1. Building Your SSI Prevention Bundle Brad Winters, PhD, MD, FCCM
Elizabeth C. Wick, MD
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

2. What is your current role?
Polling Question
What is your current role?
Surgeon
Quality improvement practitioner
Infection preventionist
OR nurse
OR technician
Anesthesiologist
OR manager
Educator
Other

3. Learning Objectives
Use surgical care audit tools to gather data on the defects your staff identified in the PSSA
Create a performance goal for your team
Develop a feasible SSI Prevention Bundle that addresses up to three surgical care processes your team can improve
Describe how to proceed with improvements that don’t have a strong evidence base
Locate SUSP resources on the project website
Say:
After reviewing this module, you will be able to:
Develop and implement an SSI reduction goal and prevention bundle that addresses up to three surgical care processes that your team feels needs to be improved to address SSIs
Understand how to use the results of your staff safety assessment to build a bundle
Review how to initiate audits of your processes
Create a performance goal (improvement in outcome) for your team
Learn how to proceed with improvements that do not have a strong evidence base
Locate SUSP resources on the project website
We ask that you share what you have learned with your teams.

4. Background1 Surgical Site Infections (SSIs):
Are most common nosocomial infection in the surgical patient
Are most common complication after colorectal abdominal surgery (3-30%)
Are associated with increased length of stay, re-admission, and mortality
Cost between $6,200 - $15,000 / per patient (superficial - organ space)
Say:
In colon surgery, you see some of the highest wound infection rates of any procedure. In the literature, the rates range from about 10% to 30%. Especially in colon surgery cases, patient with infections stay in the hospital longer, are more likely to be readmitted, and have a higher mortality and need for re-operation.
There are also the less tangible or less direct consequences of wound infections—such as lost work, and the impact on family and friends who need to help care for patients with wound infections.
There’s also the cost consideration. Estimates are that wound infections cost the health system anywhere from about $6,200 to $15,000 per patient. The cost depends on the type of wound infection, whether it’s a superficial infection—which costs about 3,000 extra dollars— or it’s an infection in the abdominal cavity (organ space infection) which costs upwards of 15,000 dollars.

5. SSI Definitions2 Deep Superficial Organ Space
Purulent drainage from wound
Positive wound culture
Pain, redness swelling
Diagnosis by surgeon
Deep
Purulent drainage from deep aspect of the wound
Dehiscence
Abscess on exam or CT scan
Organ Space
Infection in the surgical cavity (abdomen)
Say:
Let’s briefly review definitions of wound infections. These are standard definitions and they’re on the CDC website and also on the Johns Hopkins Medicine website. Superficial wound infections are infections of the skin, something you just see with your eyes and you diagnose when you are assessing a patient as part of the physical exam. For example, you note there’s purulent drainage from the wound redness and swelling and you obtain cultures from the wound which are positive for bacteria.
Deeper space infections are less common and they’re a little trickier to diagnose. They’re on the deep aspect of the wound, at the level of the fascia, and they are diagnosed with a CAT scan.
And finally, organ space infections are infections of the surgical cavity. These can be abscesses that we drain in the surgical cavity – either with interventional radiology or surgery or, anastomotic leaks. Organ space infections are the most complicated to treat, the most morbid, and the most expensive.

6. JHH Colorectal Surgery Readmissions
Readmission rate: 17.6% ( )
Say:
In colorectal surgery patients we have a real readmission problem. The readmission rate at Johns Hopkins Hospital is about 18%. The factor that is driving the readmissions are complications, and specifically infections, so, care of coordination or handoff from post-discharge to home aren’t going to help these problems. It is SSI prevention that is going to help these patients from getting readmitted.

7. Host Bacteria Procedure Pathogenesis of SSI Say:
The pathogenesis of SSI is a complicated process. It reflects the interplay between the bacteria, the host, and the type of procedure being done. For example, the colon is home to 1013 bacteria, especially gram-negative bacteria and anaerobes. This makes colon surgery much riskier for wound infections and other procedures.
Host risk factors include malnutrition, chemotherapy treatment, immunosuppressant medications or steroids – all things that might make weaken a patient’s immune system and make them more vulnerable to infection.
The type of procedure a patient receives also influences his or her risk for wound infection. For example, there’s a difference in infection risk when a patient is undergoing a rectal procedure versus on a colon procedure and whether an ostomy or stoma is involved.
Not surprisingly, there’s no one solution to preventing wound infection.

