Improvement Charter – Updated June 7th, 2006
Project Name:
Team Members:
Team Sponsor:
SSI Safer Helathcare Now! Prevention of Surgical Site Infections
Janice Victory, Mary-Ann Wythe, Thelma Velasco, Carol Cook, Sharon
Shewella, Connie Deugau, Claire Padolina, Susan Noseworthy, Dr. A.
Younger, Dr. K. Stothers, Dr. R. Moore, Dr. Glen Brown
Cheryl Bishop
Purpose of Project
To improve the quality of care delivered to patients during surgery by reducing the risk of
surgical site infections (SSI).
To prevent SSI through the optimal use of prophylactic antibiotics, appropriate hair removal and
maintainence of peri-operative glucose control and post-operative normothermia.
WHAT ARE WE TRYING TO ACCOMPLISH?
Scope & Boundaries
 Will start with a specific pt. populations under each strategy and then role out the
initiative across both SPH and MSJ sites.
 Antibiotic prophylaxis – Orthopaedics
 Appropriate hair removal – random sample of procedures
 Perioperative glucose control – foot and ankle surgery
 Normothermia – random sample of procedures
Improvement Objectives
To achieve 95% or higher in implementing 4 components of care for patients undergoing
surgical procedures
Prophylactic Antibiotic Administration
1. Prophylactic antibiotic administration within 60 minutes prior to surgical incision for
hip and knee procedures (Vancomycin 120 minutes prior to incision) by December
2006.
2. Re-administration of antibiotic for procedures > 240 minutes (reminders at 2 hours
30 mins in OR for anesthesiologist to be called) by December 2006.
3. Prophylactic antibiotics will be discontinued within 24 hours after surgery end time
for hip and knee patients by December 2006.
Appropriate Hair Removal
4. Appropriate hair removal pre-operatively as close to incision as possible by
December 2006
Maintain Blood Glucose Levels
5. Maintain blood glucose levels <8.5 mmol/l pre-operatively for patients undergoing
foot and ankle surgery by December 2006.
6. Maintain post-operative blood glucose levels < 8.5 mmol/l for 48 hours for patients
undergoing foot and ankle surgery, as per hypoglycemic protocol by December
2006.
Post-Operative Normothermia
7. Post-operative normothermia in patients going to the PAR by December 2006
219572736
Page 1
HOW WILL WE KNOW A CHANGE IS AN IMPROVEMENT?
Measures
Prophylactic Antibiotics
1. Percentage of surgical pts.
whose antibiotics were
ordered on Physician
Order sheet.
2. Percentage of surgical pts.
With antibiotic
administration within 60
minutes prior to surgical
incision (Vancomycin two
hours prior to incision)
3. For those cases > 240
minutes the percentage of
surgical pts. whose
antibiotics were readministered
4. Percentage of surgical pts.
whose antibiotics were
discontinued within 24
hours after surgery end
time. (Cardiac 48 hours
post-op)
Appropriate Hair Removal
5. Percentage of surgical
patients with appropriate
hair removal
Maintain Blood Glucose Levels
(identify further process
measures)
6. Percentage of patients
whose blood glucose
levels <8.5 mmol/l preoperatively for patients
undergoing foot and ankle
surgery.
7. Percentage of patients
whose post-operative
blood glucose levels were
< 8.5 mmol/l for 48 hours
for patients undergoing
foot and ankle surgery
Normothermia - SPH
8. Percentage of patients with
post-op temperature in PAR
>= 36.0 degrees Celsius
219572736
Current Performance
Goals
1. N/A
1. 95% or higher
2.
2. 95% or higher
3.
3. 95% or higher
4.
4. 95% or higher
5. MSJ = 5/29 = 17.24%
SPH = 47/51 = 92.0%
*Those with hair removal by
clippers
5. 95% or higher
6.
6. 95% or higher
7.
7. 95% or higher
8. 96% achieved (24/25)
8.
Page 2
95% or higher
WHAT CHANGES CAN WE MAKE THAT WILL RESULT IN IMPROVEMENT?
Change Concepts and Ideas to Test
Prophylactic Antibiotics
 Physician Pre-Op Orders – to ensure that antibiotic is ordered in clinic prior to surgery
 Timing – anesthesiologist to give antibiotics (in OR – process working as is)
 Process to flag charts with pre-op antibiotic orders
 Design a protocol to outline appropriate antibiotic administration
 Antibiotic post-op discontinuation orders
 Review possibility of having SDC stock of antibiotics and stock in OR’s for re-dosing
 Time outs to discuss whether administration of antibiotics
 As changes spread need to review clinical pathways to ensure antibiotic orders are
included
Appropriate Hair Removal
  Removed razors from the OR at MSJ
 Develop PHC protocol on appropriate hair removal practices
 Education to surgeons and staff on appropriate clipping practices
 Review process of hair removal
Glucose Control
 Pre-surgery assessment tool
Normothermia
 Baseline data showed that target (96%) is being met therefore we will not focus on this
strategy at the present time. Random audits should continue to ensure target is being
met.
HOW WILL WE MANAGE THE IMPROVEMENT PROJECT?
Other Ideas
 Communication strategy – to post best practice, audit results and accomplishments in
ORs/units
Key Dates:
SSI Schedule of Events
May 9th, 2006 – 9:00 to 10:00am SSI Monthly Collaborative Call (Janice listened in)
May 25th, 2006 – 11:00 – 12:00 SSI Tracking Call (Villa) (Janice listened in)
June 6th, 2006 – 9:00 to 10:00am SSI Monthly Collaborative Call
June 19th and 20th, 2006 – Learning Session 2 (Vancouver, BC)
June 27th, 2006 – 9:00 to 10:00am SSI Monthly Collaborative Call
October 2nd and 3rd – Learning Session 3 (Penticton, BC)
Roles & Responsibilities (3 working groups established to meet objectives)
Mary-Ann Wythe – Lead, Antibiotic Prophylaxis Initiative
Janice Victory – Lead, Perioperative Glucose Control
Sharon Shewella/Carol Cook – Co-leads, Appropriate Hair Removal
Susan Noseworthy – Qualtiy Improvement Specialist
Documentation of Progress:
 Collaborative monthly report and central measurement team
 Project Tracker (updated monthly)
219572736
Page 3
219572736
Page 4