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Peri-operative Care · The SHEA Podcast

• 0:05
  SPEAKER_00: Welcome to the updates for the SSI Compendium podcast series brought to you by the Society for Healthcare Epidemiology of America, or Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:22
  SPEAKER_00: My name is Hudson Garrett, and I'm an adjunct assistant professor in medicine in the Division of Infectious Diseases at the University of Global School of Medicine and have the pleasure of serving as today's moderator.
• 0:31
  SPEAKER_00: Shay is excited to launch this episode of the updates from the SSI Compendium on Perioperative Care.
• 0:37
  SPEAKER_00: In this episode, we'll discuss a few of the core infection control interventions that take place during the perioperative process that are found in the Shay SSI Compendium of Strategies update.
• 0:48
  SPEAKER_00: In addition, we will also review the importance of maintaining omothermia, utilizing an SSI prevention checklist, and building a cross-functional team to address this complex challenge across healthcare systems.
• 0:59
  SPEAKER_00: I'm happy to introduce our speakers for today.
• 1:02
  SPEAKER_00: First, we have Dale Bratzler, who was recently named the Dean of the Hudson College of Public Health.
• 1:06
  SPEAKER_00: He has served as a professor and chair of the Department of Health Administration and Policy, and as a professor at the Department of Internal Medicine and the College of Medicine at the University of Oklahoma OU Health Sciences Center.
• 1:19
  SPEAKER_00: For more than 20 years, Dr.
• 1:20
  SPEAKER_00: Bratzler has participated in research and guideline development on the prevention of surgical infections.
• 1:26
  SPEAKER_00: He is a past member of HICPAC.
• 1:28
  SPEAKER_02: Thank you, Hudson.
• 1:29
  SPEAKER_02: It's really a pleasure to be here today.
• 1:31
  SPEAKER_00: Awesome.
• 1:31
  SPEAKER_00: We're so glad to have you.
• 1:33
  SPEAKER_00: Next, we're joined by Ruth Carico, Senior Consultant with Carico and Ramirez.
• 1:37
  SPEAKER_00: Ruth is a professor and family nurse practitioner, gratis faculty with the University of Louisville School of Medicine in the Division of Infectious Diseases.
• 1:45
  SPEAKER_00: Dr.
• 1:45
  SPEAKER_00: Carico has received training specific for healthcare epidemiology at the CDC in conjunction with the Rollins School of Public Health at Emory and the Society for Healthcare Epidemiology of America.
• 1:55
  SPEAKER_00: Dr.
• 1:55
  SPEAKER_00: Carico has worked in the field of infection control and healthcare epidemiology for more than 30 years and has served as a member of HICPAC and on CDC work groups.
• 2:04
  SPEAKER_00: She's also participated as part of the compendium author group and has helped with the implementation of those recommendations through training programs focused primarily on infection prevention for national and international audiences.
• 2:16
  SPEAKER_01: Hey, it's a delight.
• 2:17
  SPEAKER_01: Thank you so much for the opportunity.
• 2:18
  SPEAKER_00: Awesome.
• 2:19
  SPEAKER_00: We're glad to have you both.
• 2:20
  SPEAKER_00: Let's jump right into some questions that we have around this particular topic.
• 2:24
  SPEAKER_00: And the first one, Ruth, I'm going to throw your way if that's okay.
• 2:27
  SPEAKER_00: And it's can you discuss really the importance of the barriers to maintaining normal thermia and the overall SSI prevention strategy?
• 2:34
  SPEAKER_00: We know that's such an important topic for our viewers.
• 2:37
  SPEAKER_01: You know, we've talked about normothermia for years.
• 2:40
  SPEAKER_01: And I think this is a great example that we have long recognized the importance, but we just have a problem in actually getting it done.
• 2:48
  SPEAKER_01: So when we think about normothermia, I know in previously we've thought about, well, let's maintain temperature in the operating suite, just in the OR during the performance of the procedure.
• 2:59
  SPEAKER_01: But I really liked the inclusion and the information in this update regarding a reminder that maintaining normothermia really begins from the time the person, uh the patient gets into uh the operative environment, including their pre-op area.
