MUSC Health: Standardizing Processes —Small Steps Are Key to Preventing SSIs

One Surgical Site Infection (SSI) is one too many for the team at MUSC Health in Charleston, South Carolina. MUSC’s mission is “Do no harm and change what’s possible”; MUSC knows that decreasing SSIs is “an absolute change that IS possible.” Once the health system began implementing their SSI reduction initiatives, numbers improved significantly.

MUSC’s team focused on developing a plan for standardized, sustainable interventions to prevent SSIs and ensure optimal patient outcomes, including:

• The creation of a surgery patient handbook to set expectations and guidance for preoperative, intraoperative, and postoperative care. The handbook includes addendums customized for each surgical service line.
• A hard stop for chlorhexidine gluconate (CHG) was added to the Holding Nurse Worklist to ensure all surgical patients are bathed prior to surgery.
• Guidelines for preoperative management of glucose control was implemented to ensure proper handoff from the Holding Nurse to the anesthesia team.
• An Enhanced Recovery After Surgery (ERAS) protocol field was added to the OR Snap Board to help nurses identify ERAS protocol patients.
• A Red Zone protocol was put into place to reinforce non-distraction during critical portions of the surgical case (i.e., Time Out and Counts).
• An instrument tracking software that uses bar code technology to track the location and movement of Sterile Processing Department (SPD) instrument sets was implemented to help identify opportunities for improvement that lead to optimal patient outcomes.
• Nasal decolonizer is applied in the Holding area for patients identified as being MRSA positive. Postoperative patients are sent home with nasal decolonizer to apply at home to reduce the risk of infection.
• Normothermia management guidelines were created to ensure that patient temperatures are maintained to avoid complications and improve patient outcomes.

The peri-operative quality and safety team worked with risk management to add discrete fields for SSI review into their safety event reporting platform. There are a total of 58 elements included in the report including the patient’s body mass index, wound classification, temperature, antibiotics used, enhanced recovery after surgery protocols followed, and more. Using this dataset, team members can sort information in many different ways to help identify gaps in care and present specific service line or surgeon data for improved outcomes.

The team is currently partnering with three surgical service lines — colorectal, breast oncology reconstruction and general surgery to develop a process to identify diabetic patients preoperatively to optimize glycemic control prior to surgery. A HgbA1c was added to colorectal surgical services pre-surgery lab sets to identify patients who are diabetic or prediabetic. If a patient has a HgbA1c greater than 8 or a point-of-care blood sugar (POC BS) test greater than 180 mg/dL, a referral is placed for “pre-surgery training”. The training helps maximize patients’ health prior to surgery. Patients are followed through chart abstraction to monitor training compliance and to determine if they have maintained safe metrics for a successful outcome.

The program, focused on diabetic patients and, in partnership with endocrinology services, fast-tracks patients identified as having an elevated HgbA1c or POC BS. A handbook specific to diabetes management and surgery training and education was created to both encourage and empower patients to help them achieve their pre-surgery goals.

Moving forward, the team is working to implement Telehealth visits for pre-op surgical patients who are otherwise healthy. Patients with health conditions such as high blood pressure, obesity, and diabetes, are scheduled for in-person Pre-op Clinic visits.

Implementing the SSI interventions has required a strong partnership with the entire MUSC team, including surgical providers, nurses, specialty service line providers, infection prevention and control, anesthesia providers, environmental services, supply chain, lab/pathology, pharmacy, outside vendors, and many others in the inpatient and outpatient setting. SSI reduction has, and will be, a true team sport!

The MUSC Health team recommends standardizing processes to create consistencies in practice that fit into the current staff workflow and are easy to use. “If whatever it is that you are trying to accomplish is too cumbersome or hard to use, staff will not use it or will create work-arounds that fit into their already busy workloads,” said Cheryl Rodriguez, RN, Peri-operative Quality Safety Manager. Starting small and working toward bigger change is key to preventing staff from becoming overwhelmed or resistant to the change. “If you add one rung to the ladder at a time, before you know it, you will be at the top,” Rodriguez added.