INSTITUTE OF QUAILTY MANAGEMENT

Health Care TQM Diploma

Six breakthrough to reduce open heart surgical site wound infection By Abdelfatah Basioni Supervised By 17/7/2011

Sharq El Madina Hospital is a tertiary care hospital serving a large catchment area in the east region of Alexandria & the nearby governorates

Its mission is to provide outstanding health care for the community that is effective and efficient using modern medical equipments through well trained skilled staff. It is considered as social organization under authority of Ministry of Health (MOH).

Sharq El Madina Hospital was constructed at 1977 and started the open cardiothoracic surgery activities at 1996.

The cardiology & open cardiothoracic surgery became the core competence of the hospital which is evident by performing about 10,000 open heart surgeries & about 17,000 diagnostic & therapeutic cardiac catheter in the period from 1996 2007.

Appendix
The surveillance rate for open heart surgical site wound infection suddenly raised from 3.8%(the global accepted ratio 5.1 %) in December 2010 to 8.1% in Jan 2011 &11.1% in Feb. 2011 y Our reputation as center for open heart surgery in Alex was threatened y Infection control team started to discover the root causes y We use the six sigma steps in our project
y

References : oxford journals-medicine-American journal of epidemiology-Volume 161,isuue 7- Pp>661-671

0% 1% 8.00% 11.10%

1010 1111-

SSI- Open Heart surgery-

12% 10% 8% 6% 4% 2% 0% 1010 1111Series1

Project benefits Financial and operational benefits

y

Each post operative infection cause readmission for debridement and closure of wound and approximately increase LOS by 10 days at cost of an additional 6000 LE in extra charge An averaged 5 infections per month ,approximately 60 infection per year at a total cost of 360,000 LE If infection decreased to 4% a saving of about 235,000 LE will take place

Soft Benefits
To follow the best practice for aseptic techniques methods y To improve patient safety and customer confidence y To save the good reputation y To be adherent to the global percentage of post operative infections
y

Six sigma steps

Define Measure Analyze Improve Control

Define phase
Project Definition
 y

problem statement

The surveillance for surgical site infection of post operative cardiac surgery show an increase of infection rate on Feb.2011 to 11.1% ( about 2.7 ) y The accepted infection rate is up to 5.1% y This leads to increase rate of readmission to cardiac center with raising cost y This may lead to loss of reputation

Players Roles & responsibility

y y y

Executive leaders Champions: Process area( measurement areas ):

Dr, Mahmoud Eldamaty ,medical director Dr, A Basioni, Infection control Team leader Operating Room Open Heart ICU Word Outpatient Clinic dressing room

D
y

Project Goal
lowering and preventing post operative cardiac surgery wound site infection y To minimize the infection rate to less than 5.1% (3.3 ) y Keep the good reputation of cardiothoracic center

Project scope
y

Open heart surgery start from physician order of entry & ends by ensure complete healing after discharge by one month

Project team D ( Cross-functional team ) Crossy y y y y

Infection control team

( Dr./abdelfatah basioni ,Miss/kamilia Sami, Miss/Hayat Ibrahim )

Quality director
(Dr./Sali abdulraof)

Operating Room manager

( Dr./Alaa Omar)

Open Heart surgery manager

( Dr./Farid El-Medany)

Bacteriology specialist
( Dr. Fatma Hamdy)

Project team
y y y

Central Sterilization Unit manager

( Dr./Houda Ramadan)

Head nurse of Open Heart & ICU

( Miss/Houda Tolba Miss/ Doha Gaber)

Link nurses in measurement areas

D VOC
VOC Wound infection CCR Clean wound CTQs Clean wound Target Up to 4%wound infection

Readmission Secondary suture

No No secondary suture

No readmission Clean wound

No readmission Clean wound

Long stay

No more than the average LOS

Average LOS

Average 7days

D Project plan

Define 1/3/2011-15/3/2011
Measure 16/3/2011-31/3/2011 Analyze 1/4/2011-15/4/2011
Improve 16/4/2011-30/4/2011

Control 1/5/2011-15/5/2011

Measure phase

Tools

M SIPOC Diagram open heart surgery

Suppliers Cardiothoracic physician Anesthesiacist Operating room nurses ICU nurses Word nurses Patient
Inputs (Specifications) Process (blood transfusion) Physician order for surgery Check by anesthesia sp Admission and prepared for surgery surgery ICU for 48 hrs Transf to word Outputs (Requirements) Customer