• 3:15
  SPEAKER_01: So starting normothermia then, and it's more than just providing somebody with a warm blanket.
• 3:21
  SPEAKER_01: So, in order for this to actually occur, this is a great example that you look at what your process is, figure out what the overall goal is, and that is to begin that warming process at least 30 minutes.
• 3:32
  SPEAKER_01: And many of us think that, you know, probably a longer period of time than that is going to be important, and then allow that person to be very warm as they enter the actual OR.
• 3:43
  SPEAKER_01: So problems arise when we don't look at the process and then try to figure out where are we failing and then what are some many times easy fixes to make this happen.
• 3:53
  SPEAKER_01: Dale, what can you add to this?
• 3:55
  SPEAKER_02: Back when we first started the surgical care improvement project, purely 15, almost 20 years ago now, this was a particular performance metric on keeping patients warm in the operating room that wasn't being done very commonly in many places in the country.
• 4:09
  SPEAKER_02: And we know that when patients get cold in the operating room, they're more likely to bleed, you'll get wound hematomas, and other problems that can result in risk for surgical side infection.
• 4:19
  SPEAKER_02: So we think it's really important to keep patients warm through the operative procedure.
• 4:24
  SPEAKER_02: When I first started going out and meeting with hospitals about this, a lot of them talked about the ambient temperature in the operating room.
• 4:31
  SPEAKER_02: And I know that many operating rooms are pretty cold.
• 4:33
  SPEAKER_02: But as you pointed out, Ruth, we think it's really, really important to start warming the patient before they ever get to the operating room.
• 4:40
  SPEAKER_02: If they get to the operating room, they're already cold.
• 4:43
  SPEAKER_02: It's going to be much more difficult to keep their body temperature up.
• 4:46
  SPEAKER_02: So get the patient warmed up in preoperative holding before they go to the operating room if that's feasible.
• 4:52
  SPEAKER_02: And then use the many different devices that are available to keep the patient warm in the operating room.
• 4:58
  SPEAKER_02: I don't really know that any one particular device is better than another, but use, particularly for the longer operations, devices to keep the patient warm in the operating room, which will lower the risk of surgical site infection.
• 5:13
  SPEAKER_00: Great insight, you know, and I think one of the things I heard from both of you is the importance of maintaining that process, right, from sort of the start to the finish.
• 5:20
  SPEAKER_00: So that's a great observation for us.
• 5:23
  SPEAKER_00: That sort of leads nicely into our second area of interest, which was really the concept of antiseptic wound lavage.
• 5:29
  SPEAKER_00: And so I'd like to start with you, Ruth, and hear from Dale as well, sort of what you think that role is in terms of standard of care.
• 5:36
  SPEAKER_00: You know, should antiseptic wound lavage become standard of care for all of our surgical patients, or is there enough data for that yet?
• 5:43
  SPEAKER_01: Well, I think one of the many changes that we see in the updates were the movement into and clearly defining uh statements as essential elements, and this is uh this is one that we have long recognized that wound lavage is used by you know many, many of our surgeons for uh for many of the surgical procedures.
• 6:04
  SPEAKER_01: But what differs is what solution, the volume of solution, and and so forth.
• 6:09
  SPEAKER_01: So certainly this is a discussion that should be part of a preparation before the procedure starts.
• 6:16
  SPEAKER_01: What is the physician, the surgeon preference?
• 6:18
  SPEAKER_01: Um, but I think that it has become such a widespread um process, part of surgical care, that you know it is the assumption that it will be used at some point, primarily as part of the prophylactic approach.
• 6:30
  SPEAKER_01: Now, again, in the past, uh the use of saline as a lavage may have been a standard practice in many facilities, but now then there's a movement away from the use of saline into uh different uh types of solutions.
• 6:44
  SPEAKER_01: I would just caution, not a solution necessarily that is an antibiotic solution, but something, for example, such as povodone iodine solution.
• 6:54
  SPEAKER_01: So uh several really excellent randomized control clinical trials have demonstrated a benefit.
• 6:59
  SPEAKER_01: And so now it's how do we figure out how to get it done?
