Meeting Minutes For Surgical Site Infection Prevention Collaborative

Meeting Minutes For Surgical Site Infection Prevention Collaborative Meeting Date: Time: Tuesday, January 6 th 2009 3:00 P.M. to 4:00 P.M. Leaders: Attendance: Stephanie Randa and Dr. Addison May Vicki Brinsko Susie Leming-Lee Nancye Feistritzer Stephanie Randa Dr. William Obremskey Dr. James Berry Facilitator: Dr. Addison May Dr. Naji Abumrad Dr. Tom Talbot Audrey Kuntz Amy Dziewior Brian Nelsen Dr. LeAnn Stokes Susie Leming-Lee Barbara Martin Lorrie Ingram Oscar Guillamondegui Julie Poulsen Colleen Cassidy Mary Duvanich Donna Nolan Project: Surgical Site Infection Prevention Collaborative Location: Conference Room 3164 MCE Guest/s: Note: Record additional attendance on opposite side Objective(s) of the meeting 1. To review Standardization of Surgical Prep 2. To review SCIP Initiative Progress: Infection Control Database 3. To review SSPIC and AOS Collaboration Progress 4. To review Infection Control Data Report, CDC Surgical Site Infection Database 5. To review UTI Initiative 6. To review Prevention of Unsterile Instrument Use Time Who Topic I. INTRODUCTIONS 2 mins Stephanie Randa/Group A. Introduction of Guest or New Members: Mary Duvanich, Surgical Clinic Representative, Children s Hospital Representative, Dr. LeAnn Stokes, Radiology Representative; Donna Nolan, Perioperative Services, MCVCH. Ms. Randa called the meeting to order and introduced new members Mary Duvanich, Surgical Clinic Representative, Dr. LeAnn Stokes, Radiology Representative, and Donna Nolan, Perioperative Services, MCVCH representative. No further action is required. 2 mins Stephanie Randa/ Dr. May B. Reason for Today s Meeting Ms. Randa provided the reason for today s meeting. II. OLD BUSINESS No further action required. 1. Initiative Directed Toward SCIP Elements Compliance 3 mins Cindy Garcia a. Standardization of Surgical Hand Scrub 1) Protocol, Poster, and Staff Education 1. Ms. Cindy Garcia presented the Surgical Hand Scrub Protocol, poster, and staff education to the Committee members. Ms. Garcia stated she completed a literature search that supports the Sterile Procedure Surgical Hand Scrub Protocol to ensure the protocol is evidenced based medicine. She also stated that the Hand Scrub Poster will be posted at each scrub sink as apart of the staff education. Ms. Garica also stated the Hand Scrub Protocol and practice will be presented to the staff for educational purposes, in a power point educational module that will be distributed electronically through the web-in-service program. No date for distribution of the educational

module has been determined; this date will depend on the approval by the Hospital Quality Council and the Institutional Critical Care Committee. A discussion ensued regarding the extent of the scope of the Hand Scrub Protocol. Ms. Feistritzer indicated the Protocol probably needs to apply to the entire organization, to include 100 Oaks, the Clinics, ICU, etc. Donna Nolan, MCVCH representative, stated the MCVCH does not use Avagard for their hand scrub and asked does MCVCH need to switch to the Avagard product. Infection Control Practitioners indicated that MCVCH should send their hand scrub product to Infection Control Department for further investigation of the current product being used. Dr. Stokes stated that Radiology is currently using the Avagard product. A discussion then ensued regarding the cost of Avagard, with conclusion in the section below. There was a discussion around what would trigger the use of the Hand Scrub Protocol. Ms. Feistritzer stated that the trigger could be a sterile procedure, but no final trigger was determined. Ms. Kuntz discussed the education plan and asked who is the target audience for the Sterile Procedure Surgical Hand Scrub Protocol, is the audience greater than Perioperative Services? Ms. Feistritzer stated that the Hand Scrub Protocol should probably be implemented house wide and that this will be discussed at the Hospital Quality Council meeting and she would provide feedback on the Hospital Quality Council input. The group stated that the Sterile Procedure Surgical Hand Scrub Protocol should be a competency for all employees that perform surgical hand scrubs. 1. Ms. Nancye Feistritzer will present the Surgical Hand Scrub and Poster to the Hospital Quality Committee and ask for input on the implementation and educational scope of the Surgical Hand Scrub. Ms. Feistritzer will also ask for implementation agreement for the Sterile Procedure Surgical Hand Scrub Protocol and discuss the scope of Surgical Hand Scrub implementation from a hospital wide perspective. Ms. Feistritzer will provide the response from the Clinic Administrators at the February 2009 2. Ms. Barbara Martin will present the Sterile Procedure Surgical Hand Scrub Protocol and Poster to the Institutional Critical Care Committee for implementation approval. Ms. Martin will provide the response from the Institutional Critical Care Committee at the February 2009 SSIPC meeting 3. Ms. Nancye Feistritzer will investigate the cost of Avagard product for the entire medical center. Ms. Feistritzer will provide the cost of Avagard at the February 2009 SSIPC meeting 4. Ms. Mary Duvanich will present the Sterile Procedure Surgical Hand Scrub Protocol to Racy Peters and Margaret Head, Clinic 2

