Reduction of Surgical Site Infections, Clinical Charter

CLINICAL CHARTER

INITIATIVE: Reduction of Surgical Site Infections

DATE: 3/20/2014

BACKGROUND/ CONTEXT

Aim: Compliance with administration of the appropriate prophylactic antibiotic within 0-60 minutes before surgical incision will be >95% in 6 months. Population: Surgery patients who have not required continuous or prolonged antibiotic therapy. Scope and Boundaries: Focus on clean and clean/contaminated surgeries for patients who were admitted pre and post-surgery.

OUTCOMES/DRIVERS/MEASURES

Outcomes

* Administration of on-time prophylactic antibiotic compliance >95%

* Surgical site infection rates for clean and clean/contaminated rate reduction by 50% per 100 procedures.

Key Drivers Analysis

1. Antibiotic not given in 0-60 minutes prior to incision.

2. Antibiotic given by nurse on unit, but then OR backups cause delay past the 0-60 minute window for administration.

3. Antibiotic given on unit, but poor communication during handoff causes confusion.

4. Antibiotic given is not optimal given the surgery being performed; weight of patient.

5. Antibiotic not re-dosed if surgery lasts longer than 4 hours or if there is significant blood loss.

6. Surgical Site Infection Rate at 4.8%, which is double than desired level

Measures, Goals:

KEY MEASURES | TYPE OF MEASURE(Outcome, Process) | BASELINE (DATE) | GOAL | BY WHEN | LEADER |

SSI rate per 100 procedures | | 01/31/20124.8% | 2.4% | 07/31/2013 | Ashley |

Systematic process of prophylactic antibiotic for decrease in SSI | | RANGE72% - 92% | >95% | 07/31/2013 | Samantha |

Notes:

1. Our initiative begins in January, 2013, with the expectation to reach our goal by July, 2013.

2. Our definition for the word “compliance,” is that the...