• 7:03
  SPEAKER_01: How do we make sure that those solutions are prepared properly and then they are used in a manner that that maintains then the uh sterility of the process.
• 7:13
  SPEAKER_02: So, what I'd like to do is talk about a couple of things or problems that can occur here.
• 7:18
  SPEAKER_02: So when we were when we were developing uh the updated compendium, we talked about this particular practice a lot because there are good trials now that show that either the use of antibiotic solutions, typically a beta-lactam or amino glycoside, or povadoniodine, as Ruth pointed out, can reduce the risk of surgical site infection.
• 7:40
  SPEAKER_02: One of the problems with povadoniodine is finding a sterile solution to mix.
• 7:45
  SPEAKER_02: It has to be sterile.
• 7:46
  SPEAKER_02: It's not povadoniodine that comes out of a bottle at the bedside.
• 7:50
  SPEAKER_02: So you got to make sure you have a source of sterile povadini iodine if you're gonna do this to lavage the wound, it's very, very important.
• 7:57
  SPEAKER_02: And then the other important point we made is that many surgeons for a long time used to use uh bassitracin in their mixture that they put in the peritoneum.
• 8:08
  SPEAKER_02: It's not recommended, and in fact, it's been pulled by FDA because of risk of anaphylaxis that have occurred in some people getting peritoneal lavage.
• 8:18
  SPEAKER_02: So I think it is an important practice, particularly if you're still struggling with higher rates than expected of surgical side infection, and you're trying everything, all the other processes of care, using sterile povidone iodine in the solution that's used for lavage, or some antibiotics are being used, particularly beta-lactams or amino glycosides and in uh dilute concentrations may reduce the risk of having a surgical infection.
• 8:47
  SPEAKER_01: You may need to work with the surgeon to determine what type.
• 8:50
  SPEAKER_01: So colorectal surgeons may have one approach, other surgeons uh may have another.
• 8:55
  SPEAKER_01: So, you know, getting that outlined before the initiation of the surgical procedure will be an important part for preparation.
• 9:03
  SPEAKER_00: And interesting, you know, given how many of the new commercial concentrations are coming out with FTA clearance, which is helpful for us too, to sort of evaluate the evidence behind those as well.
• 9:12
  SPEAKER_00: So this leads us nicely into sort of another area of focus, which I think, you know, Dr.
• 9:17
  SPEAKER_00: Gawande did a beautiful job of sort of setting up many years ago.
• 9:21
  SPEAKER_00: Dr.
• 9:21
  SPEAKER_00: Bratser, you've certainly done a lot of work too.
• 9:24
  SPEAKER_00: And so I want to start this question with you, which is sort of that role of the checklist, right?
• 9:28
  SPEAKER_00: We know that historically with IHI and other organizations, that checklist had made big differences in helping us be more standardized in our practices across health systems.
• 9:37
  SPEAKER_00: Is this something that you think that that SSI checklist should be implemented across a health system?
• 9:42
  SPEAKER_00: And how will that sort of contribute to garnering traction?
• 9:46
  SPEAKER_02: Yeah, so I think using a checklist is incredibly important for so many quality improvement efforts that we do in healthcare.
• 9:54
  SPEAKER_02: And so let's go back to, you know, you you mentioned the Tua Gwande, the use of checklists.
• 10:00
  SPEAKER_02: It's been done in aviation for many, many years and has been shown to uh substantially improve the safety of aviation.
• 10:08
  SPEAKER_02: The World Health Organization did a trial, a multi-country trial of a surgery checklist that focused on preventing surgical infections.
• 10:18
  SPEAKER_02: And what they found in that particular study was that an implementation of the checklist reduced the rates of surgical site infections.
• 10:27
  SPEAKER_02: We have used it in our own health system not only as a way to remind ourselves of all of the processes of care that need to be met, but also it's very useful for auditing the charts when you're looking to see after the fact, particularly if you're doing audits, to have that checklist available to see that somebody actually did walk through the checklist to make sure that all the processes of care were implemented.
• 10:54
  SPEAKER_02: And I'd be remiss if I didn't mention also thinking about using a bundled approach to surgical site infection prevention by holding providers in the system accountable for a bundle of interventions that are all evidence-based, we can reduce the risk of surgical infection.