administrators for implementation agreement. Ms. Duvanich will provide the response from the Clinic Administrators at the February 2009 5. Ms. Vicki Brinsko will present the Sterile Procedure Surgical Hand Scrub Protocol to the Clinical Practice Policy Committee. Ms. Brinsko will provide the response from the Clinical Practice Policy Committee at the February 2009 6. Ms. Kuntz and the Perioperative Educators will post the Surgical Hand Scrub Posters at each scrub sink and will distribute the Sterile Procedure Surgical Hand Scrub Protocol educational module to Perioperative Services employees. Ms. Kuntz will provide a follow-up on the Surgical Hand Scrub education plan at the February 2009 2) Thank you to Cindy Garcia The SSIPC members publically thanked Ms. Garcia for her work on the Hand Scrub Protocol and for taking her valuable time to develop a process that would prevent surgical site infections. No further actions required. 3 mins Tom Talbot b. Infection Control Database Update 1) Infection Control Data for Pods Update- When Will Data be Available? Ms. Randa asked when infection control data would be available for the Pods. Ms. Brinsko stated that Brian Nelsen is working toward a feed from VPIMS that would allow Infection Control to integrate the VPIMS data with the Infection Control for a more robust data set that would feed into the dashboard of indicators. Mr. Nelsen, who just entered the meeting, stated we do have a VPIMS feed it is clucky, but it works. Ms. Feistritzer asked could the infection control data be obtained at a service line level. Mr. Nelsen asked for a definition of service line level and Ms. Feistritzer stated as an example, Cardiac Surgery, as far as infection rates could Cardiac see what their rates are?? Mr. Nelsen stated yes, those rates would be reflected in SS1 indicator on the In-Site Dashboard. We started the work to understand how to breakdown the data to reflect the Pod paradigm, but we have questions about that, but I think we will be able to do that. There was a question if Children s could also have such data reports and Mr. Nelsen stated, I do not see why not There was a question as to if the Pods could retrieve these data reports now and Mr. Nelsen stated that the Pods need to be defined first before the report can be produced. There was another question regarding Children s gaining access to reports because they are not a Pod. Ms. Randa stated if we could just have the reports by service line, which would include Children s Hospital, we could then ensure the Pods and Children s receive their reports. There was also a question regarding the Cath Lab and EP Lab having access to infection control reports. Mr. Nelsen states that these two areas are not in the infection control data 3

sets yet. 1. Ms. Leming-Lee will send the Pod structure that includes the service lines within the Pods to Brian Nelsen 2. Mr. Nelson will then group the infection control data according to the Pods and provide an example of the report at the February SSPIC Meeting. 2) Centralized Website for Information Sharing-Each Pod Needs to send Representative to IC for Training-Date of Training? There was discussion about how to access infection control reports once they are available and Ms. Randa asked would you go to a website or is there link that would take you to the reports? Mr. Nelsen stated that The agenda item is pending. IC Training will be discussed at the February 2009 SSIPC Meeting when more information regarding IC training is available. 3) VPIMS Feed to I-Cart to CDC Database Update See item b-1 above. The VPIMS Feed to I-Cart to CDC Database is now complete. See Action/Conclusion b-1 above. 4) Benchmarks Added to Database Update There was not discussion regarding this agenda item. Pending further work by Infection Control. 2 mins Stephanie Randa, Dr. May, Brian Nelsen, and VPIMS Programmers c. VPIMS Reports Update 1) Meeting with VPIMS Programmers to Improve Reporting Update: VPIMS/VORS Data Report: Compliance Level for Each Service with SCIP Elements in a User Friendly Format: 1) Add following Variables to the VORS Report Wound Class Level of Case This agenda item will be discussed further at the February 2009 Ms. Randa stated the Meeting with VPIMS has occurred and talks are in progress regarding the SSIPC informatic needs. This agenda item will be discussed further at the February 2009 Ms. Randa stated the Meeting with VPIMS has occurred and talks are in progress regarding the SSIPC informatic needs. This agenda item will be discussed further at the February 2009 2 mins Stephanie Randa d. Aseptic Technique Training: Back To Basics Update (Started in October 2008) Ms. Randa stated that the initial Back to Basics training has been completed and there will be ongoing Back to Basic training as new employees come on board. No further action regarded. 2 mins Stephanie Randa e. OR Attire Policy: Reinforcement of Policy Update Ms. Randa stated all lockers are now in place to begin enforcement of the OR Attire Policy. Education for the OR Attire Policy and the Surgical Hand Scrub is in progress. 4

