When UCSF Benioff Children's Hospitals saw surgical site infections (SSI) following spinal fusion operations jump from zero events to five in a single year, it demanded prompt attention. As the hospital’s quality improvement team dug into the problem, a clear solution emerged.
“We realized we didn't have a surgical infection prevention bundle in place for these particular procedures,” said Scout Hebinck, MSN, RN-C, quality and safety consultant, UCSF Benioff Children's Hospitals in San Francisco. “So, we started to ask ourselves some questions around how we would develop one.”
Hebinck and her colleagues spent more than a year researching and developing a surgical bundle for spinal fusion operations for children with adolescent idiopathic scoliosis (AIS). Their work paid off—in more than three years following the bundle’s implementation, there’s been just one SSI at the hospital related to this procedure.
The multidisciplinary and quality improvement-based approach provides a blueprint for children’s hospitals seeking to solve similar SSI concerns. It includes five key elements:
1. Use the village.
UCSF Benioff Children's enlisted input from nearly every corner of its system, as well as patient families and vendors. By working with everyone from surgeons and frontline clinicians to housekeeping and facilities staff, Hebinck and her team were able to identify all possible risk factors that could lead to infections. “You can't leave out any discipline when you're doing this, because everyone comes with a different perspective,” Hebinck said.
2. Don’t go it alone.
The team pored over the available medical research to confirm the need for a surgical SSI prevention bundle. In all, they examined nearly 60 studies on the topic. From there, they determined the best solution would be to adapt a similar bundle from Texas Children's Hospital. Hebinck considered it “the gold standard” because it already had demonstrated evidence of effectiveness. It also addressed many of the concerns UCSF Benioff Children’s had around skin pathogens that commonly led to SSIs, including pre-operative preparations for acne and body hair.
3. Explore every detail.
“It’s important to be really curious when developing a surgical bundle,” Hebinck said. In her experience, that meant observing several cases from beginning to end and asking a lot of questions along the way. She and her team even attended pre-operative appointments with the care team to see all preparations and instructions given to the patient’s family. Bathing protocol was an emphasis area in the patient instructions, which the hospital translated into three languages. They also observed how the operating room was cleaned and set up prior to the surgery. “It’s essential to understand all aspects of care before you can think about changing anything,” Hebinck said.
4. Keep communication lines open.
It’s critical to maintain consistent communication with all stakeholders during the process. Notably, Hebinck worked closely with frontline personnel to explain the rationale behind any proposed changes and respond to any questions. “They can see metrics on the wall, but they may not know it's applicable to them or to their particular cases,” Hebinck said. Additionally, Hebinck provides the surgical teams with quarterly progress reports, including any tweaks to the protocol. They also instituted consults with the surgeon following an SSI to determine possible causes. “We go through the entire case together very diligently because it's important to understand why or how it could have happened,” Hebinck said.
5. Test and revise.
One of the process changes Hebinck proposed was pre-operative bathing of the patient both the night before and the morning of surgery. The team ran a Plan-Do-Study-Act (PDSA) cycle on this process before rolling it out as an order set in the surgical bundle. “It’s really important to pilot changes before you implement them,” Hebinck said.
Compliance is key
A surgical bundle is only effective if it’s widely used, so gaining buy-in is crucial. Investing the time and resources in each of these five steps can go a long way toward compliance, according to Hebinck.
“If the care team is not given the rationale or have an understanding of the data, they won't see need to change their practices,” Hebinck said. “It really comes down to effective change management and what's best for our patient."
