EP20EO Clinical nurses are involved in the review, action planning, and evaluation of patient safety data at the unit level.
Provide two examples, with supporting evidence, of an improvement in patient safety that resulted from clinical nurses' involvement in the evaluation of patient safety data at the unit level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1
NAME OF INITIATIVE
Catch a Falling Star - 3 South Falls Prevention Program
BACKGROUND/PROBLEM
The Falls Committee traditionally oversaw hospital-wide falls initiatives. Over the years, it struggled with maintaining membership attendance. Initiatives that the council implemented did not make much of an impact on the falls rate. In light of this challenge, Magnet Project Director Julie David, ARNP, recommended to Chief Nursing Officer and Vice President Gail Gordon, RN, the creation of a Nursing Quality Council (NQC) that would review nurse-sensitive indicators (NSI) including falls. This council would also develop and implement corresponding action plans to identified areas of opportunities. Upon Gordon’s approval, David established the NQC in December 2011. She organized it as a hospital-wide council and incorporated it into the shared governance structure. Its membership consisted of shared governance council chairs, including Unit Practice Council (UPC) chairs who were clinical nurses, nurse leaders, clinical nurse educators, nurse scientist, risk manager, and staff from the ancillary departments. David also invited the members from the previous Falls Committee to be part of the NQC. The council’s initial activities included the development of its charter and review of NSI scorecards and data to identify priority areas.
NQC members decided to tackle fall prevention as its first project because they identified an upward trend in inpatient total falls and falls with injury. In order to gather more information as to why patients were falling, theNQC revised the post-fall huddle form in December 2012 to include more data on the predisposing factors. Using data from the post fall huddles, Nurse Scientist Maria Ojeda, ARNP presented an in-depth analysis of trends in contributing factors to falls during the May 2013 meeting. During this same meeting, NQC also reviewed the monthly falls incident reports and quarterly NDNQI falls data. Clinical Nurse and 3 South UPC Chair Shelly Ann Commock, RN, noted that her unit’s incidence of total falls (N=16) and falls with injury (N=8) has increased in the past 6 months (Exhibit EP20EOa) and only exceeded the NDNQI benchmark 3/8 quarters. 3 South is a 27-bed Medical-Surgical/Telemetry department that specialized in orthopedic patients. Falls prevention was always a focus but more so in this department with a patient population consisting of elderly, orthopedic, multiple comorbidities and end-of-life patients. Commock brought back the information to her manager and UPC. Discussions transpired among the UPC members, staff and department leaders regarding the data.
Exhibit EP20EOa: 3 South Incidents of Total Falls and Falls with Injuries
GOAL STATEMENT
The department decided to tackle falls head-on and set a goal of meeting or exceeding the NDNQI national benchmark for falls with injury per 1000 patient days.
Clinical Nurses Involvement in Unit-Level Data Review and Action Planning.
Patient Care Manager Linda Simpson, RN, discussed falls during the May 2013 monthly staff meeting. She shared data from NDNQI and Risk Management department. She engaged her staff in a dialogue about the importance of quickly addressing this patient safety concern and solicited their input on the contributing factors and possible solutions through brainstorming. The staff wholeheartedly agreed this was a concern and eagerly embraced the focus on fall prevention. The UPC assumed the task of analyzing data and action planning with the guidance and support of their nurse leaders. Thereafter, Commock requested David to facilitate a fishbone analysis during the June 2013 UPC meeting to further explore causative factors. (Exhibit EP20EOb) The fishbone analysis helped the UPC in identifying trends. For example, they noted that most of their patients were falling from 4-6 in the morning and afternoon while going to and from the bathroom. The team identified several factors that predisposed patients in their departments to fall. During the same meeting, the UPC also came up with 4 quick, actionable items in the action plan.
Exhibit EP20EOb: 3 South Falls and Falls with Injury Fishbone Analysis
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
Commock discussed the results of the fishbone analysis and proposed an action plan to Simpson who gave the green light to proceed. The UPC took the “back to basics” approach for its first intervention. This involved reeducating the staff on the fall prevention policy, HH 400-767 Fall Prevention Program. In the latter part of June 2013, Clinical Nurse Educator Sandy Jones, RN, reviewed with the staff the following: Morse fall scale assessment and documentation on admission; shift and change of condition reassessment; hourly rounding using “4Ps” (asking the patient about pain, potty, position, and possessions); maintaining a clutter-free environmen; not leaving patients alone while toileting; and the placing of a blue magnet on the door frame of patients at risk for falls. Patient Care Supervisors (PCS) monitored and enforced hourly rounding.