8. No Single SSI Prevention Bundle
Deeper dive into SCIP measures to identify local defects
Emerging evidence
Abx redosing and weight-based dosing
Maintenance of normogylcemia
Mechanical bowel preparation with oral abx
Standardization of skin preparation
Capitalize on frontline wisdom
CUSP / Staff Safety Assessment
Say:
Based on this complexity, we believe that there is likely no one checklist or bundle for SSI reduction. We also recognize that many hospitals have spent an enormous amount of energy and resources toward improving performance on the SCIP measures, and it doesn’t make sense to ask hospitals to refocus on areas they are already doing well.
So in this program, we’re asking teams to identify local opportunities to improve in one of three ways:
1.In addition to SCIP measures, identify local defects that may be contributing to SSI infection rates
2.Focus on some emerging evidence relating to SSI reduction, including antibiotic re-dosing and weight-based dosing, maintenance of normoglycemia, the use of selected mechanical bowel prep with oral antibiotics, and standardization of the skin preparation
3.Mine the wisdom of frontline caregivers using the second step of the CUSP program—to identify defect, for example, by using the Staff Safety Assessment, where we ask staff, how do you think the next patient will be harmed, how will they develop a surgical-site infection, and what we can do to try to prevent that harm?

9. Deeper Dive Into SCIP Measures to Identify Local Defects

10. Does SCIP give us enough information?
Johns Hopkins
Comparison Hospitals
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection
98%
97%
Surgery patients who were given the right kind of antibiotic to help prevent infection
Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
100%
96%
Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery
99%
Say:
Remember that for most hospitals, SCIP represents a random sample of patients undergoing colon surgery. For example, SCIP data usually represents only about six patients a month even though you may do about 30 to 40 colorectal operations a month.
Looking at Johns Hopkins as an example, you can see that based on Hospital Compare data, Johns Hopkins Hospital does quite well when it comes to giving the right antibiotic to the patient at the right time. Johns Hopkins also does quite well in discontinuation of antibiotics. However, other domains relating to antibiotic utilization can be improved.

11. NSQIP Report 2009
Say:
This chart shows the thirty day morbidity O/E ratios for colectomy from NSQIP in 2009.

12. Polling Question Do you have… Strong SSI performance
Weak SSI performance
Strong SCIP performance
Weak SCIP performance
A and C
A and D
B and C
B and D

13. Does your hospital have a colon SSI bundle?
Polling Question
Does your hospital have a colon SSI bundle?
Yes No

14. Safety Issues & Improvement Opportunities4
CUSP Step 2:
Safety Issue Identified
CUSP Steps 4 & 5:
Opportunities to improve
Infection Control
Skin preparation
Hypothermia
Contamination of bowel contents into the wound
Antibiotic timing
Selection and redosing
Length of case
Coordination of Care
Increase utilization of preoperative evaluation center,
Improve surgical posting accuracy (case name and duration)
Computer assistance for antibiotic selection and redosing
Communication and Teamwork
Improve communication throughout perioperative period
Empower team members to speak up
Improve compliance with briefings/debriefings
Implement teamwork tools
Equipment/ Supplies
Accurate temperature probes
Point of care glucose monitoring
Under body warmers
Sanitizing wipes near anesthesia machine
Policies/Protocols
Standardize care/protocols/policies
Monitor sterile technique policies
Education/Training
Ongoing education (with supportive data)
Development of a SSI prevention checklist
Say:
These are the results of our Staff Safety Assessment when we first started this work. And you can see, we surfaced defects with SCIP measures that hadn’t been picked up by our quality folks.
The front line said, you know, we’re not always giving the antibiotics at the right time. You know, sometimes they’re getting pushed very quickly. They’re maybe being pushed right at the incision. We are not always using the right antibiotic, and we’re definitely not re-dosing them. They questioned whether or not our temperature data was even accurate because they questioned the utility of our temperature probes, and they thought we needed some kind of under-body warmer. So, those are things that we all thought we’d been working on as part of the SCIP measures, but the front line said we were not there.

15. Michigan Surgical Quality Collaborative5
Perioperative Antibiotic Compliance
Michigan Surgical Quality Collaborative5
Say:
This slide shows data from the Michigan Surgical Quality Collaborative where they noticed only 80% of patients were receiving proper types of antibiotics. In emergency cases—where patients tend to be a high risk for complications like wound infections— only 50% of patients were getting the proper antibiotic.
You can see that weight-based dosing of cephalosporins and re-dosing was done even more rarely. We are going to talk about these later in this talk as “emerging evidence” to prevent SSIs.
So even though there’s excellent level-one evidence to support the role of antibiotics in preventing wound infections, we have a long way to go, despite having worked on SCIP for so long.

16. Auditing Your Practice
Evaluate a sample of patients undergoing your targeted procedure for compliance with processes your team identified as potential areas to improve
For example, the next patients
Adapt tool from SUSP website or develop new tool
Practical and feasible strategy to evaluate performance and surface defects
Empowers frontline staff
Say:
It can also help to start with small tests of change, for example, evaluating patients.

