Safer Healthcare Now Our Normothermia Surgical Site Infection Experience

1. Safer Healthcare NowOur Normothermia Surgical Site Infection Experience Eating the SSI Elephant: A workshop to help Ontario Hospitals reduce SSI while meeting provincial reporting requirements March 12, 2009 Julie McBrien – Patient Care Manager PAC, SDC & PACU

2. Objectives • Background – HHS and SSI • Our Goal for Normothermia • Measures & the Data • Change Initiatives • Our Results • Lessons Learned/Challenges • Next Steps

3. Our Hospitals • Halton Healthcare Services is comprised of three acute care community hospitals - Oakville-Trafalgar Memorial, Milton District and Georgetown Hospital. • Our mission - to provide quality compassionate care and services to meet the needs of our population in a timely and effective manner - grows out of a culture of care and is shared by our staff, physicians and volunteers. • HHS is committed to being an innovative centre of excellence in community hospital care.

4. Facts and Figures • 294 Acute Inpatient beds • 61 Complex Continuing Care • 39 Rehab beds • 77,600 surgical procedures • 17,519 admissions • 132,470 Ambulatory visits • 97,700 ER visits • 2,346 staff

5. Our SSI Team • Oakville Site: Cindy MacFarlane, Cathy Goacher, Lynn Singh, Julie McBrien • Milton Site: Dr. Kolbasnik, Dr. Chow, Barb Roelofson, Jan Dziapak, Susan Barrett • Georgetown Site: Deb Hill • Infection Control & Prevention: Dr. Szakacs, Cynthia Shorrock • Patient Safety: Lynn Budgell • Pharmacy: Jill White

6. In the beginning with SSI …. • Oakville site initiated first (Nov 2005) • Our program sponsors - Surgical Care Committee • Established a small working group of key stakeholders • Use ‘Model for Improvement” and Plan-Do-Study-Act (PDSA) cycle to conduct small tests of change • Milton and Georgetown sites incorporated later

7. In the beginning with SSI… Cont’d…… • Selected & prioritized 3 of 4 components of care: • #1 appropriate hair removal • #2 antibiotic timing; • pre-incision & post-close discontinuation • #3 post-op normothermia (colorectal surgeries) Done Ongoing Most Recent Challenge

8. Aim: Through prevention, monitoring and action achieve Normothermia to Prevent Surgical Site Infections (SSI) For identified at risk populations, maintain the patient’s core body temperature at a minimum of 36 degrees Celsius, throughout the entire surgical experience; admission through discharge from PACU

9. Targeting the ‘Right’ Surgical Patients • Identified our surgical populations based on; risk, volumes, evidence of inconsistent practice & degree of support anticipated from the service; • Total Knee Arthroplasties • Total Hip Arthroplasties • Colo-Rectal Surgeries (elective only)

10. Improvement Objectives Maintain normothermia ( 36C) peri-operatively for selected surgical populations Measures Temperature documented at each phase of the surgical process (SDC, OR, PACU) Report % open-body cavity surgical patients with Temps  360C post-op in PACU Goal: To achieve 95% or higher in maintaining patients core temperature at 36 C • Key Changes • Use of pre-op, intra-op and post-op warming devices on populations at risk • Education • Efforts to improve temperature monitoring methods

12. Normothermia Change Initiatives & Highlights • Patient gowns improved – Aug 2008 • Change of warming blanket supplier – Sept 2008 • Ease of IV and arterial line access • Fixed plastic head drape • Heat sensor at point of patient delivery heating • Warming units available in all ORs • Inventory increased in PACU and a unit dedicated to SDC - Sept 2008 • Warming blankets are stocked, added to the picklist & picked in CSR for the case – Sept 2008

13. Normothermia Change Initiatives & Highlights Cont’d… • Hot lines used regularly in cases over 1hour • Patient recliners in SDC with warming feature – Trial Jan 2009 • Skin temperature probe trial & consistent placement of probe - Jan 2009 • OR bed warmed with warm flannels or heating unit - more consistent practice • Normothermia Education: Dr. Szakacspresented to; • Surgeons – April 2008 • Anesthesia – May 2008 • Nursing - SDC, OR, PACU, and surgical floor – May 2008

14. Halton Healthcare ServicesSurgical Program – Oakville Site (June – Dec 2007)

15. Halton Healthcare ServicesSurgical Program – Oakville Site (2008)

16. Lessons Learned… • Smaller sites able to get buy in and spur change forward quickly – i.e. DS patients bringing housecoats and slippers from home • Integration, collaboration and standardization across HHS sites • Don’t under-estimate the need/value of a physician champion and the importance of education and physician/staff support • Dedication and effective use ‘rapid cycle change’

17. Lessons Learned… • Achieved a number of improvement changes – share with stakeholders • Tremendous sharing and support available • collaboration within HHS, LHIN and SHN community • Understand and analyze cost implications upfront • Be creative about keeping team engaged and moving forward in spite of competing projects and chaos • Data management is an enormous barrier without electronic solutions (in long-term)

18. Challenges … • Physician culture/attitude/practice changes • Literature was challenged -- education needed • Ongoing data management • More paperwork!! • Resource intensive • Manual collection/collation • Cost implications of improvement changes

19. Next Steps … • Continue to develop automation capacity in our data management process • Documentation • Reporting & analysis • Initiate new cycles of change for; • Check success of normothermia changes • Monitor and report results consistently • Ensure we have a plan to sustain …. • Celebrate well and often!

20. Still Smiling and Moving Safety Forward Questions? Thank You… Julie McBrien Halton Healthcare Services 327 Reynolds St. Oakville, ON (905) 845-2571 x6420