• 11:12
  SPEAKER_01: And I think, you know, this this really follows the importance of having a process that's reliable.
• 11:16
  SPEAKER_01: And that reliability then requires that you have some way of assuring or assisting with a process that will occur repeatedly.
• 11:25
  SPEAKER_01: So if we are looking to have the same types of interventions occurring repeatedly and then being able to measure the effectiveness of those, uh, that we have to have some way of doing that.
• 11:37
  SPEAKER_01: And that in a checklist, a well-designed checklist becomes essential.
• 11:41
  SPEAKER_01: It also is a way then that you can take the information on the expectation outlined in the checklist and then use that as part of the training that you need to have for all personnel.
• 11:52
  SPEAKER_01: So it forms the basis not only for the practice that you want to occur, but it's also evaluating the practice that you want to occur and then training to those practices.
• 12:02
  SPEAKER_00: So what I'm hearing in addition to sort of the systems work, right, is it's also about having the right people.
• 12:07
  SPEAKER_00: And that actually is a great segue into our next topic of conversation, which is really building that right dinner table, if you will, of team members.
• 12:15
  SPEAKER_00: So I'd love to hear Dale from you first and Ruth from you as well is to who are those right team members that need to be a part of this SSI prevention team so that we are truly approaching this from a cross-functional perspective.
• 12:27
  SPEAKER_00: So, Dale, I'll throw that one your way first.
• 12:29
  SPEAKER_02: Yeah, thanks, Hudson.
• 12:30
  SPEAKER_02: So I think this varies sometimes depending on the health system that you're actually working in, but there are a few core functions of people that you need on the team that I think are particularly helpful.
• 12:42
  SPEAKER_02: So obviously, I think it's really important to have a surgeon who is at least going to uh champion some of the uh processes of care uh that will actually kind of be the cheerleader for the team, who has credibility with other physicians in the team and others.
• 13:00
  SPEAKER_02: I think that's important.
• 13:02
  SPEAKER_02: But oftentimes, you know, we've included quality improvement nurse or personnel in our teams, infection preventionists, I think are incredibly important.
• 13:11
  SPEAKER_02: The people that are doing surveillance for NHSM can be very, very useful on that team.
• 13:17
  SPEAKER_02: A performance improvement team or a PI team that puts into place certain processes like Six Sigma processes to make sure that you have a process to go about measuring and assessing your performance and then doing improvement, identifying the barriers within your system.
• 13:36
  SPEAKER_02: So somebody leadership, I think, is really important.
• 13:39
  SPEAKER_02: So I had the honor of serving as a chief quality officer for about 10 years and had the administrative authority to actually make things get done in the system.
• 13:50
  SPEAKER_02: And that's incredibly important when you're trying to prevent surgical infections and have a team that has that responsibility.
• 13:58
  SPEAKER_02: The other people that I've included, we have a pharmacist that participates with us, making sure that we have the right antimicrobials available.
• 14:05
  SPEAKER_02: If you're going to do lavage, make sure you have those materials available to do in the operating room.
• 14:11
  SPEAKER_02: And then your operating room nurses are just critical to this.
• 14:15
  SPEAKER_02: And right now I'm working with a team where we have one of our lead surgical nurses that's very important part of the team that we're working with to improve and reduce surgical infections.
• 14:27
  SPEAKER_01: You know, I think I would add also individuals that are responsible for taking care of the surgical instruments.
• 14:33
  SPEAKER_01: So individuals from sterile processing and also environmental services personnel that are responsible for cleaning and disinfection of the room and the items, and then making sure, you know, that turnover is done quickly and efficiently.
• 14:47
  SPEAKER_01: So it really points out to, you know, it can be a very large group of or very broad representation.
• 14:53
  SPEAKER_01: And that may change according to the particular site.
• 14:57
  SPEAKER_01: You have a small community hospital, you may have fewer people, they may uh be responsible for multiple functions.
• 15:04
  SPEAKER_01: Or if you have an ambulatory surgery center, you may have different individuals, but but still those that have that general function, uh, Dale, all of those that you outlined.
