Reducing Surgical Site Infections through Standardization and Process Improvements

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Patient Safety and Quality

Todd Schneider
Improvement Advisor / Management Engineer
Tallahassee Memorial Healthcare

One organization made dramatic improvements in publicly reported measures associated with Surgical Site Infections and prophylactic antibiotic administration. In the pilot group, 100% of patients received antibiotics within one hour prior to surgery. Learn techniques to improve your organization's performance through standardization, reliable systems, and influencing surgeon behavior.

Tallahassee Memorial worked to improve measures associated with Surgical Site infections. Three measures are reported to CMS that will ultimately be reported to the public. Currently, these measures are: Prophylactic antibiotic administration within one hour prior to surgery, appropriate antibiotic selection, and discontinuation of antibiotics within 24 hours. As part of this project team, we also focused on appropriate hair removal, glucose control, and normothermia. The outcome measure that was tracked was days/cases between infections. To make improvement, small and rapid tests of change were used. The first area of testing was related to antibiotic administration prior to surgery. We tested multiple methods to meet the appropriate period, standardized the process across all procedures, and used data to convince surgeons that we could perform reliably for all cases. We started at a baseline (Sept 04) of 70% in our pilot group and improved to 100% in May 2005. We worked with our pharmacy to create guidelines for appropriate selection to educate surgeons and nurses. We also worked to change order sets to reflect the recommendations. We have recently begun testing changes related to discontinuation. We have achieved 100% in hair removal and normothermia.