The UPC identified in the fishbone analysis a knowledge deficit among the staff with the activation/reactivation of bed exit alarms. Jones included this in her in-services which she conducted after the staff meetings and utilized the “teach back” method to evaluate staff understanding. She also revisited with the staff the “No Pass Zone” initiative. The UPC previously implemented this project which asked any person passing by to respond when a call light or bed alarm was on. She thought that this was a critical piece in decreasing the fall incidents. Additionally, the UPC and 3 South nurse leaders reiterated the importance of indicating “Fall Precaution” under the patient factors screen of the electronic medical record to facilitate interprofessional communication. Staff provided non-skid footwear to fall risk patients and reminded them frequently to ask for assistance when getting up. Staff also educated the patient and family on fall prevention and communicated with them frequently about the plan of care during bedside shift report.
Since most of the falls in the department were related to toileting and occurred in the bathroom when patients were attempting to stand, the UPC recommended placing a bedside commode on all toilets and extended hand rails in the bathroom. Simpson realized that it would take a longer time to make the hand rails available because installation was involved. Thus, she approved the purchase of 25 bedside commodes in July 2013. She then had the staff place the commodes in every bathroom over the toilet to provide extra support to the patient. To decrease falls with injury, 3 South staff rented low beds with cushioned mats for every fall risk patient. Jones worked with the biomedical department to have the bed exit alarm sound in the nurses’ station. Staff also asked family and friends to stay with a high fall risk patient overnight. If no family is available, the nurses had the autonomy of requesting a sitter for the patient and discontinuing it when no longer indicated.
The UPC rolled-out a new project called “block assignments”. The premise of the project was to congregate the nurses and care partners’ assignment to consecutive or nearby rooms. In this way, the staff was more accessible and closer to their patients to preempt a fall; hear the alarms; and respond quickly. Commock presented the project during the July 2013 staff meetings. Based on staff and UPC member feedback, the project was modified into “zoning assignment with flexibility” in August 2013. This concept was a liberal block assignment, more of a “zone” to allow a very difficult patient assignment to be modified by one or two rooms. This still allowed the staff to be more accessible and closer to their patients. The staff liked this flexibility as the patient assignments became more realistic. The UPC rolled zoning in November 2013.
Another tactic that the UPC utilized was enhancing communication about its fall initiatives to the nursing leaders and staff. As UPC Chair, Commock has regularly scheduled meetings with Simpson to go over UPC projects, challenges and resources need. Additionally, UPC has a section in the daily “stand up” agenda. The PCS went over the agenda items including falls in the “stand up” every shift over a 2-3 week period. Simpson also gave Commock a time slot in the monthly staff meetings to discuss ongoing UPC projects. As a result, falls became a standing agenda item not only in the UPC meetings but also in the daily “stand up” huddles and monthly staff meeting. During these meetings, the staff received current falls data and they had the opportunity to provide feedback about the interventions. Simpson and the PCS provided continuous encouragement to the staff and recognition when the monthly target of zero falls was met. Additionally, they rounded frequently in each shift. During these rounds, they conducted audits on fall prevention interventions using a tool they developed and provided coaching to the staff, when needed.