CVP S Dressing chest tube Thoracic canula OR H LUNG Machine ICU Suction Jars Dressing car Antibiotics Inf set & Inf pump Tables , beds, monitors ) Safety box

EFFECTIVE PROCEDURE OF OPERATION

Patient Hospital MOH

dressing & ttt for 5 days discharge

Dressing and F up in OP clinic Complete healing of the wound within 1 month

Flow diagram open heart surgery & f-up in OPC dressing room Admission
operation End of process Post op 48 hr ICU
No

weaning yes Word Dressing & ttt 5 days

No

yes Clean wound

No

Readmission

Clean wound

yes

Discharge & f-up OP

Data collection
 Sample

unit : (patient) candidate for open heart surgery process( random choice)  Sample size : 20 pt  Sample method : simple random sampling  Type of data : ( discrete- no of errors in each process )

Areas of measurement
Operating room Central Sterilization Unit laundry Open Heart ICU Out Patient Dressing Room Commitment to Antibiotic Policy Word Calibration & Dispensing Unit Medical Files

Collected data
1- Commitment to antibiotic policy ( preoperativepostoperative type ) 2-Predisposing factors (diabetic immunity ) 3- positive Swabs from potential places( areas of measurement ) 4- Commitment to antiseptic measures (in measurement areas ) 5- Type of Surgical procedure ( graft- valve-..) 6- Surgical team (Relation between each team and infection) 7- Operation time ( long- more than average time )

M Data collection plan

Project name
Process name Data plan prepared by Period from and to (what?)

Six sigma improvement of post operative infection rate in OHS Decrease rate of surgical site wound infection for open heart surgery Dr, abdelfatah basioni 1-3-2011 to 15-5-2011
Operational Def Who is responsible for collection When will data be collected Haw will be data collected Computing the no of errors in each process By documenting all data related to area of measurement through sampling Where will the data be collected

Clean wound

The patient must discharged within 7 days with clean wound and follow up in OP clinic for 30 days without complication 0r developing wound infection

Infection control team Quality team Link nurses

Randomly from the start of the process till the end of the process

Points of measurement

Haw data collected

y

Computing the no of errors through the steps of the process ( As is ;)

y y y y y y

Number of non Hand washing during deal with each sample unit Number of non Wearing of PPB during deal with each sample unit Number of Positive swabs from area surrounding the patient at ( measurement area) Number of positive swabs from medical equipment Number of Non commitment to Antibiotics policy ( patient file ) Number of immunocompromised pt

M Culture & Sensitivity Test

M Surveillance Form

M HH & PPB

Data collection M HH &PPB

procedure Sample size ( done )+ve -Ve HH 20 6 14

HH & PPb
25 20 15 HH & PPb 10 5 0 sample size no HH & PPB done 20 14 6

M Suction Jars
procedure Sample size Contaminated with yeast & Gm ve bacilli Not contaminated 25 20 15 10 swabs for C & S Test 5 0 sample size contaminated not with gm -ve contaminated bacilli 20 11 Swab C&S test 20 11 9

swabs for C & S Test

M Immune compromised Patient

procedure Sample size Uncontrolled ( insulin therapy ) Good immune Patient Immunity
(DM- low immunity-....)

20 1 19

immunity status
25 20 15 10 5 0 20 1 19

immunity status

M Swabs from outpatient dressing room

procedure Sample size Not contaminated
Swabs from Op dressing room

20 13

Contaminated with gm ve bacilli(drums) 7

Swab for C &S Test

25 20 15 10 5 Swab for C &S Test 0 20 13 7

Swabs from Heart-Lung machine Heartprocedure Sample size positive negative

Swabs from Heart lung machine

20 0 20

Current situation
y

We tracked the errors in each situation & arrange them in descending order

Current situation ( As, Is )

Type of errors Frequency of occurrence 14 11 No H H or PPB Contaminated suction jars with ( mainly yeast, few Gm-ve bacilli) Rust Contaminated equipment in OP dressing room Contaminated antiseptic sol in OP dressing room Positive swab patient's bed Immunecompromised Patients Long time surgery Positive nasopharyngeal swab for m staff improper use of antibiotics

7 6 2 1 1 0 0

Line chart
Frequency of data
15 13 11 9 7 5 3 1
frequency

14 11 7

6 2

1-

Analyze phase

Brain storming Causative defects Fish bone diagram Pareto diagram

Brain storming A causative defects

Identifies the possible cause of the problem y Identifies potential remedies y Identifies potential resistance to remedies
y

