71. – Revised
PROJECT NAME: Sustaining the Reduction of DSWI
Institution: UT Southwestern Medical Center
Primary Author: Philip Greilich MD
Secondary Author: Margaret Dupre’ MS, RN, CNL
Project Category: Surgery
Purpose/Aim:
Deep sternal wound infections (DSWI) following cardiac surgery are associated with
some of the highest mortality and represent a serious economic burden to the
healthcare system and patients. Nearly all DSWIs are preventable. In CY 2011, the rate
of DSWI for patients undergoing sternotomy at UT Southwestern was 5.8% and a DSWI
best practice workgroup was mandated by executive leadership.
The workgroup defined best practices for preventing the occurrence of DSWI and
implemented changes in practice which was successful in reducing the rate of DSWI to
0.4% in CY 2012 (Figure 1). Our concern was the reduction in the incidence of DSWI
was primarily attributed to the Hawthorne Effect.
Figure 1
In 2013, standardized order sets for sternotomy patients were introduced into the EMR
which reflected the best practices identified by the DSWI workgroup. Chart reviews for
adherence to best practices were completed for Q1 and Q2 of CY2013 to assess for
compliance to best practices and identify barriers to these practices. Direct observation
of adherence to best practices within the operating room by trained observers continues
in CY2013.
The purpose of this project is to maintain the rate of DSWI at <1% in CY 2013 and
2014. The scope of this project includes all patients having a median sternotomy
incision. Patient outcomes are the primary measure of success. Secondary measures
are related to processes: adherence to the identified best practice elements in the pre-,
intra-, and post- operative phases of care. We aim to have >90% compliance with the
identified best practices (Figure 2).
Figure 2
Stakeholders:
 Cardiac surgeons, fellow, and midlevel practitioners
 Anesthesiologists
 CVICU and floor staff
 Pre-admission testing
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Same Day Surgery
Patients
Information Resources
Cardiology and Pulmonary Services
Infectious Disease Physicians and Infection Prevention
Pharmacy
Endocrinology
Environmental Services
Executive leadership
Tools and Measurement:
The DMAIC method was used to guide the quality improvement project. The issue was
defined, measured and analyzed in CY 2012. The project team is focused on improving
and controlling the progress with preventive and corrective actions.
The project team continues to utilize quality tools for the project including:
 Project Charter (Appendix 1)
 Control the scope of the project
 Provides milestones
 Keep on schedule
 Fishbone diagram (Appendix 2)
 Process mapping (Appendix 3)
 Affinity sort
 FMEA: assisted in prioritizing interventions (Appendix 4)
 Observation check list and chart audit tool with definitions
 Structured form for collecting data
 Definitions led to consistency among trained observers
 Bar charts and histograms were utilized in interpreting data and sharing
information
 Brainstorming and nominal group techniques are utilized during meetings to elicit
team members’ ideas regarding preventive and/or corrective actions when
barriers to best practices are identified.
 Pareto diagram
 Analysis of pre-operative work flow by Industrial Engineering students for
improving the provider/EMR interface
 Analysis of each new DSWI in CY 21012 and CY13/Q1-2
 Assess compliance with best practices
 Share “lessons learned”
 Identify opportunities for improvement.
 Control Plan to guide transition from project team to hospital operations (Infection
Control, CVTS).
 Debriefing of project team to gain “lessons learned” for other high-priority
institutional quality improvement efforts
Intervention and Improvement:
The primary interventions for this project are:
1. DSWI Best Practice workgroup: Led by CVTS surgeon, managed by CVT
QI/Safety Coordinator and Co-Championed by University Hospital Quality Officer
and Chairman of Department of CVTS. Five-member Core group meets monthly
and full workgroup now meets quarterly. Agenda items include review data,
discussion and modify of efforts to improve compliance and sustain
improvements. Minutes are distributed to entire workgroup including Executive
sponsors (CMO, AVP CVT service line).
2. Standardization of Order Sets:
a. Standardized preoperative orders for inpatients were implemented
February 2, 2013 (Figure 3). Preoperative order sets for transferred and
outpatients will be implemented by August 31.
b. The post-operative cardiac orders were implemented February 2, 2013.
c. The post-operative LVAD orders were implemented on June 3, 2013.
d. The estimated date for the postoperative heart transplant orders is
October 15, 2013.