17. How Do We Conduct Audits?
Retrospective chart review
Concurrent review
Place audit tool on chart
Complete over continuum of care
We recommend auditing 5-10 patients
Larger samples yield better estimates of performance
Your data does not need to be submitted
Say:
There are several steps involved in conducting audits.
The first is to conduct a retrospective chart review on 5-10 patients. You will also want to conduct a concurrent review on an additional 5-10 patients. To conduct a concurrent review, you will place an audit tool in the chart and follow the audit over the continuum of care for each patient.
If you are able to audit more than 5-10 patients, it will yield better estimates of performance.
This data does not need to be submitted. Its simply a benchmark for your team to use as you evaluate current progress.

18. Antibiotic Dosing: Gentamicin
Interventions
Increased amount of gentamicin available in room
Added dose calculator in anesthesia record
Educated surgery, anesthesia, and nursing staff
Say:
When the colorectal surgery CUSP team began to audit its practices, it found that our patients indeed weren’t always getting the right antibiotic, particularly if they were penicillin allergic. Partnering with a senior executive, the team implemented a variety of interventions once it understood what the barriers were. And as a result, now over 90% of the time patients can count on getting the appropriate dose of gentamicin.
Despite a 95% compliance on SCIP!

19. SUSP Antibiotic Audit Tool
This is the antibiotic audit tool – it has detailed questions related to best practices for antibiotic use. Using this tool will help to surface defects that need to be addressed.

20. Normothermia Interventions
Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)
Initiated forced air warming in the pre- operative area
Say:
Again, the team used an audit tool to better understand its performance. The team found that patients coming out of the operating room were at a temperature greater than 36 degrees only 80% of the time. The audit process provided an opportunity for the team to obtain a better understanding of performance barriers, tapping into the wisdom of frontline providers. Working with the team’s senior executive partner, the team was able to achieve desired temperatures in greater than 90% of patients.

21. SUSP Normothermia Audit Tool (1 of 2)
This is the temperature audit tool – it has detailed questions related to best practices for maintaining normothermia. Using this tool will help to surface defects that need to be addressed.

22. SUSP Normothermia Audit Tool (2 of 2)
This is the temperature audit tool – it has detailed questions related to best-practices for maintaining normothermia. Using this tool will help to surface defects that need to be addressed.

23. What about interventions with no data to support them?
In this section, we will review interventions that do not have published supportive data.

24. Separation of “Clean” and “Dirty” Instruments
Intervention
Built separate tray of instruments used for bowel anastomosis
Extra suction along with both bovie tip and gloves opened and changed after anastomosis
Educational sessions with scrub techs and nurses about instrument separation
Real time audits
Say:
When you hear a lot of colon infection talks, most people talk about implementing a closing set, so they have a little separate instrument tray that they use when they’re closing the fascia and the skin, and that’s fine, but our front-line folks, our scrub techs and nurses, didn’t think that that was the way to go. They wanted to build a separate little set for anastomoses, so when we were doing the bowel portion, they would have a separate set of instruments they could use and then they dispose of them. And they felt that they could tell exactly the point of the operation where you were doing the anastomosis much more easily than they could tell the point that you were closing.
We also include an extra suction and we change our gloves. And they took it on themselves to spread it and to audit it, and they spread it from general surgery to gynecology to the pancreas surgeons, because they all operate on the bowel. And now it’s really practice in the operating room, and this is something that there’s no evidence to support, but we were still able to do it because we felt it was the best practice.

25. Bringing Emerging Evidence for SSI Prevention
to Your Patients
Say:
In this section we will review emerging evidence for SSI prevention. Evidence that is not a SCIP requirement but in which there is reasonable evidence to support adding to your SSI bundles.

26. Have you reviewed the new antibiotic guidelines?
Polling Question
Have you reviewed the new antibiotic guidelines?
Yes No

27. Have you reviewed the draft HICPAC guidelines?
Polling Question
Have you reviewed the draft HICPAC guidelines?
Yes No

28. Emerging Evidence for SSI Prevention
Antibiotic Usage
Re-dosing
Weight based dosing of cephalosporins
Utilization of mechanical bowel preparation with oral antibiotics
Normoglycemia / Prevention of hyperglycemia
Standardization of skin preparation
Say:
First, related to antibiotic usage in these new guidelines, the evidence talks about re-dosing antibiotics for cases that are longer than four hours, depending on what age that you’re using. Also, weight-based dosing for cephalosporins, they focus on weight-based dosing for cefazolin, but we’ve at Hopkins have extended it to weight-based dosing for cefotetan, so for larger patients we give 3 milligrams/kg of cefotetan. Also, in those guidelines they advocate for the use of mechanical bowel preparation with oral antibiotics for colon surgery, so again, this is a group of national societies that’s endorsed this, so it helps to get buy-in to consider these interventions.
And then there’s also emerging evidence not in the guideline format but for maintenance of normoglycemia or prevention of hyperglycemia in the perioperative period. And finally, there’s also emerging evidence to support standardization of skin preparation with a dual-agent prep that includes alcohol.

