Organization: MedStar Franklin Square Medical Center Solution Title: Reduction of Peripheral Vascular Bypass Infections in the Vascular Operating

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1 Organization: MedStar Franklin Square Medical Center Solution Title: Reduction of Peripheral Vascular Bypass Infections in the Vascular Operating Room Project Description: The purpose of this project is to reduce peripheral bypass surgical site infections in the vascular operating room (OR). Prior to project implementation, the rate of infection (SSI vascular bypass patients / total vascular bypass patients x 0) in our vascular OR ranged from 5 percent to.2 percent in This rate exceeded the National Healthcare Safety Network (NHSN) pooled mean of 6.93 percent and was greater than the 50 th percentile of An interdisciplinary team concerned about the increased infection rates, increased patient length of stay and resulting financial burden to both patient and hospital and adverse impact on overall patient outcomes was established to reduce the peripheral vascular bypass infection rate to at or below the national average of 2.7 percent set by the NHSN. Process: The interdisciplinary taskforce established to evaluate the infection rate in the vascular OR included the Infection Preventionist Nurse, the Director of the Surgical Service Line, the Chief of Infectious Disease, the Chief of Surgery and the Specialty Resource Nurse (SRN) for the vascular and endovascular surgical area. Team members evaluated research evidence supporting applicable policies, procedures, and protocols implemented in the vascular OR. Additionally, type and frequency of infections and OR surgical staffing and instrumentation were explored for commonalities, patterns and trends. To further understand current practice, the SRN observed and documented infection control practices of the vascular surgical team. She validated that Surgical Care Improvement Project (SCIP) measures including use of prophylactic antibiotics within one hour before surgical incision, appropriate antibiotic selection, use of hair removal clippers were being followed. However, the two preoperative showers using 4% chlorhexidine gluconate (CHG) had not been implemented due to cost burden on the surgeons offices. Additionally, the SRN found inconsistencies in surgical skin preparation methods and duration of applicator use, and noted many practitioners following wrong practices for prepping femoral site. Finally, staff had not been wearing a sterile gown during prep but were now required to wear a sterile gown to control fallout of skin flora from the arms of the person performing the skin prep. Solution: To accomplish this goal, the SRN first led a review of the literature in early 20. Through this review, she identified the 20 AORN Standards, Recommended Practices and Guidelines as the highest level of evidence available to guide this project. She shared these results with the taskforce. The SRN, as the clinical lead for this project, compared the hospital s current policy with the guideline recommendations. While all AORN recommendations were pertinent to reducing surgical site infections, the SRN focused primarily on Recommendation #1: patients should have two CHG showers before surgery. Building on the current evidence provided by the AORN guidelines, the SRN developed a standardized approach to skin prep for patients undergoing a vascular surgical procedure and presented this to the OR taskforce.

2 The prep included the following: 4% CHG scrub required for every bypass, endovascular abdominal aortic aneurysm and open abdominal aortic aneurysm Use of multiple Chloroprep applicators to cover the body surface area of the incision, and groin prep in case a post-operative angiogram is required A thirty-second scrub for clean sites and 2-minute scrub for dirty sites Wearing of a sterile gown by staff during the skin preps to reduce skin flora from sloughing off the arms of the staff The SRN presented this scrub protocol based on the AORN guidelines recommendations to the taskforce in early 20. The taskforce concurred with the recommendations and the policy and practice were changed to incorporate these recommendations The program was fully implemented in June 20. In order to ensure that all staff were aware of the revised surgical scrub in the Vascular OR, the SRN conducted 1:1 inservices with each vascular surgical operating room nurse. The updated eight step surgical prep in-service included a demonstration by the SRN, an opportunity for the the staff to perform the surgical scrub with the SRN collaboratively, and for the surgical nurse to complete the surgical scrub independently. This same 1:1 return demonstration process was completed with all newly hired Operating Room RNs who completed and signed a checklist. Additionally, this information was reviewed at Vascular OR staff meetings. Measurable Outcomes: The Vascular Surgery Infection Rate chart attached depicts the results. Prior to implementation of the skin prep protocol in the Vascular Operating Room, the rate of vascular surgical site infections ranged from 5.0 to.2%. The program was fully implemented in 20 and the rate of surgical site infections dropped to a range of 0 to 4.0. When an aberrant spike is identified, the SRN monitors practice and reviews the procedure with staff. Gains have been sustained in the improved surgical site infection rate in 20, 20 and 2013 YTD. These results fall well-below the national benchmarks established by NHSN. Sustainability: The skin prep protocol is firmly embedded into the culture of the vascular surgical area. OR policy has been updated to reflect the new protocol. Annual competencies are conducted to ensure staff competency. Results continue to be benchmarked internally and against national norms. The protocol and results have been published in the Journal of Vascular Nursing to improve surgical infection outcomes of vascular patients everywhere. Hospitals have contacted our organization for guidance in implementing this protocol. Role of Collaboration and Leadership: This initiative received tremendous support from the Infection Control Committee, the Chief of Surgery, and the leaders of our operating room by supporting this program implementation, including time for staff education. Innovation: There was a dearth of literature regarding best practices for reducing infections in vascular surgical patients prior to the development of this protocol. The protocol developed by the Vascular SRN is unique in establishing best practices for preventing and reducing vascular surgical site infections in an acute care hospital OR.