The time frame for initiating the orders was dependent on the availability of EMR
programmers and allowed for using the “lessons learned” to be included in the future
order sets.
Figure 3
3. Trained observers
a. Observation of 15 cardiac cases by trained individuals each quarter began
in July 2012. These observers provide prompts in the operating room to
correct actions inconsistent with the best practices standards established
by the DSWI workgroup.
b. Chart reviews of 100% of cardiac patients began in January 2013. (Figure
4).
Figure 4
4. Improvements in the EMR-provider interface
a. Collaboration with Industrial/System Engineering department of at the
University of Texas Arlington (UTA) to map work flow and identify
opportunities to improve provider-EMR interface. (Figure 5)
Figure 5
Variables:
•
Patient Point of
Origin
•
CareEverywhere
•
MRSA Screen
b. Introduction of a CVTS preoperative checklist (Figure 6)
 Prompts the provider to verify the results of MRSA screening
 Documents the use of preoperative Chlorhexidine gluconate showers
and mupirocin
Figure 6
c. Modification of EPIC preoperative anesthesia record to provide:
 MRSA screening results
 other culture reports
 Workflow prompts to administer antibiotics
5. DSWI Best Practice workgroup meetings.
6. Team Communication activities (Figure 7)::
 Time Out prior to incision
 Briefings (June 2012)
 De-briefings (January 2013)
 Structured transfer of care from the CVOR to the CVICU
Figure 7
7. Antibiotic Selection Matrix (Figure 8):
a. Standardized preoperative antibiotic selection, dosing and re-dosing chart
was created, approved and distributed by the DSWI workgroup.
Figure 8
8. Environmental Services (EVS):
 Hand hygiene dispensers have now been installed and maintained with
greater consistency at key locations within/around the CVOR, CVICU and CV
Floor locations.
 A scheduled OR cleaning surveillance program (DAZO) was initiated (Figure
9).
Figure 9
9. Debriefing of DSWI: All DSWI are reviewed, discussed, and shared with
providers to heighten awareness and seek opportunities for improvement
10. Communication of Interventions/Modifications and Results:
a. Announcements at the Joint Conference of Cardiothoracic Anesthesiology,
Nursing and Surgery Providers for Safer Cardiac Surgery meetings
b. Interdisciplinary Unit-based Safety Program meetings
c. Non-CUSP CVOR,C VICU, CV Floor meetings
d. DSWI workgroup meetings
e. In-services
f. E-mail of minutes and summaries
Intervention Results:
The effectiveness of the DSWI workgroup is tracked by measuring compliance with best
practices (process measure) and outcomes (sustaining reduction in DSWI). We
believed our ability to sustain the DSWI rate at <1% achieved in CY 2012 would require
a significant re-engineering of our processes to increase the reliability and compliance
with the best practices we have established for our cardiac surgical patients.
Compliance with best practices is shown in Figure 10. Our goal is to achieve >90%
compliance for each of the best practices measured. Definitions were refined to
increase clinical relevance and inter-rater reliability based feedback from the surgical
team and the trained observers.
Figure 10
Based on a review of the literature and our FMEA, we elected to initially focus on
preoperative processes and postoperative wound care. Collaboration with a team of
Industrial/System Engineers from UT Arlington assisted us with mapping out our
preoperative processes in greater detail and recommended opportunities for increasing
reliability.
Data collected by the trained observers (Figure 11) provided the project team with
critical feedback on why compliance with best practices were not >90%.
Figure 11
CHG Showers x 2 not
done preop
MRSA Screening not on Chart Mupirocin x 2 not given
preop
preop
Orders done by Cardiology
CareEverywhere not accessed
Preop Order Set Not Used by CVTS
Result unavailable
Preop checklist not done
Orders done by Cardiology
CVTS not Primary Surgeon
Preop Order Set Not Used by CVTS
Orders done by Cardiology
CareEverywhere not accessed
Results not available/not ordered
from OSH
EPIC/Interface Error
CVTS not Primary Surgeon
Preop Check list not completed:
no documentation.
Preop Order Set Not Used by CVTS
CVTS not Primary Surgeon
Orders done by Cardiology
8
7
6
5
4
3
2
1
0
HgbA1c not available
preop
Data from the Pareto analysis (Figure 12) helped direct the project in prioritizing efforts.
