When it comes to surgical site infections (SSIs) and patient safety, the goal at our orthopedic ambulatory surgery center is always zero. However, to hit that elusive benchmark, it takes a lot of work on multiple fronts. Patient safety is our number one priority and we pride ourselves on evidence-based, proactive protocols and practices that greatly minimize SSIs in our patient population. Since opening in January 2020, we have doubled our capacity by adding total joint replacement and spine surgery to our scope of services, and then with COVID arriving very shortly after we began our expansion of services added another challenge.
Nevertheless, our rates of infection continuously remain extremely low, currently at 0.4%. Here’s everything we do to keep our patients and staff infection-free:
Patient Selection and Qualification
We have developed protocols with built-in criteria for patients to be eligible to have their surgery in the outpatient setting. They must be in relatively good health with no high risk comorbidities. If a patient falls into the category of risk, we have triggers. Our anesthesiologists and surgeons review the patient’s medical history very closely. We consider all of our total joints and spine patients to be higher risk for SSIs by default. Because these patients often receive implants, we take extra precautions.
Patient Education and Engagement
We have a registered nurse assigned as what we call our Total Joint Coordinator. All patients are routed to her so she can speak with them before surgery. Patients also attend a comprehensive total joint education class. When patients come in for their pre-op appointment and it is decided they will have total joint surgery, they are scheduled for a total joint class. They must attend the class with someone they know and trust, whom we call “their coach”. We want the patient to have their coach’s support when they go home. The role of the coach is very important to have a successful outcome and optimize patient safety.
During the class, which is held at our surgery center in a room we built purposefully for this task, our total joint coordinator talks about everything the patient and coach need to know before, during, and after surgery. The content addresses how the patient will progress through the surgery center, what they need to do preoperatively in terms of testing, their medications, assistive devices they might need such as walkers, preoperative nutrition, and what their postoperative experience will be like, including discussion about wound care, physical therapy, exercises and more.
Many of the topics discussed connect to infection prevention, and we find that the more educated and engaged the patient and their coach are preoperatively, the less likely they will be to develop an SSI postoperatively. We believe in the power of this class so much that we’re preparing this year to roll out an online virtual class that can be accessed through our website. Because we operate in Montana, which is such a large state with a low population density, we know that it’s inconvenient for some patients to get to our facility to attend the class in person, as some need to travel several hours to get here. With the virtual class, they will be able to get all the information they need from the comfort of their own home.
Antimicrobial showers and prep. Our total joints and spine patients are instructed to shower using a 4% chlorhexidine soap both the night before and the morning of their surgery. When they arrive on the day of surgery, they are screened for MRSA and MSSA, with any positive results treated with a mupirocin antibiotic ointment nasal decolonization protocol, as well as IV vancomycin preoperatively.
Even though patients have demonstrated compliance with the two preoperative chlorhexidine showers, for added assurance all total joint and spine patients are instructed to give themselves a head-to-toe, rinse-free pre-prep with 2% chlorhexidine gluconate disposable cloths for long-lasting antimicrobial protection that stays on their skin and lasts for hours. We give them six wipes and tell them what to do step by step through diagrams in the preoperative bay. They wipe down whatever they can on their own, and then we help them to make sure they are covered from head to toe.
Sterilization for Patient Safety
We shifted to rigid containers that reduce the use of blue wrap and the associated risk of holes and tears that could go unnoticed and possibly result in contaminated instruments. The goal was to reduce IUSS to less than 10%, but our monthly tracking has shown that it has stayed below 3% since we moved to the rigid containers. If we ever see sudden increases, we immediately examine the reasons why. We also added a designated sterile processing technician position, and also have certified surgical technologists work in the reprocessing room with our sterile processing techs every day. By tracking our IUSS rate and making sure we stay below the 3% threshold, we uncover insights that can improve other areas such as our overall operational efficiency.
We employ heightened environmental cleaning surveillance throughout our facility, especially in our ORs, using a device that detects the presence of ATP (adenosine triphosphate), which is indicative of live bacteria. By swabbing high-touch surfaces, we can monitor trends and adjust our cleaning and disinfection practices, and share opportunities for more thorough cleaning with our OR and housekeeping staff. One example of an improvement we made using these results was the purchase of keyboard covers for the ORs that allow for easier disinfection of keyboard surfaces that had failed the cleanliness threshold.
Our OR supervisor leads this project and performs it regularly in each operating room, but she has also tested other areas like our recovery room and in our waiting room, just to make sure we were keeping surfaces clean everywhere. Every quarter we report results or new findings in our quality meetings to make sure we are always meeting our standards for cleanliness.
Warming Devices For Infection Prevention
We use active warming in pre-op on all patients scheduled for procedures greater than 60 minutes, and it stays on the patient throughout the procedure. Clinically, we warm patients to minimize risks of complications and infections. Inadvertent perioperative hypothermia is linked to increased intraoperative blood loss and increased chances of surgical wound infection. However, the patient experience is another factor. We use active warming for elderly patients, children, whenever it seems prudent. However, we primarily warm patients for infection prevention purposes.
Patient Safety and Hand Hygiene
We perform secret hand hygiene audits monthly using an observation method to verify compliance and share results. The audits include observations of our entire patient care team — our staff, our surgeons, and our anesthesiologists. However, it’s not a supervisor performing, our team members volunteer to participate. While they are working in the department, they are also observing everyone’s hand hygiene practices for a certain period of time. The volunteers observe everyone — transporters, anesthesiologists, surgeons, nurses, radiology techs, anyone who might touch a patient — for appropriate use of gloves when indicated and hand washing before and after patient contact. Nobody ever knows when or who is performing the audits. We report on those statistics in our quarterly quality meeting.
As knowledge about COVID has evolved, we also modify our policies to reflect evidence-based information. It hasn’t required too much on top of what we already do. Our standard of patient care has always been to wear gloves, for example. Besides our staff and patients masking, our patient care hasn’t changed too much from prior to COVID.
The real work has been outside of direct patient care. We increased our cleaning of the waiting room, spaced patients apart, and added signage everywhere we could to make sure people wore masks. We use a decision tree that guides our practice with employees and patients, and it’s ever changing as our understanding of COVID changes. While we never required patients to get COVID tests, we performed extensive screening during preoperative phone calls, at the door and at check-in, and many cases were reviewed by our anesthesiologists. If we found that patients were having cold symptoms, for example, we took extra precautions to make sure it would be safe to perform surgery on them at our center.
Passing Grade for Optimal Patient Safety
We’re doing all the right things to prevent SSIs. When a consultant visited our facility to provide objective feedback about our sterile processing department, we asked if she could give us any recommendations. Not only didn’t she have any, but she asked to use us a model for a hospital. She liked how many rigid containers we have, that we didn’t stack sets that were wrapped in blue wrap, that we had enough space so it wasn’t crowded.
It may be impossible to ever achieve “zero SSIs,” but we get as close to zero as we can every month. Our multipronged strategy, that is constantly enforced and evaluated, allows as to adjust protocols, policies, and behavior quickly. Our patients benefit from that eternal vigilance.
By Kelly O’Brien, MSN, RN, CPAN, Clinical Director at Missoula Bone & Joint Ambulatory (outpatient) Surgery Center