Clinical Nurses Involvement in Evaluation of Unit-Level Patient Safety Data
In September 2013, Jones presented data to the staff regarding compliance with instituting fall prevention interventions. Jones collected the data while rounding on patients on fall precautions. The results showed that some beds were not plugged to the wall into the central station alarm system (2%); bed exit alarms were not always set (32%); and door magnets were not always on patients at risk for falls (4%); while door magnets were placed on patients with no identified risk for falls. She reeducated the staff on proper fall precautions. In the April 2014 staff meeting, Jones reviewed the recently revised updated fall policy with the staff which included putting a red falling star magnet on the door of patients that had fallen in the last 3 months or during current hospitalization. Commock provided update on falls.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Shelly Ann Commock BSN, RN, CMSRN |
Clinical Nurse |
3 South |
UPC Chair |
Gloria Gamboa, RN |
Clinical Nurse |
3 South |
UPC Member |
Beatriz Taboada, BSN, RN |
Clinical Nurse |
3 South |
UPC Member |
Maria Ramirez, BSN, RN, CMSRN |
Clinical Nurse |
3 South |
UPC Member |
Stephanie Jean-Baptiste, RN |
Clinical Nurse |
3 South |
UPC Member |
Linda Simpson, BSN,RN, CNML |
Manager |
3 South |
Provided administrative support |
Sandy Jones, BSN, RN, CMSRN |
Clinical Nurse Educator |
3 South |
Instituted education and in-services |
Maikel Luis BSN, RN, CMSRN |
Patient Care Supervisor |
3 South |
Monitored and enforced implementation of falls initiatives |
Nayrovis Gonzalez, BSN, RN |
Patient Care Supervisor |
3 South |
Monitored and enforced implementation of falls initiatives |
Rupinder Gil, BSN, RN, CMSRN |
Patient Care Supervisor |
3 South |
Monitored and enforced implementation of falls initiatives |
Tracy Moore, BSN, RN, CMSRN |
Patient Care Supervisor |
3 South |
Monitored and enforced implementation of falls initiatives |
Aylen Gordillo, RN, CMSRN |
Patient Care Supervisor |
3 South |
Monitored and enforced implementation of falls initiatives |
Nancy Munoz, RN |
Patient Care Supervisor |
3 South |
Monitored and enforced implementation of falls initiatives |
Janet Jackson, RN |
Clinical Nurse |
3 South |
UPC Member |
Anthony Ware |
Orthopedic Tech |
3 South |
UPC Member |
OUTCOME(S)
Exhibit EP20EOc: 3 South Falls with Injury per 1000 Patient Days
Analysis: Exhibit EP20EOc depicts that 3 South has exceeded NDNQI benchmark for falls with injury and sustained it for 4 consecutive quarters.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP20EOa: 3 South Incidents of Total Falls and Falls with Injuries
Exhibit EP20EOb: 3 South Falls and Falls with Injury Fishbone Analysis
Exhibit EP20EOc: 3 South Falls with Injury Rate per 1000 Patient Days
Example 2
NAME OF INITIATIVE
Surgical Site Infection Reduction Program
BACKGROUND/PROBLEM
Surgical Site Infections (SSI) are a major cause of morbidity, mortality and increased health care costs in surgical patients (Coello R, Charlett A, Wilson J, et al., 2005; Kaye KS, Anderson DJ, Sloane R, et al., 2009; Kirkland KB, Briggs JP, Trivette SL, et al., 1999; de Lissovoy G, Fraeman K, Hutchins V, et al., 2009). Patients who have colorectal surgeries tend to experience higher rates of SSI (Cima et. al., 2012). Bundled perioperative measures have been recommended by The Joint Commission Center for Transforming Health Care to reduce SSI rates in colorectal surgery (CRS) (The Joint Commission [TJC], 2013). Data derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) demonstrates that bundling care can be an effective means of preventing infections (American College of Surgeons [ACS], June 30, 2012). The ACS encourages the utilization of the “comprehensive unit-based safety program” or CUSP, an evidence-based multidisciplinary approach to safety improvement that focuses on the involvement of frontline staff such as nurses and technicians (Center for Innovation in Quality Patient Care, No date.).
Homestead Hospital is an active participant of the ACS NSQIP program. In July of 2012, the Surgical Services Department (SSD) leadership reviewed the ACS NSQIP report ending in December of 2011. They noted that the risk adjusted rate of SSI for Homestead Hospital was 14.71%, higher than the expected rate of 9.93%. This indicated an opportunity for improvement in regards to SSI rates related to CRS (ACS NSQIP, December 2011). Performance Improvement Nurse Patricia Yulkowski, RN, conducted a chart review. It revealed that 5/6 cases of colorectal SSI at Homestead Hospital had required an additional surgery to correct the problem. A multidisciplinary team was assembled in August of 2012, led by Yulkowski, to begin addressing the problem of colorectal SSIs at Homestead Hospital based upon ACS recommendations.
GOAL STATEMENT
- To reduce the rate of colorectal SSIs at Homestead Hospital to be less than the expected benchmark rate.
- To achieve a 2% reduction of SSIs for colorectal surgeries.
Outcomes were determined using the following measures:
- The ACS NSQIP Semi-annual site summary report data were used to track the project’s success at reducing SSI related to colorectal surgeries. The risk-adjusted observed rate of SSI for colorectal surgeries at Homestead Hospital was tracked and compared to the previous report, to determine improvement from baseline (December 2011).