Cause and effect diagram Fish bone diagram-Ishikawa diagram diagramPeople

Med staff not follow P&P of antiseptic tech Improper HH No wearing of PPb Rains suction jars in Pt toilet Improper disinfection Improper dilution of disinfectant Bad habits of visitors

Place
contaminated beds

Medical supp
contamination Suction jars
contam drums

Improper dressing
No HH or PPB
Contaminated drums Contaminated Btadine

Improper Pt

Post Operative Wound Site Infection

Uncontrolled DM Patient's relative

Disinf sol
contam Betadine (dressing)

manipulation long time surgery

bad hygiene

Provision

procedures

Patrons

Contaminated drums

OP Dressing room

Contaminated surface

OP Dressing room

Rusted suction jars

Untrained staff- visitors staff-

M Surface work place contamination

OHICU

Contaminated floors

SMALL O R

Improper wastes disposable

Female word

Predisposing factors

Male word

Contaminated laryngosope

OHICU

Medical suppliers contamination in OHICU

OHICU

Contaminated surface

Male word

contamination

OHICU

Contaminated surface

OHICU

Use of pt toilet in rains M Eq.

Swabs C & S test

Swab C & S test

Bilogical indicator f-up in CSU f-

CSU observation

Dispensing & Calibration

unit

A
Type of errors
No HH or PPB Contaminated suction jars Contaminated equipment in OP dressing room Contaminated antiseptic solution in OP dressing room Positive swab from patients bed Immunocompromised Pt Long time surgery Positive nasopharyngeal swab from open heart team Improper use of antibiotics

frequency Cumulative cumulative %

14 11 7 6 2 1 1 0 0 42 14 25 32 38 40 41 42 42 42 33.33 59.52 76.19 90.48 95.24 97.62 100 100 100

A Pareto chart
40 35 30 25 20 frequency % cummulative15 10 5 0 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00

14

11 7 6 2 1 1 0 0

Identify root causes

Non compliance to policies and procedures of antiseptic measures y Contamination of medical equipment with gm ve bacilli y Contamination of disinfected solution with gm ve bacilli y Contaminated out patient dressing room environment
y

I
y

Improve phase
Solution alternative (corrective plan ) Remedy selection matrix
Selection matrix Alternatives Criteria Name Cost Training Time Benefit /cost Resistant Effectiveness Health & Safety Rating Remedy A
Rains & disinfect suction jar in CSU

Remedy 2
Reconstruction of OP dressing room

Remedy 3
Implement policy & Procedures of antiseptic technique

1 2 5 3 5 5 21

3 1 5 3 5 5 22

1 3 5 1 5 5 20

Remedy selection matrix

Selection matrix alternatives criteria Name Remedy D
New strategy for floor and work surface disinfection

Remedy E
Purchase new equipment

Cost Training Time Benefit /cost Resistant Effectiveness Health & Safety Rating

2 2 5 1 5 5 20

5 1 5 4 5 5 25

Designating the remedy

Corrective action
y y y y

Publishing of aseptic technique policy and procedures as regards the MOH guidelines Confirm sterilization & disinfection Reconstruction of OP dressing room New strategy for Floor and surface wall disinfection

Tree Diagram
Provision of supplies Implement HH and PPB policy &procedures Train medical staff Publishing policy & procedures Disinfection of drums in CSU Rains & disinfection of suction jars in CSU Allocate new room Purchase New drums

Confirm sterilization and disinfection

Decrease wound site infection

Reconstruction of OP dressing room

Antiseptic solution Disinfection of floor and surface working areas Dispensing and calibration unit Training

Barriers & Aids chart

Barriers
To obtain new room for dressing CSU staff refuse new responsibility

Expenses

Staff resistant

Decrease post surgical wound site infection

Management support

Keen on good reputation

Aids
contributors
Infection control committee agreement

incentives

Countermeasures

Prove Effectiveness
Pilot test
Sample size; 5 patient

What? Status of wound

Results of different swabs Comply with the instructions

Where?
Areas of measurement

When?
preoperative Post operative After discharge

How follow?
Infection control team & link nurses

Haw?
Observing, training & guides

Prove Effectiveness

pilot test Sample scale ; 5 patient

Test Disinfection of suction jars in CSU Implementation of policy and procedures of HH & PPB during dressing Suction jars (swabs ) Aseptic techniques methods Aseptic solution preparation Out patient dressing room environment Positive Done Followed Negative Date 16-4 16-4

