stronger Actions Architectural/physical plant changes Tangible involvement and action by Warnings & labels Increased staffing/Reduce workload leadership in support of patient safety New procedure, memorandum or
Simplify the process/remove unnecessary Redundancy policy steps Enhance communication (read-back, Standardize equipment and/or process of Training and/or education SBAR, IPASS the BATON, etc.) care map Software New device usability testing before Additional study/analysis enhancement/modification purchasing Eliminate look alike/sound alike(s) Engineering control (forcing functions)
Eliminate/reduce distractions Adapted from John Gosbee, MD, MS Human Factors Engineering INTERVENTIONS AND ACTION PLANS The analysis, interventions and action plan should be shared with staff and physicians. SSIs should be monitored and reported to physician and staff committees. Additional meetings to evaluate interventions should be scheduled ,as indicated, by surveillance or requests from team members, staff or physicians.
Summary While the form looks very time intensive, it is not, as each person completes their own section. It allows the team members to identify areas they might not have considered and allows for a process to assure that the
procedures we have in place are being followed. Changes in practice that were identified during event analysis have led to decreased SSI infections and provides more emphasis on prevention and evidence based practice. Physicians have been supportive of the process as it has helped to prevent SSI. It is a great way for the Infection Preventionist to develop relationships with staff and work toward a common goal. A TEAM APPROACH TO PREVENTING SSI A team approach allows staff to identify opportunities for improvement and provides our patients with a safe environment in which to receive their care.
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