Medical Professional Publications

How an Eight-Step Protocol Helps Reduce Cardiac Surgical Site Infections

Columbus, OH - July 2016

Nationwide Children's Hospital already had a low rate of cardiac surgical site infections in 2012, but doctors, nurses and quality improvement specialists teamed up to develop an eight-step protocol to further reduce the preventable harm.

They determined that the keys to success would include standardized care, use of digital photography and detailed analysis of all suspected surgical site infections (SSIs). And over three years, the SSI rate dropped from about 2 percent to 1.5 percent.

Those figures include all cardiac surgeries, not just the types — about half those performed — tracked by the Centers for Disease Control and Prevention. For those cases, the infection rate dropped from 2 to 0.8 percent.

"We made an effort to be complete and to start surveying these children prospectively rather than retrospectively," says Janet Simsic, MD, a cardiologist in The Heart Center at Nationwide Children's and member of the SSI improvement team. "The goal was to come up with something that made sense and had some evidence-based medicine behind it, then do it consistently, track it and see if it made a difference."

The team's findings are published in the American Journal of Critical Care.

To begin, the researchers implemented preoperative steps based on guidelines from state and national collaboratives focused on reducing SSIs. These include standardized skin cleansing for the patient the night before surgery, the next morning and in the operating room; and consistent dosing, timing and redosing of antibiotics based on the child's weight and gestational age.

In the second year of the study, the team added standardized use of a silver-impregnated dressing that remains in place for up to seven days following surgery.

The team also devised a set of practical postoperative steps.

At discharge, team members place a digital photograph of the surgical site into the patient's electronic record. If a suspected infection develops while at the hospital, the team will include a series of photographs to document the event. The photos help the team learn the infection process and distinguish a superficial SSI from a stitch abscess, wound dehiscence or erythema.

With parents' permission, copies of the photographs are mailed to the child's primary care physician and referring cardiologist, since a 2010 study estimates 36 percent of SSIs are diagnosed after discharge. The photos allow for later comparison.

If concerns arise, parents or their child's doctor take their own photos and email them to Nationwide Children's, enabling the team to determine whether a child needs to return and be treated.

Surveillance continues for 30 days after surgery, when a final surgical site photograph is added to the record.

To help assess and analyze each suspected infection, the team created two forms. The first, a post-operative infection assessment form, is used to describe the wound findings, including erythema and characteristics of drainage.  This form is used for surveillance documentation of suspected SSI. 

"When we've identified an SSI and are performing the analysis, having those pictures, the documentation and the review process has been very helpful," says Melissa Cannon, APN, a member of the cardiothoracic surgery nurse practitioner team at Nationwide Children’s and a study author.

Having a picture to correlate with a description, Cannon said, helps eliminate inconsistencies.

The second suspected surgical site infection form tracks compliance with the SSI bundle elements and is used in multidisciplinary meetings held to determine the root cause of each infection and potential interventions.

Cannon M, Hersey D, Harrison S, Joy B, Naguib A, Galantowicz M, Simsic J.Improving Surveillance and Prevention of Surgical Site Infection in Pediatric Cardiac Surgery.American Journal of Critical Care.2016 Mar; 25(2):e30-7.

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