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Ellen Cherkassky Structure or Process Indicators List the steps or key pieces that your clinical practice guideline or systematic review suggest that should be in place to improve outcomes (these become your measurements):

Indicator What data will be collected

1. The addition of medications that would be helpful in preventing MRSA infections post-operatively.

Topicals (such as nasal mupirocin ointment application and CHG baths) as well as systemic antibiotics will be researched. We will create a study using both an experimental and control group with the chosen indicator. We will test surgical patients 60 days post-operatively with a venous culture, wound culture, and nasal swab for MRSA.

2. Proper identification/screening of patients with MRSA prior to surgery.

All patients receiving surgery will be pretested for MRSA to prevent cross- contamination.

3. Improving wound care when patient leaves the hospital.

Have clinical educators assess how RNs educate their patients on wound care at home. Items taught need to include importance of handwashing, noticing signs and symptoms of infection, and how to maintain sterility during a dressing change. Additionally, social workers should assess who can help the patient perform these dressing changes at home. If not, home health may

need to be considered.

4. Re-educating staff on proper hand hygiene.

Creating a hand- washing team that audits hand washing for all staff in contact with patients to check compliance. Team will provide re- education to staff if not 100% compliance is observed.

5. Ensuring sterility is maintained during a dressing change.

Observations and audits by wound care personnel will be done to assess how staff performs dressing change.

6. Enhanced decontamination of patient areas (such as beds) should be cleaned with bleach detergent and hot water after discharge.

Develop a formal training in-service for cleaning staff and perform audits for proper cleansing.

Plan for Improvement (for each item listed above, complete the following):

1. Indicator: Prescribing and using mupirocin nasal ointment twice daily for a few days before patients go into surgery.

This is key to improving outcomes because: JBI evidence proves that mupirocin ointment can decolonize nasal MRSA and may prevent transmission. Operational definition: the process of using cotton swabs with mupirocin ointment in patients pre- operatively to prevent MRSA transmission. Numerator: Number of MRSA infections Denominator: Surgical patients Data collection method

Who Surgical patients

What Mupirocin ointment will be prescribed

Where In hospital room

Why Decolonization and prevention of MRSA transmission in the operating room

When At least 2 days pre-operatively. How Mupirocin ointment will be administered twice daily by nurses on the hospital floor. We will

test surgical patients 60 days post-operatively with a venous culture, wound culture, and nasal swab for MRSA.

Goal for this indicator: All pre-operative patients will be given mupirocin ointment twice daily

pre-operatively for at least 2 days before surgery.

Benchmark: x<1% of MRSA infection rates.

2. Indicator: Proper identification/screening of patients with MRSA prior to surgery. This is key to improving outcomes because: Pre-testing can prevent cross-contamination and encourage appropriate precautions to be implemented in the OR and postoperatively. Operational definition: All patients receiving surgery will be pretested for MRSA to prevent cross- contamination. Numerator: Number of surgical patients screened for MRSA Denominator: All surgical patients Data collection method

Who Surgical patients

What MRSA screening

Where Hospital floor

Why To identify patients who need to be under contact precautions to prevent transmission of infection.

When At least 1 day before surgery

How Patients will have venous culture, nasal swab, and wound culture done pre-operatively. This will be newly-included in the pre-op checklist as well to ensure testing is done.

Goal for this indicator: All pre-operative patients will be tested for MRSA at least 1 day prior to

surgery. Benchmark: 100% of patients will be tested before surgery

3. Indicator: Improving wound care when patient leaves the hospital. This is key to improving outcomes because: Either nurses may not be educating properly, or the patient is not fully aware of how or when to perform clean dressing changes.

Operational definition: All nurses will have the hospital’s nurse educator watch them as they educate patients on a proper dressing change and how to look for signs and symptoms of infection. Numerator: Number of patients performing good teach-back Denominator: All patients learning how to do a dressing change Data collection method

Who Nurses, nurse educator, patient

What How to perform a proper dressing change and identify signs/symptoms of infection.

Where In hospital room

Why Ensure that patients are able to change their dressing at home, or have support doing so, and are clean.

When At least 1 time prior to the patient’s discharge.

How Nurse educator will perform random rounds on how well nurses are educating patients on their dressing changes. Patient will perform teach-back. Nurse educator will later meet with nurse and discuss findings and ways to improve teaching methods.

Goal for this indicator: Most patients will perform good teach-back in how to do a proper dressing

change and will list 2 ways to check for signs of infection. Benchmark: 85% of patients will understand how to do a proper dressing change.

4. Indicator: Enforcing proper hand hygiene

This is key to improving outcomes because: sometimes hand hygiene is an every-day factor that can be often overseen, however it is vital to preventing transmission of infections.

Operational definition: All of staff will be observed for proper hand hygiene, and if not done, staff will be re-educated Numerator: All of surgical staff/RNs performing and adhering to standard hand hygiene practices Denominator: All of surgical staff/RNs involved in patient’s care Data collection method

Who All of surgical staff/RNs involved in patient’s care, hand-washing audit members

What Auditing roper hand-washing technique

Where In OR, pre/post operatively in patients’ rooms

Why To prevent transmission of infection

When Once a week

How Creating a hand-washing team that audits hand washing for all staff in contact with patient to check compliance. Team will provide re-education if not 100% compliance is observed.

Goal for this indicator: Staff will be reminded of the importance of handwashing, and will be re-

educated if not properly performed.

Benchmark: 100% of staff will perform adequate hand washing techniques.

5. Indicator: Ensuring sterility is maintained during a dressing change.

This is key to improving outcomes because: Nurses and surgeons may be rushed on a daily basis and may not perform adequate sterile technique when doing a dressing change. However, maintaining sterility is important in preventing infection, especially with a new post-operative wound.

Operational definition: Patients who have a wound post-operatively will receive a sterile dressing change as often as required while in the hospital. Numerator: number of patients who had a sterile dressing change performed on them Denominator: all patients with a post-operative wound dressing change Data collection method

Who Patients, surgeons, RN, wound care staff

What Sterile dressing changes on post-operative patients

Where In hospital room

Why Prevent transmission of infection

When Once daily

How Wound care personnel will assess and assist staff if necessary on how to perform a sterile dressing change.

Goal for this indicator: Surgeons and RNs will understand how to perform sterile dressing changes

and the importance of maintaining a clean environment Benchmark: 85% of nurses and surgical staff will understand and perform sterile wound dressing

changes

6. Indicator: Enhanced decontamination of patient areas (such as beds) should be cleaned with bleach detergent and hot water after discharge. This is key to improving outcomes because: clinical guidelines recommend that instruments or equipment should be single patient use, and items that are re-used should be cleansed appropriately to prevent transmission of infection.

Operational definition: Cleaning staff will use taught how to properly disinfect an operating room and a patient’s room then audited. Numerator: Cleaning staff that performs proper decontamination Denominator: All of cleaning staff Data collection method

Who Cleaning staff

What Cleaning technique

Where Patient rooms, operating room

Why Prevent transmission of infection

When At least once a month

How Develop a formal training in-service for cleaning staff and perform audits for proper cleansing.

Goal for this indicator: Cleaning staff will partake in the in-service and execute a proper cleaning. Benchmark: 85% of cleaning staff will clean the rooms to adequate hygiene standards.