Resisting Surgical Infections
By JANICE FITZGERALD, MS, RN, CPHQ
February 1, 2009
DVT ProphylaxisImprovements in DVT prophylaxis can occur through developing and deploying an order set that incorporate recommendations for mechanical and pharmaceutical prophylaxis based on the American College of Chest Physician Guidelines for screening and prophylaxis for surgical populations. All patients undergoing surgery should be screened for DVT risk before admission, and recommended prophylaxis is a part of the surgical procedure-booking process and, in many cases, started preoperatively. Mechanical prophylaxis is applied to all patients whose surgical procedure is expected to be longer then 30 minutes across all sites (opt-out process).
Real-time review by clinical-effectiveness nurses and hospital case managers will reinforce the process and ensure appropriate prophylaxis on the basis of each patient’s risk.
Localized: Baystate Medical CenterThe results of our work have been impressive — appropriateness of initial antibiotic selection, initially 88 percent, increased after the process redesign and stands now at 98 percent. For administering antibiotics within 60 minutes before incision, the baseline rate was 11 percent. After implementation of the strategies to address timing, the percentage of antibiotics administered within the 60-minute period improved and is currently 99 percent.
Discontinuation of antibiotic therapy within 24 hours after surgery had been our toughest measure to improve, but continued focus, work and redesign has increased our rate to 97 percent from a starting point of 10 percent. DVT prophylaxis was 45 percent when we began and year to date is consistently at 100 percent, as is the continued use of beta blockers in eligible patients. Since we started the SIPP/SCIP, our surgical site infection rates continue to be the lowest in the 15 years we have tracked them, and Baystate Medical Center continues to have the lowest rates among our comparison hospitals.
Early success in both increased rates of process measures and decreased hospital-acquired events have encouraged the team to continue process redesign and have helped sustain interest in the project. Case managers have been key in identifying appropriate patients (such as antibiotic selection and dosing) and interventions preoperatively, as well as prompting for appropriate interventions postoperatively (such as DVT prophylaxis) or accurate documentation in the clinical record to ensure the care is clearly reflected prior to the case being finalized — acting as a veritable safety net.
There is clear evidence that a number of practices can help reduce the incidence of postoperative complications. Hospitals are encouraged to evaluate their existing protocols and processes to ensure that the care delivery conforms to the described standards of practice. Team work, transparency and openness are implicit in our work to ensure continued focus and support from not only the staff that care for surgical patients but from senior leadership.
In addition, mandatory public reporting initiatives provide an optimal stage for case managers to impact not only surgical care provided to patients but the financial bottom line. Overall, this recent evolution has helped to maintain energy and focus and increase awareness and buy-in by all.