Sterile followed perfect excellent

20-4 16-4 20-4 25-4

Implement
Reconstruction of OP dressing room

Implement
purplish of policy & procedures of antiseptic techniques

Implement
disinfection of suction jars

Implement
Training

Implement
follow aseptic techniques

Results
The surveillance result as regards wound site infection of open heart surgery for months March and April in order as follow: y March 2011 3.2% y April 2011 3.1%
y

control phase
As the team know the root causes for post surgical wound site infection of OH surgeries ,put correction plan and implemented this plan , an obvious improvement (decrease the rate of wound infection to 3.2% ) was noted y To ensure the maintenance of the project quality control spreadsheet was designed
y

C Quality control spreadsheet

Control variable Post operative wound site infection
Compliance with IC policy & procedures

How measured

Where measured
Word Outpatient dressing room

Standard

Who analyzes
Infection Control Team

Who acts

What done
Sterilization steps Antiseptic technique Check staff Training advise

=,< 4%

Surveillance Reports

ICT Leader IC team

Auditing Report

OR ICU Word Outpatient dressing room ICU

guidelines

ICT Link nurses

ICT leader Link nurses

Suction jars disinfection

Swab for C&S Test Auditing Swabs for C&S test Reports

-ve

Bacteriologist

CSU staff ICT ICT OP dressing room link nurse

Check disinfectant Check staff and equipment Training Status of room

Out patient dressing room

OP dressing room

guidelines

ICT Link nurses

Audit the control

Report results
Frequency of errors after improvement sample size (20patient ) (20patient
Frequency

Frequency

20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0

2 0 0 0 0

2 0 0

Report results (L.O.S) Sample size : 20 patient

average l o s
9 8 7
days LOS

6 5 4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

average l o s

No of patient

C Auditing the control

C Poka yoke ( error proofing)

y Determine

methods that will ensure that a process will not allow defect y Ensure that tasks can only be done the right way

C Pokayoke / Error Proofing

y

Dressing seal : dressing must be done through senior cardiologist only (signature on dressing include
name and date )

y y

All antiseptic procedures should be followed and supervised by ICT (through schedule sheets) Antiseptic solution provided in areas of measurement (labeled with concentration and date of
preparing )

Suction jars should be disinfected in CSU( packed,

labeled)

purpose 1- A prospective design for possible ways in which failure can occur 2- Eliminate the possibility of failure 3- Stop a failure before it reaches people 4- Minimize the consequence of a failure

The Joint Commission requires the proactive risk assessment of at least one high-risk process per year Goal is to reduce risks, improve patient safety, and enhance patient satisfaction

C
1. 2. 3. 4. 5. 6. 7. 8.

9. 10.

Constitute of multidisciplinary team choosing a high risk process Develop flow chart Identify all ways process could fail Rate each failure mode Determine the risk score Calculate primary outcome measure Identify failure modes greater than a designated score and develop action plan Propose steps to implement action plan Rescore the primary outcome measure

C
Identify what could go wrong at each of the process steps on the flow chart why causes effects

Severity 1-10

Probability 1-10

Detection 1 -10

Determine the Risk Score

for postoperative wound site infection

Process & sub Failure process Mode

Effect Proximate causes

Severity

Probability

Likelihood of detection

RPN Critical index

Immunocompr 1-asses Pt. omised Neglected

Wound infection

Uncontrolled DM

Insufficient ant diabetic Therapy

pt not received proper therapy when indicated

C
2- antiseptic Technique contaminated O.R contaminated equipment contaminated surface contaminated floor contaminated suction jars improper disinfection wound inf Delayed healing

diluted concentration of antiseptic non killing of solutions micro-organisms lead to contamination and wound infection

improper sterilization

non killing of micro-organisms lead to contamination and wound infection

C
3- compliance to non antiseptic technique policy compliance and procedures ( pepper HH and PPB) lack of supplies spread of contamination and infection through patient which lead to delayed healing resistent staff

untrained staff

Add the totals of all RPN scores to get a grand total () Score provided a baseline for comparison

Identify the failure modes that have an RPN Score of 200 or higher. Develop an action plan The action plan should include who, what, when, why, etc

C
Implement Action Plan

C
Baseline score: Final score: Reduction in scored risk assessment: %

12% 10% 8% 6% 4% 2% 0% 0% 1% 8.00%

11.10%

3.10% 0.00%

3.50% 0.00%

yThank

you