Quality Update

Making sure that operating-room staff follow evidence-based protocols to prevent surgical-site infections sounds like a no-brainer. After all, Hopkins Hospital’s Epidemiology and Infection Control and operating room staff put a lot of time into researching and then introducing the guidelines into the OR’s daily preoperative routine. And the result was starting to reduce infection rates among patients.

So the Hospital’s surgical- site infection task force last spring developed a paper compliance form containing questions such as whether a surgical site was marked and initialed by the surgeon, whether antibiotics were given at the proper time and whether the operating room was clean. Circulating nurses (those not scrubbed in for surgery) filled out the forms. The completed audits were collected and placed in files and remained there unused sometimes for months until someone could be sprung from other duties to enter the information into a database.

What to do about this vital delay in compliance tracking became a classic use of a rapid-cycle solution to a system problem, a signature tool of the Hopkins Medicine Center for Innovation in Quality Patient Care. This accelerated process involves identifying problems, planning a solution, getting a pilot project started quickly with small resources, adding necessary changes and measuring results. 

Laura Winner, a quality innovation coach for the Center, was working with Cardiac Surgery to reduce its infection rate when the issue of timely monitoring came up. The initial idea was to make an electronic copy of the audit and connect it to a Cardiac Surgery database. But there were no computers in the cardiac OR and it wasn’t scheduled to get them for another year, when a new computerized operating room management system (ORMS) was ready for a phased rollout. Additionally, the plan was to implement the audit tool in all operating rooms.

Two Cardiac Surgery information technology team members, Diane Alejo and Joe DiNatale, came up with a solution: Make the electronic audit form Web-based and tie it into a database in the Department of Surgery. The Center and cardiac surgery IT worked together to develop the application, and within several weeks, the paper form was migrated onto a secure Web site. Operating-room nursing leadership decided to pilot the application in the computer-equipped Weinberg OR.

By using the rapid-cycle process to get the pilot up and running, the Web-tool project bypassed the time-consuming method of gathering information, taking it to a committee and waiting for the right opportunity. “We could’ve waited until all of the ORs had computers to start this project,” Winner points out. “The pilot has given us the chance to make some tweaks before the online audit form goes to a broader use.”

The online audit version is tied to the electronic patient record system, making it easier to get the surgical patient’s name or identification number. Drop-down menus and Yes and No answers allow the nurse to simply point and click the results with a computer mouse. The tool also has a comment field to point out concerns that aren’t addressed by answering the questions. Results for each surgery are automatically submitted to the surgery database.

The data helps to pinpoint opportunities for improvement and helped staff reach 100 percent compliance with evidenced-based OR best practices.