• 15:14
  SPEAKER_01: You know, in addition, I think it's it's also important, you know, you spoke about having somebody that will be a champion.
• 15:20
  SPEAKER_01: I always try to gather somebody that is really good with identifying the problems.
• 15:24
  SPEAKER_01: So maybe someone that, you know, brings problems to you frequently.
• 15:28
  SPEAKER_01: It's important to have that perspective because they may not hold back on some of the issues that maybe others either have been hesitant to bring up or or perhaps haven't recognized.
• 15:39
  SPEAKER_01: So it all you know involves a willingness to listen, gather very broad input, and uh be very inclusive so that you are able to represent as many of those activities that occur both before, during, and after a surgical procedure as is possible.
• 15:55
  SPEAKER_00: Ruth, if I can, I want to ask a follow-up question about, you know, we we and I know you specifically have worked a lot across different disciplines and and with success.
• 16:03
  SPEAKER_00: What do you think is the biggest barrier to preventing that sort of interprofessional collaboration?
• 16:09
  SPEAKER_00: Because we know it's needed, we know it's necessary and it and it really yields tremendous success, but what's holding us back from getting to it?
• 16:16
  SPEAKER_01: Well, I think a lot of times it's just the approach and pulling people together and making sure that, you know, at the very beginning we're very clear on what our goals are and uh and listening then to concerns that people have, and then making some some really important decisions regarding, you know, who we need to include.
• 16:35
  SPEAKER_01: It may not be somebody that you have thought of previously, but being open, I think, to the ideas.
• 16:40
  SPEAKER_01: I think we've learned a lot from things like the you know Toyota production model, where you know, we say the people that do the work know the work best.
• 16:47
  SPEAKER_01: So making sure we are including the people that are actually doing that work because they are the ones that may be able to help us identify some problems.
• 16:56
  SPEAKER_01: So, you know, and sometimes it takes you a while to pull your team together.
• 17:00
  SPEAKER_01: So I always say don't be in, you know, in such a hurry to pull a team together that you don't pull the right team members together.
• 17:07
  SPEAKER_02: To that last question, I would just simply add that these are really busy people usually.
• 17:13
  SPEAKER_02: And anytime you're trying to schedule a team of surgical nurses, maybe infection preventionists, facility folks, and others, uh sometimes it's just difficult to get all those people together.
• 17:24
  SPEAKER_02: So sometimes there are just some challenges that we all face when it comes to doing performance improvement that you just have to think about.
• 17:31
  SPEAKER_02: But it's really critical that you get as many of the members of the team together when you can to walk through.
• 17:37
  SPEAKER_02: And we've gone through a process now, not only auditing where we've done looked at infections and things like that, but but then kind of doing that root cause analysis of the individual infection and figuring out what processes were missed.
• 17:51
  SPEAKER_00: Great insights.
• 17:52
  SPEAKER_00: You know, but people matter, right?
• 17:54
  SPEAKER_00: I think we all agree to that.
• 17:55
  SPEAKER_00: And getting the right people matters even more than that.
• 17:58
  SPEAKER_00: So this really leads us into our last topical area, which I think you'll both have perhaps a different perspective on, which is which is great.
• 18:05
  SPEAKER_00: And it's really around sort of the concept of who is best equipped to potentially lead these efforts across a health system, particularly as we look at more aggregation of health systems.
• 18:15
  SPEAKER_00: So, Dale, I'd like to get your perspective first and then we'll go to Ruth.
• 18:19
  SPEAKER_02: Yeah, so I'm actually not sure who the best person is to lead many times.
• 18:23
  SPEAKER_02: And I think again, it kind of depends on the system that you're working in.
• 18:27
  SPEAKER_02: You know, I mentioned earlier, I think it's really, really important to have a physician champion.
• 18:31
  SPEAKER_02: It could be a surgeon, anesthesia we found that does a very, very nice job of leading some of these quality improvement efforts like this.
• 18:39
  SPEAKER_02: But you need a champion, somebody that has the respect of other clinicians that can kind of uh help you be ambassador for your efforts, your improvements that you're trying to do.