3 Tools and Resources (selected): Association of Operating Room Nurses, (2013). Perioperative standards and recommended practices. Colorado: AORN. Emuna,J. & Kisner,D. (20). Surgical site infection initiative: Implementations and observations, November 20, Journal of Vascular Nursing, 24(1), doi:.16/j.jvn Mu, Y., Edwards, J., Horan, T., Berrios-Torres, S., Fridkin, S. (20). Improving risk-adjusted measures of surgical site infection for the national healthcare safety network. Infection Control Hospital Epidemiology, 32(), Doi:.86/ Contact Person: Jennifer Emuna, RN,CNOR Title: Assistant Nurse Manager, Vascular and Endovascular Surgery Phone:

4 Vascular Bypass Surgical Prep Process Supplies Needed: Chlorhexadine 2% wipes, Chlorhexadine 4% prep kit, Chloraprep, Sterile gown, Sterile gloves x2 In pre-op holding area: Circle Yes or No when action when completed Yes No 1. Ensure patient receives groin and leg hair clipping, if needed. Yes No 2. Chlorhexadine 2% wipes umbilicus to ankle operative leg; to knee on non-operative leg. If AAA or Aorta-bi-fem nipples to knees. In operating room: Circle Yes or No when action completed Yes No 1. After intubation insert foley catheter Yes No 2. Open Chlorhexadine 4% (CHG 4%) prep kit. Yes No 3. Raise leg and put into candy cane stirrup, if needed Yes No 4. Don sterile gown and gloves Yes No 5. Lay down drip towels from kit, and extras, if needed Yes No 6. Clean umbilicus with sterile Q-tips, and CHG 4 %. Yes No 7. With the CHG 4% - begin distally on the leg(s), advancing up the leg circumferentially to just above the knee, discard sponges. Take more sponges, clean the thigh up to the proximal portion. Obtain more sponges clean the abdomen, side of hip, and then to the groin once the groin is touched go nowhere else with the sponges. For the opposite leg also begin distally anterior surface only, thigh, side of hip and finally to the groin once again once the sponges touch the groin go nowhere else with the sponges. Yes No 8. Pat dry with towels from prep kit. Yes No 9. Remove gloves. Yes No. Open three to four Chloraprep applicators for distal bypasses, AAA s, Aorta-bi-fem s, and two for fem-fem s, and some ileo-fem s. Yes No. Don another pair of sterile gloves. Yes No. Prep in the same order as the pre-scrub. If peripheral bypass, distal incision site first, for thirty seconds, scrubbing back and forth with friction, then circumferentially ankle to above knee. Yes No 13. Obtain new Chloraprep applicator prep thigh and around lower hip up to abdomen closing in on the groin two minute scrub on groin site, being careful not to take prep stick to any other area, only after two minute scrub swipe down inguinal fold. Yes No 14. Prep the non-operative leg beginning at the knee, proceeding up leg, to abdomen, closing in on groin area, two minute scrub, then down inguinal fold. Yes No 15. Carefully remove drip towels and discard. Ready for draping. Signature: Date:

5 6 MedStar Franklin Square Peripheral Bypass Surgical Site Infection Rates, CY PV Bypass Surgical Site Infection Rate Full program implementation June 20 Infection Rates NHSN 50th Percentile NHSN 25th Percentile Infection Rates NHSN 50th Percentile NHSN 25th Percentile Linear (Infection Rates)