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Infection levels in mothers after cesarean sections were reduced at a California hospital with a remarkably simple fix: providing the right size bandage so too-large ones didn’t have to be cut by hand.
The issue was recognized by a team at Sharp Mary Birch Hospital for Women & Newborns in San Diego, a freestanding women’s hospital with more than 9,000 deliveries per year. Superficial surgical site infections (SSIs) were partly responsible for increasing readmissions each year, and they were becoming more common with an increasing number of cesarean sections, explains Lauren Korrub, RN, BSN, clinical nurse at the hospital. They also were costly for the hospital and there was no standard reimbursement. In addition, SSIs are reportable events to the California Department of Public Health.
Korrub and others at the hospital worked on the issue in the Clinical Scene Investigator (CSI) Academy sponsored by the American Association of Critical-Care Nurses. Their goal was to reduce superficial SSIs in postoperative cesarean section patients by 50% and to provide education to 100% of staff on superficial SSI prevention. They also sought to increase hand hygiene patient education to greater than 95%.
The team developed the slogan “A healthy wound is a happy wound.” They provided interactive learning to staff, with monthly giveaways of gift items and spa days. Staff also received badge clips with the motto and the project’s smiley face logo.
Patient education also was important. The team developed a patient handout in English and Spanish, which was available electronically in the medical record and as a handout located near discharge folders. The patient handout explains how superficial SSIs happen, why they are dangerous, and how to prevent them. It provides specific advice such as checking the incision daily, keeping the wound open to air after 48 hours, and not using any lotions, creams, powders, or ointments on the incision.
The team also introduced a container of hand sanitizing wipes to the patient’s bedside table, accounting for the fact that cesarean section patients are confined to bed for days and can’t easily wash or sanitize their hands in the bathroom or with the hand sanitizer on the wall.
But the most effective intervention also was the simplest. The team realized that the size of the bandage supplied for cesarean section incisions was contributing to infection rates.
“We observed our nurses and some of the habits we had when we were taking care of incisions after removing staples and applying Steri-Strips,” Korrub explains. “Our OR had pre-cut Steri-Strips that were the right size for their needs, but we had to cut ours in half to make them the right size after we removed staples. We realized nurses were taking scissors and cutting them in half, which introduced bacteria on to the Steri-Strip.”
The supply orders were changed so that nurses had the smaller bandages available for post-op cesarean section patients, and nurses were instructed to stop cutting bandages to fit. Hand hygiene also was emphasized more during the staple removal process.
“People were touching the bed and going back to take out a staple, not being as clean as they could when they were taking out staples and caring for the incision,” Korrub says. “We also had nurses in the habit of putting a pad across the incision site, but we stopped doing that because the doctors’ orders are to remove any dressing after the first 48 hours.”
From June 2015 to June 2016, the hospital had 13 readmissions for superficial SSIs, with Escherichia coli and Staphylococcus aureus isolated from wounds when cultured. The average loss to the hospital was $30,197 per readmission. In the same one-year period after the intervention, there were only four readmissions for superficial SSIs. That amounted to a savings of $272,769.
Hand hygiene showed improvements, according to nurse documentation of their own habits. Patients also showed evidence of better understanding of superficial SSIs, with 97% of post-discharge patients saying the tape stayed adhered to skin and 97% saying they showered and checked the incision daily.
“Everything took a lot longer than expected, but the results were worthwhile,” Korrub says. “It can take a long time to make changes in a hospital, even something as simple as getting the right size Steri-Strips. It’s not enough when your manager says it’s a great idea, because she has a manager, and they have a manager, and it’s a whole process to go through. Stick with it.”