• 18:50
  SPEAKER_02: But I also find that sometimes busy physicians, surgeons may not be the best at organizing the effort.
• 18:57
  SPEAKER_02: And that's why many times in the systems I've worked with, we've had a quality improvement uh staff person, nurse, a performance improvement team member, or somebody that's um infection prevention, they often do a great job of leading these efforts because they have access to the data, they're very data-oriented, they capture the information, they know how to look for the processes of care.
• 19:22
  SPEAKER_02: You need a leader that can keep the team moving forward.
• 19:26
  SPEAKER_02: And that's not always the physician champion, but I I truly believe that you need to have that healthcare provider that's really the champion for this effort that can bring along the rest of the staff.
• 19:39
  SPEAKER_01: I agree with much of what you have said, Dale, that it's really tough to say there is a particular discipline that uh would lead this effort.
• 19:47
  SPEAKER_01: And I think that as we recognize that preventing surgical side infection is becoming an increasingly complex situation.
• 19:56
  SPEAKER_01: And so now we're trying to lead change.
• 19:58
  SPEAKER_01: And I think in leading change, uh that requires some very specific skill sets.
• 20:05
  SPEAKER_01: And oftentimes I think people, some people are born to be facilitators, you know, born to really talk about the problem, being able to pull in a variety of perspectives, you know, keep the group moving forward, not be sidetracked or, you know, or or suck down a you know a rabbit hole, but that ability then to lead a discussion about addressing a complex process in a system, a healthcare system that is constantly changing and constantly adapting, this is a real skill.
• 20:36
  SPEAKER_01: And so I think we we've seen that in a number of the initiatives that talk about, you know, how do you implement change?
• 20:41
  SPEAKER_01: How do you take a situation and be able to make the required adaptations or change and what that involves, both in the people that will be leading those efforts and those then that you are are going to hold accountable for making those changes.
• 20:58
  SPEAKER_01: So I think more than anything else, it's looking for those skill sets, people that have some competence in being these group facilitators that will be able to deal with some very strong personalities.
• 21:09
  SPEAKER_01: Because I think, you know, one of the reasons why we have done such a really an outstanding job in the operative settings are really because of the way operating rooms are structured, the OR personnel, their commitment to consistency and reliable practice and and so forth.
• 21:24
  SPEAKER_01: And that, you know, what we've all come to love and know is that surgical conscience.
• 21:29
  SPEAKER_01: You know, we've talked about that for many, many years.
• 21:32
  SPEAKER_01: So with these strong personalities, um, I think that we have to have very strong and competent leadership.
• 21:38
  SPEAKER_01: So maybe something that we can think about is how do we begin to instill and teach those abilities so that facilitation is a real recognized talent.
• 21:49
  SPEAKER_00: Well, thank you so much both for the conversation.
• 21:51
  SPEAKER_00: This was very informative and quite insightful.
• 21:54
  SPEAKER_00: We appreciate you joining us today.
• 21:56
  SPEAKER_01: It's been a delight.
• 21:56
  SPEAKER_01: Dale, it's uh wonderful to have the chance to work with you again.
• 21:59
  SPEAKER_01: Uh, same thing with you, Hudson.
• 22:01
  SPEAKER_01: I appreciate the opportunity to be part.
• 22:03
  SPEAKER_02: Yeah, absolutely.
• 22:04
  SPEAKER_02: Great to uh to be here today.
• 22:06
  SPEAKER_02: I want to say that uh when we were writing the compendium, we had a lot of really smart people that came together, reviewed a lot of literature, put a lot of thought into the recommendations.
• 22:16
  SPEAKER_02: I really encourage everyone to read the compendium on prevention of surgical side infections because it has good information that I think can help reduce the risk of this infection.
• 22:26
  SPEAKER_00: Fantastic.
• 22:27
  SPEAKER_00: If you're looking for more educational content like this podcast, you can locate it on Shay's online education center, learning CE at www.learningce.shay online.org.
• 22:39
  SPEAKER_00: This concludes today's episode of the updates from the SSI compendium series.
• 22:43
  SPEAKER_00: Thanks so much for tuning in, and we look forward to seeing you soon.