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In the early hours of a crisp December morning, Millie Jackson's son helps her from the car into a wheelchair. Snow flurries dust her favorite navy woolen blanket. She is taken to the preop waiting room of Prince William Hospital (PWH), Manassas, VA, to check in for surgery. Plagued with an arthritic hip for many years, Millie, 72, finally has consented to a total hip replacement.
One by one, family members and friends give her a final hug and kiss her lightly on her wrinkled cheeks before Tena Beal, RN III, OPS, preop nurse, wheels Millie back to prepare her for surgery. "One of you may come back with her if you like," Beal says. Millie's husband of 51 years shuffles along behind the wheelchair, leaning on their daughter's arm to steady himself.
Once in the bright preop area, Millie's clouded eyes focus on Beal's smile as she explains that Millie should remove her clothing and place it in a plastic bag. "Before putting on the hospital gown, wipe your skin with these warm cloths from the packet. Your daughter may help you, or I will be happy to assist if you like," Beal says, then offering further instructions. "Use one for the neck down and the second on your right hip, which is where you're having surgery. Do not use on your face. This cloth will reduce your risk of infection. Please sign the form when you finish and I'll be back with a warm blanket," Beal concludes.
Seeking Even Better Outcomes
Despite a surgical site infection (SSI) percentage rate that was below the National Nosocomial Infections Surveillance System average, in August 2006 PWH was unwilling to settle for that and made an initial investment for SSI prevention to bring that down to zero incidents. The hospital instituted a protocol using 2 percent chlorhexidine no-rinse cloths for presurgical cleansing of all surgical patients the morning of their procedure. This initiative was supported by medical staff, nursing, infection control, quality and administration.
Preoperative nurses educate patients on the use of the CHG cloth and provide assistance if needed. After completion of the preop cleansing, the patient signs the instruction sheet and returns it to the nurse. Completed forms are forwarded to Infection Control for data collection.
"We have been using the process for a year now and the numbers are very reassuring," Beal, a member of PWH's Institute for Healthcare Improvement Surgical Care Improvement Project (SCIP), said.1 "There has been a positive response from the patients knowing this is an effort toward prevention of infection for them. The wipes involve the patient, and sometimes the family, with their care. This is extremely enlightening as they realize they are part of a team working toward improvement in healthcare.
"There's tremendous satisfaction when preventive care proves beneficial to the patient and we can see these results."
And patients are noticing the change in procedure, including Millie Jackson's family.
Millie's Family Notices
"Aunt Vivian's hospital didn't do this 'bath thing' when she had her surgery," Millie's daughter states.
As Millie is being prepped, her thoughts are of Vivie, her sister and best friend. Vivian Stevens, age 67, never recovered from a fractured hip. Shortly following a total hip replacement she spiked a fever and was rushed back into surgery for removal of the hardware due to an infection. She spent her last days in the ICU where she died from sepsis and pneumonia, becoming a statistic in national data.
In the U.S., between 500,000 and 750,000 surgical site infections occur annually.2,3 Among orthopedic surgery patients, it is estimated up to 355,500 patients per year develop surgical site infections.4
After a visit from the anesthesiologist and her surgeon, the OR nurses come to take Millie to the OR. "We'll take good care of her," assures Patricia P. Kerns, BSN, RN IV, CNOR, OR staff nurse.
Millie is taken through the double doors across the red line into the OR sterile core. Her family gathers her few belongings and settles in the waiting area in the hopes Millie will be okay. She is a wife, mother, grandmother, aunt, neighbor and friend. Millie is a real person, not just a case or a number.
Patient Outcomes
Ten months following institution of the pre-op cleansing cloths, PWH decreased its SSIs from 25 to 11. Readmissions were reduced from 18 to 5. "An investment of $8,721 yielded a return of $348,923," explained Bonnie Harris, CIC, infection control practitioner.
A member of the PWH SCIP team, Kerns said several proactive measures attributed to the decrease in infections:
Converting to clippers for hair removal and eliminating the use of razors,
Maintaining body temperature during procedures,
Preop antibiotic administered within 1 hour before incision is made,
Implementing the use of CHG wipes prior to surgery and
CHG use in the OR for surgical preps.
Increase Satisfaction, Decrease Infection
These five steps are showing positive results at PWH.
"The initiative resulted in a 60 percent decrease in SSIs," said Jeanne Lese, RN, CNOR, CRNFA, nursing governance president at PWH. "Our change in practice to use clippers rather than razors as well as the use of CHG wipes for the body and surgical site area has been a major contributing factor. These measures have increased staff and surgeon satisfaction and decreased post-op infections."
Millie recovered from her surgery without complications. One year later on a crisp December morning her husband drives her to the entrance of PWH. She walks through the front doors, shakes the dusty snow from her coat and takes her seat at the information desk in her "pink lady" jacket where she starts her day as a PWH Auxiliary volunteer.
End Note
The small flakes of snow are illuminated by the lights of Prince William Hospital's Circle of Lights, a 24-year tradition established by the PWH Auxiliary to raise funds for special hospital projects. Each light on the trees represent a donation in memory or in honor or as a thank-you. Several lights shine in memory of Vivie Stevens, sister, mother, grandmother, wife and best friend.
As nurses we can ignore evidence-based research and be part of the problem or we can choose to work toward improvement of patient care. At PWH, we have chosen the latter.
References for this article can be accessed at www.advanceweb.com/nurses. Click on References on the left navigation bar under Education.
Bonnie Harris is infection control practitioner at Prince William Hospital, Manassas, VA.
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