- Homestead Hospital’s Surgical Services Department (SSD) identified a strategic goal of a 2% reduction in SSIs for the fiscal year 2013, which began in October 2012. The odds ratio of acquiring an SSI post colorectal surgery at Homestead Hospital represents a comparison to ACS NSQIP national benchmarks. Odds ratio’s were calculated thusly:
Odds Ratio = Odds of acquiring SSI at a particular site
Average Odds of the event at all sites
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
The team utilized the “Plan, Do, Check, Act” (PDCA) model to guide the inquiry. They developed and implemented multiple interventions across the entire surgical episode of care.
Plan
In August of 2012, the first assembly of an interprofessional team consisting of members from the Surgical Services Committee (SSC), Medical Staff, and PI department was conducted. The team was charged with the task of determining the best way to implement the ACS NSQIP bundled approach in reducing colorectal SSI’s at Homestead Hospital. Throughout the project, the team exchanged information and met informally via email and telephone calls. Yulkowski became the communication hub and ensured that team members were apprised of project updates. The group determined that changes needed to be made to processes involving the pre-operative, intraoperative, and post-operative stages of colorectal procedures as follows:
Action Plan for Changes
- Pre-operative changes
- Pre-operative bathing using 4% Chlorhexidene Gluconate showers
- Evening before and morning of scheduled surgery
- Application of warming gown (Bair Paws)
- Maintain normothermia throughout surgical experience
- Pre-operative clipping in the pre-operative suite when applicable
- Pre-operative antibiotics within one hour of incision
- Appropriate surgical hand scrub by all members of surgical team
- Intra-operative changes
- Glove change prior to fascia closure
- Sterile instrumentation tray for skin closure
- Re-dosing of antibiotics for procedures >4 hours in length
- Limit traffic in the surgical suite
- Post-operative changes
- Application of Mepilex dressing immediately post-operatively
Clinical Nurses Involvement in Unit-Level Data Review and Action Planning
Additionally, Yulkowski engaged the clinical nurses in the data review and action planning processes through the Surgical Services Unit Practice Council (UPC), chaired by Clinical Nurse Archelle Quintana, RN. She attended the UPC meeting in September 2012 and presented the department’s SSI rates. The risk adjusted SSI rate was 14.71%, higher than the expected rate of 9.93%. She solicited ideas from the clinical nurses. The portion of the SSI action plan that the clinical nurses were able to influence was the intra-operative phase pertaining to fascia closure. OR Clinical Nurse Shannon Newton, RN together with a surgical technician volunteered to develop a log and collect the data in the OR. On the other hand, Clinical Nurses Janice Gates, RN, Jessy Varkey, RN and Barbara Gross, RN participated in developing the sterile closing tray and process during fascia closure. Clinical Nurse Educator Lamberto Hernandez, RN presented the 2011 ACS/NSQIP results during the October 2012 staff meeting in a presentation titled “Surgical Site Infection: A Closer Look” to inform the staff and harvest additional feedback for the action plan.
Do
Initial testing and implementation began in August 2012 and continued through April 2013. The team integrated the CUSP framework within the PDCA to guide the implementation of the necessary practice changes. The CUSP was introduced during the “Do” stage of the PDCA because it speaks specifically to the gradual introduction of practice changes aimed at improving safety by allowing enough time for full integration into practice. The framework’s components are:
- Train staff in the science of safety.
- The implementation of each practice change was preceded by an educational presentation to SSD staff. All staff education was presented in-person by Hernandez. He gave a total of 6 educational sessions to the clinical staff during the period of implementation (August 2012, September 2012, October 2012, December 2012, and March 2013). Some of the sessions included simulation activities on the use of new supplies / equipment.
- Engage staff to identify defects.
- Hernandez conducted the educational sessions during staff meetings. He encouraged the staff to provide input regarding the proposed changes during that time or by directly contacting a project team member with any concerns.
- Senior executive partnership.
- Todd Mangione, D.O. became the physician champion for the project. Dr. Mangione reviewed the changes proposed by the new SSI bundle and assisted in the education and roll-out to the medical staff via the Medical Executive Committee (MEC).
Check
- Continue to learn from defects.
