1. Western Node Collaborative BC Children’s Hospital Prevention of Surgical Site Infections A collaborative approach to the reduction of surgical site infections within the cardiac population.

2. Background BC Children’s Hospital (BCCH) is a 142 in-patient facility with approximately 120,000 out-patients visits annually and is the only Children’s Hospital within BC. BC Children’s Heart Centre is part of BCCH and provides leadership and excellence in the care of infants and children with congenital and acquired heart disease from antenatal diagnosis using fetal echocardiography through to early adulthood. Approximately 250 pediatric cardiac operations and another 100 minimally invasive procedures in the hospital’s cardiac catheterization lab are performed each year. Accredited ECLS program which has treated 96 patients since 1999. Project started Fall 2005. Projected end date January 2007.

3. Background The reduction of surgical site infections within the cardiac population is important to the hospital vision and mission of providing the best care and improving patient outcomes by:  morbidity and mortality;  length of stay  surgical interventions (e.g., sternal debridement) translating knowledge (research) into practice This project has been an opportunity to partner with the following programs & services following an interprofessional model in an effort to move towards best practice by applying knowledge into practice while learning with, from and about each other. The partners are: BCCH Infection Control BCCH Surgical Suites BC Children’s Heart Center BCCH Pediatric Critical Care BCCH Division of Surgery C&W Quality, Safety & Risk Management BCCH Surgical Program Safer Healthcare Now!

4. Aim Purpose To reduce the number of surgical site infections (skin & soft tissue &/or surgical site) in cardiac surgical patients. Goals/Objectives or Aim Statements To reduce the number of surgical site infections in the cardiac surgical patient (linking to CDC definition of SSI) at BCCH by 50% within 18 months. Scope Children who receive cardiac surgery at BCCH and are cared for in surgical daycare, pre-admit clinic, cardiology clinic, operating suites, pediatric critical care, neonatal ICU and 3M (medical/cardiac ward)

5. Team Members Leslie Braun, Data Manager, Pediatric Critical Care Dr. Doug Cochrane, Neurosurgeon Rita Dekleer, Infection Control Nurse Jennifer Dunlop, CNC, Surgical Suite Caroline Kohlberg, Nurse Champion, Pediatric Critical Care Wendy Lehman, Nurse Educator, Surgical Program Barb McKnight, Nurse Educator, Surgical Suite Tracie Northway, Quality & Safety Leader, Pediatric Critical Care Amie Nowak, Enterostomy & Wound Specialist Katrina Verschoor, Quality, Safety & Risk Management Education Leader

6. Changes Tested Tested pre-op skin care after distribution of chlorhexidine EZ scrubs to pre-admit clinic (PAC). 97% compliance until PAC nurse went on vacation then approximately 30% compliance as families required to purchase scrubs from pharmacy. Testing antibiotic administration times within cardiac surgery. Approximately 50% are given within stated time frame. Minimal need for shaving in cardiac OR. Clippers introduced to other surgical programs and compliance with all but 1 program.

7. Changes Tested BACK TO BASICS. Post-op wound assessment “policy” and poster created to alert RNs and surgeons of best practice to decrease wound contamination with assessment. (See below). Conflict and non-compliance noted. Surgeons requested meeting to explain change. Policy passed.

8. Wound Care- Safe Assessment Wash your hands (protect patient, protect self) Mask (protect patient, protect self) Non sterile gloves Remove dressing (protect self) Sterile gloves For open wounds (protect patient, protect self) Thanks for promoting and practicing best aseptic practices 2006, Sponsored by ICU QA Committee & SSI Initiative through SHN

9. Results April 2006: total number of cardiac patients = 8. Compliance rate for antibiotic administration between 0-60 minutes was 75%. The range of time of administration was 31 – 92 minutes before surgical incision May 2006: total number of cardiac patients = 9. Compliance rate for antibiotic administration between 0-60 minutes was 33%. The range of time of administration was 20-94 minutes before surgical incision.

10. Challenges Limiting to the cardiac population only Antibiotic administration times in cardiac OR… “Where’s the evidence regarding 90 minutes versus 60 minutes?” Infection rate data… finding it! Bundle’s limited focus on post-operative wound management Politics!!!

11. Keys to Success and Lessons Learned Weekly meetings… keep them short and focused Set clear small goals Gathering baseline data has been an important step to understanding the surgical patient process and identifying areas for improvement Importance of having key team members, with respective expertise in the areas of Infection Control, Change Concept Model, Education and representation from the spectrum of the OR patient Divide and conquer Hospital administration & surgical administration support is necessary Adopting change is an ongoing process

12. Keys to Success and Lessons Learned Early buy-in by frontline staff & surgeons which requires: Transparency & timeliness with collaborative process Making everyone feel a part of the solution… not just a part of the problem Time to spend COMMUNICATING = introduction to topic + LISTEN + problem solve together Have your evidence ready! Maintain group momentum… Once it has caught on it runs away with you! Celebrate our wins! Keep your humour and have fun!

13. Next Steps Clarifying measurement for rates (We’d really like an annotated run chart!!!!) Spread of bundle through surgical programs and inpatient units (Testing of intra-op and pre-op bundle) Increased surgeon and physician involvement Potential for antibiotic absorption/efficacy over time study Clarification of best practice for wound care (Plan to add to bundle for our site)

14. Contact Information Rita Dekleer RN,CIC (604) 875-2345-7462 C & W Infection Control Service rdekleer@cw.bc.ca Barbara McKnight RN, BScN, CPN(C) Perioperative Clinical Educator (604) 875-2345-7857 bmcknight@cw.bc.ca Jennifer Dunlop RNAA,BSN,CPN(C) Clinical Resource Nurse Pediatric Anesthesia (604) 875-2345-7857 jdunlop@cw.bc.ca Tracie Northway, RN, MS Quality & Safety Leader Pediatric Critical Care (604) 875-2092 tnorthway@cw.bc.ca