Reducing Infection After Joint Replacement

Teamwork produces better outcomes and a shift in culture

Collaboration among disciplines toward shared goals is an important component of patient safety. Recognizing this, nurses at Einstein Healthcare Network led a collaborative effort to reduce surgical site infections (SSIs) related to hip and knee arthroplasty. By utilizing the Surgical Unit Safety Program (SUSP) framework, the team at Einstein Medical Center Elkins Park Orthopedic Surgery, in Elkins Park, Pa., has achieved a significant reduction in surgical site infections. The interventions resulted in an SSI reduction after total joint replacement from 2.85% (2013 & 2014) to 1.12% (2015).

SUSP Approach

The SUSP approach recognizes the need to combine technical work (standard delivery of evidence-based infection prevention elements and bundles) with efforts to develop a strong culture of safety (i.e., teamwork, frontline involvement from all roles). At inception, the project team was structured to involve nurses from all parts of the patient journey through surgery: orthopedic office, preadmission testing, short procedure unit, operating room, post-anesthesia care unit, and the medical/surgical unit.

The team is led by the nurse manager of perioperative services and an orthopedic surgeon specializing in total joint surgeries. Further direct involvement from other key departments includes frontline representation from anesthesia, environmental services, infection control, central processing, senior executive leadership, information technology, and patient safety and performance improvement. This structure, coupled with the team leadership, has created a culture in which all diverse voices on the team are encouraged to share ideas to prevent SSIs.

The team developed an evidenced-based plan of care (bundle) in the form of a checklist document (called a Travel Tag) that follows the patient’s course from the surgeon’s office through discharge. This created a sense of accountability in each department to check off key elements of the bundle as they are completed. These forms were collected and used to audit and monitor compliance. The data generated were discussed in team meetings and used to identify barriers and further standardize care. Strong process data made conversations more objective and helped to engage physicians. These discussions led to a deeper understanding of the relationship between roles involved in a shared improvement goal.

 All Levels Feel Impact

All levels of staff now feel empowered to speak up, share ideas and take ownership of piloting new ideas, explained Annette Yerkes, RN, nurse manager. For example, a team member from environmental services (housekeeping staff) who cleaned the OR rooms led efforts to standardize the cleaning process through checklists and additional training. Formality was left at the door, and everyone was able to learn and contribute. Senior leadership played a key role by being at the table with staff, not to direct but to listen and remove barriers as needed.

“I feel so good about what everyone is doing. I know our patients are in good hands,” Yerkes said. Julius Oni, MD, orthopedic surgeon and team co-leader, noted that “Nurses were really the drivers of this, from all aspects of the patient’s experience.”

The team’s success has provided momentum to examine SSI reduction for other types of surgery in the same format. The Einstein Orthopedic Surgery SUSP Team continues to expand its scope to use the same collaborative learning approach to identify and address any patient safety challenges. The many benefits of this shift in culture means that the team comes together to determine what to work on as well as how they work on it.