A Process Change Can Unintentionally Affect Surgical Infections: Tracing the Cesarian-Section Patient from Admission To Identify Underlying Issues

ISSUE: Baptist DeSoto is a 169 bed acute care hospital with an occupancy rate of almost 100%. During the 3rd Quarter of 2004, Infection Control (IC) reviewed recommendations for prevention of Surgical Site Infections (SSI). We revealed that razors were used instead of clippers. In November 2004, both razor kits and razors were removed from unit stock. A log was maintained by Store Room if single-use razors were issued. In March 2005 superficial SSI rate in C-Section procedures had increased. Five (5) C-Section SSI were detected since December 2004. Historically the SSI rate for C-Sections is low (FY03 = 0.51, FY04 = 0.46). This was an unexpected increase. PROJECT: A team of reviewers (IC, Womenʹs Center [WC], and Physicians) began an intensive investigation into the cause for the increasing SSI rate. Assessment included examination of surgical processes related to instrument sterilization, surgical aseptic techniques and analysis of a detailed line listing of infected patientʹs. A re-education campaign for the preoperative patient occurred in April 2005. Still 4 additional C-Section SSI occurred from May to June. The WC management team began a patient tracer on admission for C-Section patients. Tracer observations identified a missed step during the clipping process. The razor method utilized a “prep kit” which included a tray to hold water with soap and a sponge. The patientʹs abdomen is scrubbed with the soapy water and then shaved. When the process changed to clipping, prep kits were eliminated and the abdomen was clipped prior to surgery without washing. In August the prep policy was revised to include steps to clean the abdomen with the clipping technique. Educational updates occurred and units are now supplied with a single-use antiseptic sponge to clean the abdomen. RESULTS: The hospital continues to use and recommend clipping for surgical hair removal. Since the refinements to the prepping policy in August 2005 there have been 5 consecutive months without C-Section SSI. LESSONS LEARNED: Effecting even a simple process change to improve outcomes can unintentionally provide inverse results. A few key components proved to be successful. Measuring patient outcomes during change is critical to gauge successful interventions. The patient tracer strategy was useful in identifying the procedural weak link. When investigating adverse outcomes, a format for success is a team based approach. image