Many different health care professionals may come in contact with that one patient in the operating room (OR) before their surgery including nurses, residents, surgeons, and possibly environmental service workers. Due to the vast amount of touch points, a culture shift may be necessary if the goal is to have optimal communication between all members of a health care team.
The lack of communication can lead to the risk of health care associated infections (HAIs) due to the potential of different techniques for best practice in skin antisepsis. With that said, standardization is key to achieve those desirable results for the patient.
This issue, and several other infection prevention and control issues, were addressed at a virtual roundtable sponsored by Becton Dickinson (BD), earlier this year. There was panel-wide agreement about an ongoing need to raise awareness of issues related to skin antisepsis since HAIs are becoming the main reason for emergency room visits and re-admissions.
During the panel discussion, each of us was able to cite examples of when professional silos prevented health care providers (HCPs) from communicating effectively regarding best practices for skin antisepsis and product application.
Despite the growing number of hospitals and health care systems utilizing dedicated skin preparation teams, it remains commonplace for surgical residents or surgeons to perform skin antisepsis. Situations where surgeons would only agree to use one particular skin prep product with the application style they had always used, simply because “they had always done it that way” were frequently encountered.
When the status quo is maintained rather than encouraging a culture paradigm shift in the OR, then evidence-based practices may not be readily adopted. A study from the American College of Surgeons found that post-operative infection rates decreased by 33 percent when a dedicated team of “front-line” providers had primary responsibility for peri-operative procedures. Enhanced sterile techniques for skin and fascial closure were also implemented in this study.
Promoting Change Through Data
Although the example above represents just a single study, it does demonstrate how scientific evidence can be the harbinger of positive change. During the roundtable, the panelists agreed that standardization is a major key to the successful reduction of HAIs, and that variation cannot be controlled when communication breaks down in the OR. Do the perioperative nurses feel comfortable educating or challenging the lead surgeon? Can they provide direct correction to a resident applying a product incorrectly or does hierarchy and dysfunctional communication in the OR make that unlikely?
Every year, more than 75 million surgical procedures are performed in the U.S., basic infection prevention strategies such as hand hygiene, etc. must be taken seriously. A study by Beyfus et.al., published in the American Journal of Infection Control, found that HCPs failed to perform hand hygiene 37 percent of the time, even after having policies in place regarding these practices.
Fostering open communication supported by robust, outcomes-focused data would go a long way towards creating a team-based approach where everyone feels empowered, without fear of retribution, to speak up about practice. Ideally, data would be collected to determine post-procedure outcomes which are also shared between institutions if a patient is readmitted to a different health care facility due to health care associated infections. Today, the ability to collect this type of data is limited because electronic health records are not yet integrated enough to track patients across far flung facilities or competing health systems. This is a serious challenge since more than one-third of all readmissions occur at a different hospital than where surgery was performed. As a result, critical outcome information is not tracked.
Investing in Outcomes
The panel concluded the roundtable by discussing how effective communication of outcome data to providers can influence a culture shift in the OR. High-quality HAI data must be readily available to all key stakeholders on an ongoing basis. Health care facilities, researchers and the C-suite must invest time and resources into better understanding how skin antisepsis products (and variability in protocols) affect outcomes. Parties negotiating purchasing and protocol decisions can make more informed choices when armed with data.
In conclusion, every surgical HCP should advocate for excellent and standardized skin antisepsis. Ultimately, patient safety must always take precedence over egos or “we’ve always done it this way” rigidity. As HCPs, we must seek out continuing education and hold each other accountable when re-direction about application or product use is warranted. Every time we interact with a patient we must use the best evidence-based infection prevention and control practices to mitigate the risks of HAIs.
Disclaimer: The development of this piece was supported by Becton Dickinson.
Merkow et al. (2015). Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States. The Journal of the American Medical Association, 313(5), 483-495. doi:10.1001/jama.2014.18614 Accessed on May 24, 2016
Wick et al. (2012). Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. Journal of the American College of Surgeons, 215(2), 193-200. doi:10.1016/j.jamcollsurg.2012.03.017
Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. (2010) Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA Jun 23;303(24):2479-85.
Statistical Brief #188. Agency for Healthcare Research & Quality.
http://www.hcup-us.ahrq.gov Accessed May 19, 2016
United States Centers for Disease Control and Prevention (CDC). Fast Stats: Inpatient Surgery. http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed May 19, 2016
Beyfus, TA, Dawson, NL, Danner, CH, “The use of passive visual stimuli to enhance compliance with handwashing in a perioperative setting” “http://www.sciencedirect.com “Go to American Journal of Infection Control on ScienceDirect” American Journal of Infection Control, “http://www.sciencedirect.com “Go to table of contents for this volume/issue” Volume 44, Issue 5, 1 May 2016, Pages 496–499, “http://www.sciencedirect.com/
Brooke et al (2015). Readmission destination and risk of mortality after major surgery: An observational cohort study [Abstract]. The Lancet, 386(9996), 884-895.