QI Project

Requirements for QI Report of Project: Written

Background of the problem (to be complete)

· Definition of the problem with references

· Depth and breadth of the problem (e.g., national statistics and local data to demonstrate a problem exists)

Case Scenario

In the state of Indiana, our multi-drug resistant infections (MDRI) started to rise in 2018. Our hospital has experienced the same rise, especially in MRSA patients. Prior to 2018, our MRSA rates were stable at 1.3% of all surgical patients. In 2021, our rates rose to 7.8% and so far in 2022 our rates are 11.8%.

We are required to count MRSA rates as any patient who had surgery in the past 60 days that was discharged from our facility, then returned with a MRSA positive infection. This can be MRSA at the site of surgery, in the bloodstream, or anywhere in the body that resulted in a positive culture.

Our surgical patients are required to shower the day of surgery with soap and water. Pre-operatively, we cleanse the site with a chlorhexidine swab prior to the surgical incision. The sterile field is maintained throughout surgery. Our surgical suites are designed with airflow that does not go move over the surgical site. We have noticed that none of the surgical cases that return with MRSA are in one surgical suite and are not associated with any one doctor or surgical team.

Post-operatively, a nurse is required to assess the wound daily and document the site and any draining in the EMR. The patient is given supplies upon discharge of two dressing changes and are taught how to clean the site. We have 100% compliance with handwashing post-op as witnessed by our quality department.

We need to know what the best practices are for reducing MRSA infections. We would also like to know what procedures need to be changed and how we can fix our problem.

PICO question

Our group members figured out the PICO question: In patients undergoing surgery (P), does the use of preoperative intranasal mupirocin (I) as compared (C) to no preoperative intranasal mupirocin reduce the incidence of surgical site infections related to MRSA (O)?

Search Strategy (to be complete)

To find the best evidence-based strategies for reducing MRSA infections ……………….

Evidence (to be complete)

The Joanna Briggs Institute (JBI) states that the best available evidence regarding the effectiveness of strategies for eradicating methicillin- resistant Staphylococcus aureus carriage is short-term nasal application of mupirocin.

· What evidence did you find? Synthesize the evidence

· Appraisal of the evidence using appropriate appraisal tools

· Levels of evidence using hierarchy of evidence

Appraisal Tool 1 (to be complete)

The first article was reviewed by using the JBI Critical Appraisal Tool for systematic reviews. The appraisal tool was used for the following reference:

Wang, L., Ji, Q., & Hu, X. (2021). Role of targeted and universal mupirocin-based decolonization for preventing surgical-site infections in patients undergoing cardiothoracic surgery: A systematic review and meta-analysis.  Experimental and therapeutic medicine,  21(5), 416. https://doi.org/10.3892/etm.2021.9860

Appraisal Tool 2 (to be complete)

Troeman, D., Van Hout, D., & Kluytmans, J. (2019). Antimicrobial approaches in the prevention of Staphylococcus aureus infections: a review.  The Journal of antimicrobial chemotherapy,  74(2), 281–294. https://doi.org/10.1093/jac/dky421

Levels of evidence (to be complete)

The level of evidence using the hierarchy of evidence for the first article is Level 1 because the evidence comes from a systematic review. The second article is also a Level 1 because the evidence is based on clinical practice guidelines.

Analysis of Current Condition

Monthly MDRI/MRSA data:

Month	Our Unit	Comparison Unit	Comparison Unit
Jan	5	1	0
Feb	3	0	0
Mar	3	1	1
Apr	7	0	0
May	2	0	0
June	3	1	0
July	11	0	0
Aug	12	0	1
Sept	1	0	0
Oct	9	0	0
Nov	14	0	1
Dec	1	0	0
Mean
Median
Range

Table 1: Monthly MDRI/MRSA data

Figure 1: Incidence of MDRI in our unit compared to the other two units.

· Table and graph with narrative (use data from assigned problem)

· Flowchart comparing current process versus what evidence says should be done with narrative identifying missed opportunities (indicators).

Flow chart: (to be complete)

Cause Analysis  ( to be redone by Ellen)

· Root Cause Analysis with Fishbone Diagram. Identify where the problems exist. Describe causes for the problem and how each is linked to the problem.

Our case study followed the number of MDRI/MRSA infections post-operatively. Those who had surgery in the past 60 days and returned back to the hospital with a MRSA infection (at the surgical site, bloodstream, etc.) were considered positive. Materials, people, environment, methods, and equipment were questioned using a fish-bone/cause-and-effect diagram to see potential factors that could be improved upon to decrease the incidences of these infections. 

The following  materials were considered:  specimen vials, lab testing, and chlorhexidine swabs. Specimen vials used to test for MRSA may have been expired, incorrectly used, or contaminated with organisms other than the surgical wound itself. In regards to lab testing, the dishes that grow organisms could have been contaminated themselves, or their sensitivity could have been insufficient as well. Lastly, the chlorhexidine swabs used to clean the surgical site prior to the operation could have been spoiled or there was an insufficient supply available.

The  people in question were the  RN, surgical team, and patient. RNs may have had improper hand-washing technique, may not have understood that chlorhexidine swabs were included in the protocol pre-operatively, and may have not properly taught the patient of a proper dressing change before they were discharged. The surgical team may have broken sterility during the procedure, did not assess the wound post-operatively, or also may have had improper hand washing technique. Additionally, the patient themselves may have not kept their surgical site clean or did not understand how to perform their dressing changes at home. 

One of the  environments considered was the  surgical room itself. Since heat harbors bacterial growth, I wondered if the temperature of the room had been a factor in MRSA infections. I also wondered if the airflow was working properly and if the sterility of tools and the field was maintained.

There are many  methods that can be investigated. One of the hospital’s protocols was for the patient to shower prior to the procedure. In a busy floor environment, I understand that there is not always enough staff or time for the patient to shower, therefore I questioned  if patients were truly showering before their procedures. Likewise, if nurses are too busy, I questioned  if the surgical site was truly being assessed once daily per the hospital’s protocol. Additionally, assessing the site once daily may not be enough, so I  questioned if the number of assessments should be increased daily, or the protocol to be changed to assess the wound once per shift. Lastly, I wondered  if the chlorhexidine swabs were being used preoperatively on the surgical site. 

Lastly, the  equipment considered included the  dressing change kits and surgical tools used. Were there enough supplies in the dressing change kits? Did they need to be more patient-specific? Additionally, were the surgical tools appropriate in size for the surgery used, and were they completely sterile?

Action Plan (to be complete)

Structure or Process Indicators:

Action Plan for Each Indicator

· Changes that should be done in order to improve practice, according to what evidence shows. Include:

· Indicator (look at your indicator sheet): Provide the evidence to support in one sentence.

· Measurement: Numerator and denominator. How will you measure that the change is being done?

· Goal: What is your goal data? Benchmarks?

· Implementation:  Include best practices for implementing your change with evidence to support your implementation strategy

· Create a table with the following information for each indicator:

Who	What	Why	When	How	Completion Date
Describe who is responsible	Explain what they are responsible for. Address each indicator	Rationale for why this person(s) should be responsible for this action	When will they perform the action? What is the timeline for completing the task?	Explain how the person should complete the assignment (think of implementation described above)	Date for completing the action

Reference Page

Names and Contributions

Names and Summary of Group Member Assignment Contributions:

1

MMK 2020