International Forum on Qulaity and Safety in Health Care Prevention of Surgical Site Infection Liau Kui Hin, FRCS

Mission Statement To reduce surgical site infections for gastrointestinal and hernia operations in Department of Surgery by 50% over the period of 6 months.

Rationale For Preventing SSI 2nd most common type of adverse events occurring in hospitalized patients increase : - mortality - readmission rate - length of stay - cost for patients 40 to 60 % of clean and clean-contaminated wound infections are preventable

DEFINITION OF SURGICAL SITE INFECTION TYPE DEFINITION OF SURGICAL SITE INFECTION Superficial Incisional SSI Infection occurs within 30 days after the operation and Infection involves only skin or subcutaneous tissue of incision and at least one of the following: Purulent drainage, with or without laboratory confirmation, from the superficial incision. Organisms isolated from an aseptically obtained culture or fluid or tissue from the superficial incision. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is deliberately opened by surgeon, unless incision is culture-negative. Diagnosis of superficial incisional SSI by the surgeon or attending physician Deep Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation Infection involves deep soft tissues (e.g. fascial and muscle layers) of the incision Purulent drainage from the deep incision but not from the organ / space component of the surgical site. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38oC), localized pain, or tenderness unless site is culture-negative. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination. Diagnosis of a deep incisional SSI by a surgeon or attending physician. Organ / Space SSI Infection involves any part of the anatomy (e.g. organs or spaces), other than the incision, which was opened or manipulated during an operation Purulent drainage from a drain that is placed through a stab wound into the organ / space. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ / space. An abscess or other evidence of infection involving the organ / space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination. Diagnosis of an organ / space SSI by a surgeon or attending physician.

CAUSE & EFFECT DIAGRAM Environment Staff Equipment Infection Patients – Skill mix – nurse – Physiotherapy – Other patients – Aseptic technique – Cross infection – Attire – JMO education – OT-traffic/attire/A/C – Post-op: recannulation – HDU – Pre-op: when, where, showers – SCD machine – Drainage systems (closed or open) Infection Sterilization – Surgical technique – Operating time – R/O drains – Urinary catheter – Clipping – Temp Monitoring – Glucose Monitoring – Hair Removal – Prophylactic Antibiotics – – Blood loss – Drainage systems – Storage of equipment – Post-op haematoma – Dressings (time & type) – Epidural insertion – JMO involvement – Selection – Expectations – Compliance – Confusion – Pressure ulcer – Nutritional status Patients Procedure

Pareto Chart

Bundle of Interventions Preoperative Hair Removal • Remove all razors • Work with the purchasing department • Use reminders (signs, posters) • Educate patients not to self-shave Post Operative Glucose Maintainence • Implement a glucose control protocol • Regular blood glucose levels check • Assign responsibility and accountability Appropriate Prophylactic Antibiotics • Change drug stocks to only standard drugs and dosage • Reassign dosing responsibilities • Involve pharmacy and infection control staff Post Operative Normothermia • Use warmed forced-air blankets and IV fluids • Increase the ambient temperature in the operating room • Use warming blankets under patients on the operating table • Use hats and booties on patients perioperatively

Flow Chart of Process Patient selected – labeled “SSI Protocol” in OT Reservation System Surgical Site Infection Proforma Form - attached (pink) OT Attendants – Hair Removal Anesthetists – Antibiotics PACU – Glucose & Temperature Monitoring ICU/ HIGH D/ GENERAL WARD – Glucose Monitoring Day Surgery Ward– Glucose Monitoring Surgical Site Infection Proforma Form - Collected HOME Patient selected – labeled “SSI Protocol” in OT Reservation System Surgical Site Infection Proforma Form - attached (pink) OT Attendants – Hair Removal Anesthetists – Antibiotics PACU – Glucose & Temperature Monitoring ICU/ HIGH D/ GENERAL WARD – Glucose Monitoring Day Surgery Ward– Glucose Monitoring Surgical Site Infection Proforma Form - Collected HOME

Run Chart Discussion began Start of CPIP Average Target 2005 2006

Outcomes Clinical Cost Clean Clean-contaminated 0.35% 1.90% 0.00% Pre-implementation 0.35% 1.90% Post-implementation 0.00% 0.40% Percentage Improvement 100.00% 78.95% OVERALL = 82% (> target of 50%) Cost WARD SUBSIDY PROVIDED COST SAVED Private A 0% $0.00 B1 15% $335.90 Subsidized B2 35-40% $373.40 C 80% $603.40 * Based on 10 days of hospitalization with surgical site infection

Lessons Learned Standardization of workflow enhances the delivery of quality care and patient safety Each individual’s contribution has significant impact on patient safety. Quality initiatives are often welcomed when the outcome has significant impact on our patient safety. Patient safety is not no accident & not by accident.