Clinical Nurses Involvement in Evaluation of Unit-Level Patient Safety Data
Throughout the project, quarterly ACS NSQIP data was used to track progress and to determine the effectiveness of interventions. After its initial implementation in December 2012, the team made revisions to the pre-operative checklist based upon staff feedback in the February 2013 Surgical Services staff meeting. The proposed changes were presented and approved during the March 2013 staff meeting. Yulkowski received the NSQIP data initially semiannually. Accordingly, she updated the clinical nurses, Medical Executive Committee and Board Members through meeting presentations and poster boards semiannually.
Act
- Implement of tools for change.
The team added most process changes to the preoperative checklist and the Ambulatory Care Services assessment sheet. Yulkowski and Mangione have jointly presented the biannual SSI report to the MEC in June 2012 and January 2013. Yulkowski routinely conducted chart reviews on SSI to determine root cause.
PARTICIPANTS
Members of the interprofessional SSI bundle project team included:
Name/Credentials |
Title |
Department |
Role in the Team |
Patricia Yulkowski, RN |
Performance Improvement Nurse |
Performance Improvement |
Team Lead; Surgical Nurse Reviewer for ACS-NSQIP; Data collection, analysis & interpretation |
Archelle Quintana, RN |
Clinical Nurse |
Surgical Services |
UPC Chair and coordinated UPC’s involvement in the initiative |
Shannon Newton, RN |
Clinical Nurse |
Surgical Services |
UPC Member; developed data collection log; participated in data collection |
Janice Gates, RN, CNOR |
Clinical Nurse |
Surgical Services |
Developed sterile tray and process for fascia closure |
Jessy Varkey, MSN, RN, CNOR |
Clinical Nurse |
Surgical Services |
Developed sterile tray and process for fascia closure |
Barbara Gross, RN |
Clinical Nurse |
Surgical Services |
Developed sterile tray and process for fascia closure |
Wanda Vargas-Rosado, BSN, RN, CNOR |
Assistant Nurse Manager |
Surgical Services |
Administrative support, planning and coordination of roll-out of SSI bundle |
Lamberto Hernandez, SN, RN, CNOR |
Clinical Nurse Educator |
Surgical Services |
Clinical education of staff on colorectal SSI bundle components |
Pam Rozas, RN |
Information Systems Coordinator |
Surgical Services |
Data collection, trial and Unit Practice Council Chair when project was rolled-out; responsible for implementation of Bair Paws warming gowns. |
Edlina Hilson, BSN, MBA-HAS, RN, CCRN |
Patient Care Supervisor |
PACU |
Assisted with revision of pre-operative checklist. |
Jessica Roldan, BSN, RN, CGRN |
Patient Care Supervisor |
Endoscopy |
Assisted with revision of pre-operative checklist. |
Mary Montejo, BSN, RN, CWS |
Wound and Ostomy Coordinator |
Wound Care |
Assisted with acquisition and staff instruction on use of Mepilex dressing. |
Wendy Rey, RN |
Manager |
Infection Control |
Assisted with acquisition of Chlorhexedine Gluconate for showers. |
Rosa Flores |
Surgical Technologist |
Surgical Services |
Assisted with implementation of SSI bundle. |
Tiffanie Watson |
Surgical Technologist |
Surgical Services |
Assisted with implementation of SSI bundle. |
Todd Mangione, D.O |
General Surgeon |
Medical Staff |
Physician Surgeon Champion for ACS-NSQIP. Responsible for physician education on CRS SSI bundle implementation |
OUTCOME(S)
Overall, the project was a success. The project demonstrated a reduction in SSI rates and the team met their goals regarding SSI at Homestead Hospital. From the July 2013 ACS NSQIP Semiannual Report data (based on 2012 reporting period), the hospital was identified as achieving a meritorious composite quality score based on a combination of 9 surgical outcomes.
Exhibit EP20EOd: Homestead Hospital SSI Observed Rate for CRS and implementation timeline for CRS SSI bundle components
Legend:
- Presentation of 2011 ACS/NSQIP results by Yulkowski to SSD leadership – July 2012
- Initiation of project team activities to address SSI rates. Warming gowns introduced – August 2012
- Introduced hair clipping outside of surgical suite – September 2012
- Remainder of changes to pre-operative checklist implemented. Introduction of intra-operative portion of SSI bundle – December 2012
- Finalization of pre-operative checklist with changes. Introduction of post-operative portion of SSI bundle – February 2013
*Note: The nationally benchmarked vendor report was reported initially on a semiannual basis; and later on, quarterly. This explains the uneven interval of the data points.
