Evidence update on prevention of surgical site infection

Purpose of review: surgical site infection (SSI) is a common health care associated infection and complicates up to 10-20% of operations with considerable health care resources. Apart from the widely adopted use of appropriate hair removal, antibiotic prophylaxis, avoidance of hypothermia and peri-operative glycaemic control to reduce SSIs this review has considered new research and systematic reviews, and whether their findings should be included in guidelines. Recent findings: The efficacy of preoperative bathing/showering, antibiotic prophylaxis for clean surgery and perioperative oxygen supplementation to reduce the risk of SSI is still in doubt. By contrast, the use of 2% chlorhexidine in alcohol skin preparation, postoperative negative pressure wound therapy and antiseptic surgical dressings do show promise. Antimicrobial sutures in independent meta-analyses were found to reduce the risk of SSI after all classes of surgery (except dirty) whereas the use of wound guards, or diathermy skin incision (compared with scalpel incision), did not. Summary: The incidence of SSI after surgery is not falling. Based on this review of published trials and evidence-based systematic reviews some advances might be included into these care bundles. More research is needed together with improved compliance with care bundles

Optimization of Transfusion Administration Process: A Quality Improvement Project

BACKGROUND: Transfusion of blood products (transfusion) occurs infrequently for most nurses yet is a high-risk procedure for patients. To ensure patient safety, Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) created regulatory standards for transfusion administration and documentation. To meet regulatory standards, transfusion events require documentation of all six critical steps and nurse leaders must monitor compliance with regulatory transfusion documentation, taking action when rates are suboptimal. Yet, transfusion documentation in the electronic health record (EHR) has been described as fragmented, confusing, and devoid of built-in prompts to facilitate completion. Checklists can organize tasks with multiple steps to enhance compliance, and automated reports eliminate the need for leaders to spend extended time manually auditing charts. In one large hospital in the Pacific Northwest where regulatory transfusion documentation compliance was suboptimal, nurses did not have a checklist for transfusion documentation and no automated report existed for reviewing transfusion documentation compliance. PURPOSE/AIMS: The primary objective of this quality improvement (QI) project was to increase clinical nurse compliance with regulatory transfusion documentation. The secondary objective was to reduce the amount of time nursing leaders reported spending on transfusion compliance chart audits. METHODS/APPROACH: To improve transfusion regulatory compliance in a large medical center, a regulatory transfusion documentation checklist was developed in late 2020 based upon review of hospital policies, regulatory requirements, and stakeholder input. A paper copy of the checklist was supplied by blood bank with every non-emergent blood unit to be transfused. Upon completion of the paper form, the nurse returned the checklist to the manager for review against dashboard data. To streamline ongoing transfusion compliance audits, an EHR-linked transfusion dashboard was created and shared with all nurse managers to illustrate individual nurse compliance on the six aspects of regulatory transfusion documentation. RESULTS: A total of 2500 transfusion events were assessed across the medical center. Compliance with regulatory transfusion documentation increased from 62% to 92% following implementation of the checklist. Subsequent TJC and CMS laboratory and hospital surveys reflected compliance with transfusion documentation regulations. Nursing leadership reported that the new automated reports facilitated improved patient care due to an increase in transfusion regulatory compliance, enhanced nursing accountability and action planning to support compliance, a reduction in manager transfusion reporting workload, and streamlined transfusion compliance reporting to senior leadership. CONCLUSION: The process of using a paper blood transfusion checklist combined with EHR-linked dashboard auditing of transfusion compliance increased compliance with regulatory transfusion documentation and reduced nurse manager workload. IMPLICATIONS FOR PRACTICE: Deconstructing a complex, high-risk procedure like transfusion into a simple checklist may enhance nursing satisfaction, promote patient safety, and contribute to regulatory compliance. In addition, removal of manual audits may ease nurse leader burden to follow-up with staff who may need coaching on proper documentation practices. Next steps for this work include implementing the paper checklists and transfusion documentation dashboards across all hospitals in the entire region to monitor continued patient safety benefits for transfusion events. References Dang, D., & Dearholt, S. (2018). Johns Hopkins Nursing Evidence-Based Practice Third Edition: Model and Guidelines (3rd ed.). Sigma Theta Tau International. McNett, M., Tucker, S., Thomas, B., Gorsuch, P., & Gallagher-Ford, L. (2021). Use of Implementation Science to Advance Nurse-Led Evidence-Based Practice in Clinical Settings. Nurse Leader. https://doi.org/10.1016/j.mnl.2021.11.002 Speroni, K., McLaughlin, M., & Friesen, M. A. (2020). Use of Evidence-Based Practice Models and Research Findings in Magnet-Designated Hospitals Across the United States: National survey Results. Worldviews on Evidence-Based Nursing

Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries: A Randomized Controlled Trial

What We Already Know about This Topic Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. The causes of the healthcare disparity are unknown, and effective interventions are to be established. What This Article Tells Us That Is New A language-concordant, educational program regarding labor epidurals during the first stage of labor, in addition to the routine prenatal education, is feasible and does not cause any negative effect.Such an intervention increases epidural use among Hispanic but not non-Hispanic women.It also reduces misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic women. Background:Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. This may represent a healthcare disparity related to a language barrier and inadequate opportunities for labor analgesia education. It was hypothesized that a language-concordant, educational program regarding labor epidurals would improve epidural utilization in two independent cohorts of Hispanic and non-Hispanic women. Methods:A randomized controlled trial, blinded to anesthesia, nursing, and obstetric providers, was completed at an academic hospital (February 2015 to February 2017). Two cohorts of Medicaid beneficiaries of Hispanic (English- and/or Spanish-speaking) and non-Hispanic ethnicity were enrolled concurrently. The patients were randomized to routine care alone or routine care and an additional educational program comprised of three components: a video show, corresponding pamphlet, and in-person counseling. The primary endpoint was use of epidural labor analgesia. The secondary endpoint was change in response before and after delivery on common misconceptions based on a 12-point epidural questionnaire. Results:Hispanic women randomized to the intervention group were 33% more likely to choose epidural analgesia compared to the routine care group (40 of 50 [80%] vs. 30 of 50 [60%]; risk ratio, 1.33 [95% CI, 1.02 to 1.74]; P = 0.029). For the non-Hispanic cohort, no difference was detected in epidural use between the intervention and routine care groups (41 of 50 [82%] vs. 42 of 49 [86%]; risk ratio, 0.96 [95% CI, 0.80 to 1.14]; P = 0.62), but the study was underpowered to determine a result of no difference. Patients assigned to the intervention had a greater improvement in epidural understanding compared with routine care, among both Hispanic (2.26 vs. 0.74, respectively; difference in change from baseline, 1.52 [95% CI, 0.77 to 2.27]; P \u3c 0.001) and non-Hispanic (1.36 vs. 0.33, respectively; difference in change from baseline, 1.03 [95% CI, 0.23 to 1.75]; P = 0.005) cohorts. There were no adverse events during the trial. Conclusions:The educational program increased epidural use among Hispanic women. The educational program reduced misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic cohorts

Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries: A Randomized Controlled Trial

What We Already Know about This Topic Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. The causes of the healthcare disparity are unknown, and effective interventions are to be established. What This Article Tells Us That Is New A language-concordant, educational program regarding labor epidurals during the first stage of labor, in addition to the routine prenatal education, is feasible and does not cause any negative effect.Such an intervention increases epidural use among Hispanic but not non-Hispanic women.It also reduces misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic women. Background:Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. This may represent a healthcare disparity related to a language barrier and inadequate opportunities for labor analgesia education. It was hypothesized that a language-concordant, educational program regarding labor epidurals would improve epidural utilization in two independent cohorts of Hispanic and non-Hispanic women. Methods:A randomized controlled trial, blinded to anesthesia, nursing, and obstetric providers, was completed at an academic hospital (February 2015 to February 2017). Two cohorts of Medicaid beneficiaries of Hispanic (English- and/or Spanish-speaking) and non-Hispanic ethnicity were enrolled concurrently. The patients were randomized to routine care alone or routine care and an additional educational program comprised of three components: a video show, corresponding pamphlet, and in-person counseling. The primary endpoint was use of epidural labor analgesia. The secondary endpoint was change in response before and after delivery on common misconceptions based on a 12-point epidural questionnaire. Results:Hispanic women randomized to the intervention group were 33% more likely to choose epidural analgesia compared to the routine care group (40 of 50 [80%] vs. 30 of 50 [60%]; risk ratio, 1.33 [95% CI, 1.02 to 1.74]; P = 0.029). For the non-Hispanic cohort, no difference was detected in epidural use between the intervention and routine care groups (41 of 50 [82%] vs. 42 of 49 [86%]; risk ratio, 0.96 [95% CI, 0.80 to 1.14]; P = 0.62), but the study was underpowered to determine a result of no difference. Patients assigned to the intervention had a greater improvement in epidural understanding compared with routine care, among both Hispanic (2.26 vs. 0.74, respectively; difference in change from baseline, 1.52 [95% CI, 0.77 to 2.27]; P \u3c 0.001) and non-Hispanic (1.36 vs. 0.33, respectively; difference in change from baseline, 1.03 [95% CI, 0.23 to 1.75]; P = 0.005) cohorts. There were no adverse events during the trial. Conclusions:The educational program increased epidural use among Hispanic women. The educational program reduced misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic cohorts