Figure 12
100% chart review in June 2013 examined compliance of preparative best practices
related to location prior to entering the operating room (Figure 13).
Figure 13
June 2013
This analysis indicated a closer examination of our inpatient process is warranted
(Figure 14).
Figure 14 Compliance with all 5 preoperative best practices
June 2012
Efforts to increase compliance with postoperative wound care included (Figure 15):
 Placing the CHG applicator and timing for wound care on the MAR
 Training/education of nursing staff
Figure 15
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
January
February
March
April
May
June
Our data indicated, that although significant progress has been made, additional system
changes are needed in insure DSWI rates remain <1% in our high-risk cardiac surgery
population (Figure 16).
Figure 16
UTSW CVTS DSWI 2009-2013
Revenue Enhancement /Cost Avoidance / Generalizability:
Sustaining the financial benefits of avoiding non-reimbursable costs associated with DSWI
appears to be persistent. The estimated costs attributed to DSWI for CY2011-13/Q1-2 are
shown in Figure 17.
Figure 17
$800,000
$700,000
$600,000
$500,000
$400,000
$300,000
$200,000
$100,000
$0
2011
2012
2013
Current goals of the DSWI project team include
 Finalizing the control plan (Figure 18)
 Complete a project debriefing process
 Have the necessary processes in place to insure sustainability
 Cost reduction for CVTS surgery
Figure 18
Implementation of pre- and post-operative best practices with the standardized order
sets impacted several units including:
 PACU
 Pre-admission testing
 Same day surgery
 CVICU
 CV Floor
 Cardiac Floor
The communication tools utilized by the CVTS team in the OR have been tailored by
other service lines for their use. It is the plan that all ORs will have briefing and debriefing beginning August 5, 2013.
Lessons Learned
 Multidisciplinary team is essential in a quality project
 Executive leadership is essential for success
 Team building early in the project is important
Appendix 1: Project Charter
Appendix 2: Fishbone Diagram
Factors Contributing to Deep Sternal Wound Infections
Surgical Technique Issues
Materials/Medications/Products
Scrub time & technique
RBC Transfusions
No standardized
Surgical bundle
Re-operation factors
Antibiotic selection, timing, re-dosing, D/C
Variable faculty presence during closure
Mammary artery
harvest time/
technique
CHG paint post-op
Foam/ Avaguard accessibility
Open saphenous
vein harvest
Closure technique
No standard use of pre-op Hibiclens
& Bactroban
Intra-op tissue perfusion/
pressor use
Duration of open
Surgical wound
Diabetes
Ineffective hand hygiene
Smoking/COPD
No Pathways
Technical proficiency/
resident training
Parkland patient
Renal Failure/insufficiency:
pre-op creat. > 1.3
Pre-op length of stay > 3 days
“Nursing-related” issues
Pre-op nasal swabbing/
decolonization
ICU
“PT/OT/RT-related” issues
OR
Clipping inside the OR
Floor
Environmental decontamination
No pre-op navigator
# of prior sternotomies
Insufficient staffing of
CT intensivists
Inadequate aseptic training
Identification & management
Of high-risk modifiable factors
Hand-offs
“Pharmacy-related” issues
Elective/urgent/emergent
surgery
Pre-op Hibiclens
showering
Perioperative
assessment:
i.e. who gets plavix,
who is high-risk,
who needs IABP
Sub-optimal post-op
glycemic control
+ MI at time of surgery
Our current rate of deep tissue infection/
mediastinitis is currently 4-6%:
(surveillance until 12/31/2012)
The national average is <1% for
patients with sternotomy
Limited order sets
Inconsistent post-op
wound care
BMI > 30
SOI:STS Risk/EuroSCORE
Non-standardized
OR trays &
equipment
Home-laundered scrubs
Timely orders/response
To inquiries
Huddles for fall-outs
Briefing/debriefing &
Learning from mistakes
Traffic in OR
Effective multidisciplinary
rounds
Patient Factors
Problem Statement
Duration & complexity
of surgery
High-dose steroid use
Or immunosuppression
High CMI
Increased use of
saphenous veins
Variable CHG prep technique
Post-op tissue perfusion/
pressor use
Hypothermia
2012
People
Hospital Processes
Ineffective (delayed) SSI
Debriefing processes
Page 1
Appendix 3: Process Maps
Appendix 4: FMEA by Phases of Care