Analysis: Above graph shows the Surgical Service’s department ACS NSQIP overall colorectal SSI rate pre-implementation of the SSI bundle was 14.71%; Post-intervention, their colorectal SSI rate in March of 2013 was 10.0% (ACS NSQIP, March 2013) indicating that the goal was met. Furthermore, the drop has been consistent. All SSI rates have been below the benchmark for 4 consecutive quarters, with the most recent rate available at 4.44%, well below benchmark.
Exhibit EP20EOe: Odds Ratio of Risk for Acquiring an SSI with Colorectal Surgery at Homestead Hospital vs. National Benchmark
Legend:
- Presentation of 2011 ACS/NSQIP results by Yulkowski to SSD leadership – July 2012
- Initiation of project team activities to address SSI rates. Warming gowns introduced – August 2012
- Introduced hair clipping outside of surgical suite – September 2012
- Remainder of changes to pre-operative checklist implemented. Introduction of intra-operative portion of SSI bundle – December 2012
- Finalization of pre-operative checklist with changes. Introduction of post-operative portion of SSI bundle – February 2013
*Note: The nationally benchmarked vendor report was reported initially on a semiannual basis; and later on, quarterly. This explains the uneven interval of the data points.
Analysis: Above graph demonstrates that the Surgical Services Department exceeded its goal of decreasing SSIs for colorectal surgeries by 2% by achieving a 4.71% reduction by March of 2013. This reduction has been sustained for 4 consecutive quarters below the national benchmark of 1.
References
American College of Surgeons [ACS]. (June 30, 2012). New surgical patient safety program reduces surgical site infections by one-third in patients who undergo colorectal operations. Retrieved from http://site.acsnsqip.org/news/new-surgical-patient-safety-program-reduces-surgical-site-infections-by-one-third-in-patients-who-undergo-colorectal-operations/
American College of Surgeons [ACS]. (June 30, 2012). New surgical patient safety program reduces surgical site infections by one-third in patients who undergo colorectal operations. Retrieved from http://site.acsnsqip.org/news/new-surgical-patient-safety-program-reduces-surgical-site-infections-by-one-third-in-patients-who-undergo-colorectal-operations/.
ACS NSQIP. (December 2011). ACS NSQIP Semiannual report: Site summary, Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
ACS NSQIP. (March 2013). ACS NSQIP Interim semiannual report: Site summary, Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
ACS NSQIP. (September 2013). ACS NSQIP Interim semiannual report: Site summary, Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
Center for Innovation in Quality Patient Care. (No date). CUSP framework. Retrieved from http://www.hopkinsmedicine.org/innovation_quality_patient_care/
areas_expertise/improve_patient_safety/cusp/five_steps_cusp.html
Cima, R., Dankbar, E., Lovely, J., Pendlimari, R., Aronhalt, K., Nehring, S., and…Quast, L. (2012). Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program-driven multidisciplinary single-institution experience. Journal of the American College of Surgeons, 216(1), 23-33. doi: 10.1016/j.jamcollsurg.2012.09.009.
Coello, R., Charlett, A., Wilson, J., et al. (2005). Adverse impact of surgical site infections in English hospitals. J Hosp Infect, 60, 93e-103e.
Kaye, K.S., Anderson, D.J., Sloane, R., et al. (2009). The effect of surgical site infection on older operative patients. Journal of the American Geriatrics Society, 57, 46e-54e.
Kirkland, K.B., Briggs, J.P., Trivette, S.L., et al. (1999). The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infection Control & Hospital Epidemiology, 20, 725e-730e.
de Lissovoy, G., Fraeman, K., Hutchins, V., et al. (2009). Surgical site infection: incidence and impact on hospital utilization and treatment costs. American Journal of Infection Control, 37, 387e-397e.
The Joint Commission. (2013). The Joint Commission’s implementation guide for NPSG.07.05.01 on surgical site infections: The SSI change project. Retrieved from http://www.jointcommission.org/assets/1/18/ Implementation_Guide_for_NPSG_SSI_1.PDF
Summary Attachments/Hyperlinks/Evidences
Exhibit EP20EOd: Homestead Hospital SSI Observed Rate for CRS and implementation timeline for CRS SSI bundle components
Exhibit EP20EOe: Odds Ratio of Risk for Acquiring an SSI with Colorectal Surgery at Homestead Hospital vs. National Benchmark