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SSI Prevention: BundleAmber Wood, MSN, RN, CNOR, CIC, FAPIC

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Discuss evidence-based practices to prevent surgical site infections (SSI)Develop a plan for implementing a SSI bundleObjectives

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How to Build a Bundle

Lets start out the gate with how to build a bundle, then we will discuss the EBP bundle elements. Have any of you done this before? (Show of hands) Did any of you start with a literature search? If so, the 1st thing you quickly learn about bundles is that-3

No two bundles are the same

No two are the same! This can be frustrating. Youre ready to jump on the bundle bandwagon, and you get hit with billions of options to get started. Anyone experienced this? So why are there so many bundles? Which one is the best? Which one should you choose? Well its a little more complicated than we thought, but we IPs are smart people and we can do this!4

Risk Assessment

First, we go back to our old friend the risk assessment. Aha!, maybe no two bundles are the same because they were probably based on a risk assessment, whether they realized thats what they were doing or not

So you start with a gap analysis of your practices. What are evidence-based strategies for preventing SSI? We will walk through them in detail in a moment. Are any of these practices new or have yet to be implemented at your facility? Maybe they arent new, but they are areas that you need to improve on. Be comprehensive here, this is your shot to get administration, surgeons, anesthesia, and the OR behind you for this initative. Whether you do it all at once, or in phases, get your wish list in the bundle, this is so much easier to implement than doing a big SSI bundle roll out, then 1 year later telling them you need to revamp something else.

Look at procedure specific elements, will you roll this bundle out in 1 service line as a pilot? Are there things in the bundle that are standard across all procedures that you can easily identify? It will help with compliance to have the bundle tailored by service lines, otherwise people will see tasks not applicable to them and begin to write it off.

Lastly, are the bundle elements you identified in your risk assessment measurable or how will you assess compliance? We all want to be able to see the fruits of our labor, making esoteric practice changes that cannot be measured will undermine your bundle.

So through this risk assessment process, you end up with a bundle. Are you now ready for my big secret on how to get everyone on board?!5

Implementation ScienceBehavior (Human Factors)Change managementLeadership SupportResources (Equipment, Staff)Teamwork & CommunicationTeamSTEPPS (AHRQ)CUSP/SUSP (Johns Hopkins)

Implementation science is a rapidly growing field, as weve learned in Infection Prevention that we can have all the best plans in the world, but we wont get any traction if people wont follow them. There is a growing body of evidence on behavioral science in human factors, and change management. We also know that we need leadership support and to look at our resources to be successful. And there is quite a bit of evidence in the perioperative setting about the role of teamwork and communication. Weve found that formal team training programs such as TeamSTEPPS, medical team training, and crew resource management are effective in improving teamwork and communication, and even reduce surgical morbidity. The challenge with these programs is sustainability, so having a plan for ongoing team training will help keep the team on target with the training, these programs should not be the flavor of the month. Johns Hopkins is also doing great work on the CUSP or Comprehensive Unit-based Safety Program, which aligns with TeamSTEPPS, and are currently studying CUSP in Surgery, or SUSP. A great resource that ties a lot of this together is the book Preventing Hospital Infections by Sanjay Saint.6

Atul Gawandehttp://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine#t-1128716

As I was preparing this presentation, I came across a Ted Talk by Atul Gawande in 2012, who as you may know is a surgeon and a thought leader in safe surgery and use of checklists. I suggest you watch it sometime, but here are a few great insights he gave on the issues with face with change in the ORHe said there is a deep resistance to change, not too surprising to IPs!, because it forces us to behave with different set of values. Surgeons are trained to be independent, self-sufficient, and autonomous. As he talks about surgery and the immense challenge with developing a checklist, he talks about the complexity of it all, and I love this statement: As individualistic as we want to be, complexity requires group success. So now we expect humility, discipline, and teamwork, which is quite divergent and is part of that deep resistance to change.His call to action for us is that Making systems work is the great task of our generation, and he lists 3 steps to this:Find FailuresDevise solutionsAbility to ImplementI think this is such a great way to sum up our steps for building a bundle, and a good reminder of what it takes to be successful.7

Bundle Elements

So now that you know the big picture, lets talk about evidence based practices to use in your bundles. These are what we are seeing being implemented in practice, common implementation challenges, and some humble advice. Hopefully, you will have an idea of what things you want to take back for your risk assessment. Just know that Im reviewing these on a high level since you could do a whole presentation on each single intervention, so let me know if you want to go deeper in any of these topics. 8

Core Practices(not procedure-specific)

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Only when indicatedSelect agent based on clinical practice guidelinesTime the dose to be in tissue at time of incisionWithin 1 hourDosing Weight basedRe-dosing

Antimicrobial ProphylaxisOrder Sets,Time OutCDC HICPAC Draft Guideline for Prevention of SSISHEA Compendium SSI GuidelineStrategies corner

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Maintain normothermia (35.5C) perioperativelyBefore, during, and after surgeryBest method unresolvedActive & PassivePatient assessmentTemperature monitoringSelection of methodNormothermiaCDC HICPAC Draft Guideline for Prevention of SSI, SHEA Compendium SSI Guideline,AORN Guideline for Prevention of Unplanned Patient HypothermiaPre-warming,Products

Passive are insulating, like a blanket. Active warming methods (eg, conductive, convective) include increased ambient room temperature, radiant warming, forced-air warming (eg, blanket, gown), water-filled mattresses, circulating water garments, warmed IV and irrigation fluids, electric warming blankets, etc. 11

General anesthesia with endotracheal intubationIncrease FiO2Intraop and post-extubation

Tissue oxygen delivery also needsNormothermiaAdequate volume replacement

OxygenationAnesthesia ChampionCDC HICPAC Draft Guideline for Prevention of SSISHEA Compendium SSI Guideline

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Target blood glucose levels