Marshfield Medical Center – Marshfield
Reports
2023
Surgical Site Infection Reduction in the Outpatient Surgery Department
Surgical site infections (SSIs) are the most common health care-related complication. These develop in 2-5% of the more than 30 million patients undergoing a surgical procedure every year. This complication delays the healing process and can consequently keep patients from returning to work and their everyday lives. It is also associated with increased costs and a higher risk of postoperative mortality.
Following the National Health and Safety Network (NHSN) guidelines for identifying a SSI, Marshfield Clinic Health System’s Infection Prevention noted 11 SSIs in the NHSN BRST (breast) category from 11/2018 to 10/2019 in procedures spanning anywhere from a lumpectomy to breast reconstruction with an implant.
Infection Prevention began an investigation into the BRST SSIs in the fall of 2019 to identify areas for improvement. This involved a thorough examination of medical records and direct observation of BRST cases in the operating room (OR). During the record review it was noted that 100% of the patients had low body temperatures throughout surgery and 50% of the patients who had a culture collected grew bacteria that was resistant to the pre-operative antibiotic. In most cases this was Clindamycin, which was given due to allergy concerns. A bit surprisingly, none of the patients were diabetic (See Figure 1.)
Infection Prevention presented the findings from the record reviews and direct OR observations with recommendations to the surgery team in the winter of 2020. Several initiatives were implemented that included chlorhexidine gluconate bathing prior to surgery, maintaining normothermia, antibiotic stewardship, and limiting OR traffic (including not allowing relief of the surgical technologist during handling of breast implants).
Even with the challenges brought by the COVID-19 pandemic the Outpatient Surgery Center team has been successful in making significant improvements in the number of BRST SSIs with only two SSIs identified in 2022.
Following the National Health and Safety Network (NHSN) guidelines for identifying a SSI, Marshfield Clinic Health System’s Infection Prevention noted 11 SSIs in the NHSN BRST (breast) category from 11/2018 to 10/2019 in procedures spanning anywhere from a lumpectomy to breast reconstruction with an implant.
Infection Prevention began an investigation into the BRST SSIs in the fall of 2019 to identify areas for improvement. This involved a thorough examination of medical records and direct observation of BRST cases in the operating room (OR). During the record review it was noted that 100% of the patients had low body temperatures throughout surgery and 50% of the patients who had a culture collected grew bacteria that was resistant to the pre-operative antibiotic. In most cases this was Clindamycin, which was given due to allergy concerns. A bit surprisingly, none of the patients were diabetic (See Figure 1.)
Infection Prevention presented the findings from the record reviews and direct OR observations with recommendations to the surgery team in the winter of 2020. Several initiatives were implemented that included chlorhexidine gluconate bathing prior to surgery, maintaining normothermia, antibiotic stewardship, and limiting OR traffic (including not allowing relief of the surgical technologist during handling of breast implants). Even with the challenges brought by the COVID-19 pandemic the Outpatient Surgery Center team has been successful in making significant improvements in the number of BRST SSIs with only two SSIs identified in 2022.
Reduction of IV Thrombolytic Door-to-Needle Times for Acute Ischemic Stroke Patients
Because stroke is a leading cause of death, the American Heart Association and American Stroke Association have implemented the national quality improvement initiative, “Target Stroke,” to improve the care of stroke patients. Target Stroke focuses on reducing door-to-needle times in acute ischemic stroke patients and on increasing the portion of eligible patients who receive “clot busting” thrombolytic therapy within 60 minutes after hospital arrival.
To maximize the clinical benefit for the acute ischemic stroke population, Marshfield Medical Center began a focused initiative to shorten door-to-needle time for IV thrombolytic administration. The project was led by the Stroke Performance Improvement Team and required a collaborative effort by clinicians from neurology, emergency medicine, radiology, laboratory, pharmacy, EMS and administrative staff.
To decrease the overall time from patient entry to IV thrombolytic administration within the 60-minute “Target Stroke” timeframe, the following Code Stroke time goals were set, and each phase of the process was examined to identify improvement opportunities to meet these goals:
Code Stroke Time Goals:
Door to MD - 5 minutes
Door to Code Stroke - 10 minutes
Door to CT - 15 minutes
Door to CT Report - 25 minutes
Door to ISTAT PT/INR - 20 minutes
“Code Stroke” protocol modifications were made to help achieve these time goals.
To maximize the clinical benefit for the acute ischemic stroke population, Marshfield Medical Center began a focused initiative to shorten door-to-needle time for IV thrombolytic administration. The project was led by the Stroke Performance Improvement Team and required a collaborative effort by clinicians from neurology, emergency medicine, radiology, laboratory, pharmacy, EMS and administrative staff.
To decrease the overall time from patient entry to IV thrombolytic administration within the 60-minute “Target Stroke” timeframe, the following Code Stroke time goals were set, and each phase of the process was examined to identify improvement opportunities to meet these goals:
Code Stroke Time Goals:
Door to MD - 5 minutes
Door to Code Stroke - 10 minutes
Door to CT - 15 minutes
Door to CT Report - 25 minutes
Door to ISTAT PT/INR - 20 minutes
“Code Stroke” protocol modifications were made to help achieve these time goals.
- Pre-hospital notification by EMS.
- Education provided to EMS providers and medical transporters regarding warning signs and recommended EMS response to suspected stroke.
- Activation of “Code Stroke” team via pager.
- Stroke patients triaged directly to the CT scanner for initial neurologic examination and brain imaging to determine thrombolytic eligibility. In some scenarios, patients transfer directly from the ambulance bay to CT.
- ISTAT to measure international normalized ratio for anticoagulated patients. Glucose testing by EMS in the field or prior to arrival as applicable.
- Thrombolytic mixing and administration in the CT scanner, as soon as hemorrhage ruled out by neurologist. Recently, the conversion was made in the thrombolytic medication from Alteplase to Tenectaplase to simplify the administration process.
For continuous improvement, the multidisciplinary Stroke Performance Improvement Team reviews all Code Stroke patient cases and target time data to identify further opportunity for additional provider/staff/EMS education or modification of stroke protocols. The data is also shared with all stakeholders and improvements are celebrated by the stroke care team.