2 mins Stephanie Randa f. Patient Skin Pre-Op Prep: Use of Sage Wipes for Orthopedic Patient Population Update 1. Ms. Randa and Ms. Kuntz will provide a follow-up report on the progress of the OR Attire Policy enforcement and the Surgical Hand Scrub and OR Attire Policy education plan at the February 2009 Dr. Obremskey stated that the Sage Wipes are not in the Clinic at this time, this step must be in place first to ensure the Orthopedic patient population is knowledgeable of the sage wipes and can use the sage wipes pre-operatively. Education for the use of Sage Wipes for the staff is now on hold until the Sage Wipes are stocked in the Clinics. 3 mins Stephanie Randa and Dr. May g. Prep ( Intraoperative) Standardization Update 1. Ms. Colleen Cassidy will assist in assuring the Sage Wipes are stocked in the Orthopedic clinic 2. Dr. Obremskey will discuss the use of the Sage Wipes at the next faculty meeting and provide a feedback report to the SSIPC members at the February meeting. Ms. Randa stated it is still unclear that all Pods have discussed the standardization of surgical skin prep products,chloraprep or Duraprep. Ms. Randa stated the decision for the dhoice of prep product should be determined by each Pod. Ms. Nolan stated that Children s is Cardiac is using Gel Prep and Betadine. Ms. Nolan asked are you saying we need to use Chloraprep? Ms. Randa stated, we are recommending this prep, but we are trying not to be prescriptive, we are trying to reduce the variation in the type of preps being used. Ms. Nolan will discuss the prep standardization products with the MCVCH Perioperative leadership and provide a feedback report to the SSIPC members on February 3 rd 2009. 3 mins Stephanie Randa & Cindy Brown h. Colorectal Initiative 1) Colorectal Team s Action Plan Update a) Colorectal Order Sets b) Implementation of Sage Wipes (To Start December 8 th 2008) c) Colorectal Patient Responsibility Form d) Scrub Tech Protocol for Bowel Cases 5

e) Colorectal Instrumentation Update- Increase Volume of Scopes f) Bowel Preps and Protocols g) Team Building 0 mins Stephanie Randa/Dr. May (these are active items for review by the Perioperative Enterprise ) 2) Letter Asking for Follow-up Regarding Consultation Site Visits 2. SSIPC and Acute Operative Services, EGS, Trauma Collaboration-Follow-up: Standardization of Practice to Prevent Surgical Infections Issues a. Develop an antibiotic order set that would address the dosing of antibiotics for trauma cases coming form downstairs III. NEW BUSINESS 3 mins Stephanie Randa 1. Use of Unsterile Instruments: Add to In Room Check and Debrief Are Instruments Sterile? What Committee should be responsible for oversight of this issue? 3 mins Stephanie Randa 2. UTI Initiative- Catheter Associated Urinary Track Infection a. Criteria for Placement of Foley Catheter in OR 1) Recommendations to Perioperative Executive Committee: 3 Questions to ask at the beginning of each surgical case: 1) Do you want to insert catheter?, 2) Was catheter inserted per sterile technique? 3) Is catheter to be removed at end of case? 5 mins Stephanie Randa, Julie Poulsen, Colleen Cassidy, Audrey Kuntz b. Education: Instruct and Check-off the 1) Appropriate Use of a Foley Catheter, 2) CA>48 hours, 3) Insertion Using Clean Techniques, 4) Meatal Care (soap/water) for all Staff, Nurses, Physicians who would insert a Foley Catheter. 1 min Dr. May c. UTI Infection Data Needed along with % of Foley Catheters inserted in OR 1 min Audrey Kuntz d. Provide each Pod with Folder Showing all Required Competencies to include Foley Catheter Insertion 1 min e. Add to Time Out in OR the Question: Is there a need to Insert Foley Catheter? 6

Program Question into Electronic White Board 1 min f. Order Set for Removal of Foley Catheter 1 min g. Documentation of Foley Catheter Placement in OR and PACU 1 min h. Assignment of Stephanie Randa to Represent SSIPC on UTI Team 5 mins Mike Hughes 3. Flashing of Instruments Report 3 mins Stephanie Randa 4. Criteria for Silverlon Dressing 5 mins Dr. Tom Talbot 5. Infection Control Data 5 mins Vicki Brinsko/ Tom Talbot a. Longitudinal Infection Control Data Needs 1) Service Specific Data 2) High Risk Groups, ie Hysterectomy, Colorectal, etc. b. Monthly Hospital Infection Control Data Report for November/December2008 5 mins Barbara Martin c. SCIP Data Report 3 mins Barbara Martin d. Out Patient Surgical Procedure Report ( new report to start February 3 rd 2009) 3 mins Dr. May IV. NEXT STEPS Next Meeting Date: February 3 rd 2009 Recorder: Susie Leming-Lee Start Time: 3:00 p.m. End Time: 4:00 p.m. Location: 3164 MCE Signature Line:, Leader of Surgical Site Infection Prevention Collaborative 7