29. Say:
These are the new antimicrobial guidelines from ASHP. They cover all types of surgeries, so there are recommendations for every type of surgery, but they do have a little table in there which tells you about different procedures, including colon surgery. And this is the table, and it tells you, for example, it tells you that if weight-based dosing is recommended or not, and at the bottom here they talk about the bowel prep and what to recommend for the bowel prep.
Source: ASHP6

30. Redosing and Weight Based Dosing
Bowel Prep
Say:
This is the table, and it tells you that if weight-based dosing is recommended or not, and at the bottom of the page, it discusses bowel prep recommendations.

31. JHU Antibiotic Poster Perioperative Antibiotic Prophylaxis To Prevent
Surgical Site Infection
Say:
This is the kind of thing that you could use to try to make a nomogram or a standard protocol for your hospital to use antibiotics. Here is an example from Johns Hopkins University. The infection control department has taken these recommendations and looked at the culture and sensitivity of different bacteria from wound infections at Hopkins and picked out standard antibiotics used for different procedures. So for example, for colon surgery, they use cefotetan.
But this is the first step to standardizing it, to come up with a standard algorithm of what you’re going to use for each procedure to eliminate some of this variability. When you have a standard procedure, you’re less likely to under-dose or use an inappropriate antibiotic.
Re-dosing is something to also consider if you’re not doing it. The goal is to maintain therapeutic levels throughout the entire case. One thing, though, if you read the new guidelines, if you use cefoxitin, they do recommend re-dosing cefoxitin every two hours, so it’s maybe unreasonable. So if you use cefoxitin, I think it’s reasonable to consider changing to another antibiotic.
Hospitals implement policies and make mandates all the time, but we don’t always know our practice. It is recommended to go back and audit patients, see where the patients in the longer cases where they re-dosed, was weight-based dosing done, and where is there room for improvement. When you have those audit reports, share them with the front line because that’s how you engage people. People don’t know about defects or trends in your hospital until you share that data, and that’s how you start to change the culture and get the buy-in.

32. Interventions to Improve Antibiotic Efficacy
Standardize weight-based dosing of cephalosporins
Standardize antibiotics re-dosing
Maintain therapeutic antibiotic serum levels throughout procedure
Reconsider the use of cefoxitin due to its short redosing interval
Audit your practice!
Standardize selections based on your hospital procedures
Engage surgery, nursing and anesthesia areas to implement a standard protocol
Consider integrating into EMR, if available
Audit your results and share success
Say:
We know it’s important to maintain antibiotic serum levels during the entire case. What we’re learning is that antibiotic serum levels do not last as long as we thought they did. New guidelines are available from the Infectious Diseases Society of America or IDSA and recommend re-dosing at shorter intervals. For example, prior guidelines recommended redosing cefotetan as routine prophylaxis for colon surgery at eight-hour intervals. The new guides recommend every six hours.
Similarly, IDSA recommends redosing cefazolin every three hours and cefoxitin every two hours.
Cefoxitin is an SCIP approved antibiotic for colon prophylaxis. But, you can see from the new guidelines, this might not be the best choice. Most colon operations are more than two hours – so you if you use cefoxitin you would need to worry about redosing in almost every case. Your hospital may consider selecting an antibiotic something that’s longer acting.
Also, included in these guidelines is weight-based dosing of cephalosporin. Especially if you use cefazolin and Flagyl, you should consider increasing the dose of cefazolin to 3mg for larger patients. This would be something that a CUSP team could focus on because it requires education for multiple disciplines and system changes.

33. Hyperglycemia and Infection
Background
Hyperglycemia is common in hospitalized patients
38% of medical and surgical patients had hyperglycemia
26% diabetic
12% non-diabetic
In cardiac surgery, degree of post-operative hyperglycemia correlates with SSI, adopted as SCIP measures
Goal
Glucose <180mg/dl in all hospitalized patients
Say:
Maintaining normoglycemia can reduce risk for wound infection. Hyperglycemia is very common in hospitalized patients, even those patients who are not diabetic.
In cardiac surgery patients, it’s been fairly well documented that hyperglycemia correlates with the rate of wound infection, and in fact this is a SCIP measure in this patient population. Smaller studies of general surgery patients also support a correlation between post-operative glucose levels and infection.
The Association of Endocrinologists recommends that in all hospitalized patients maintain a glucose level less than 180 mg/dL. We believe that achieving this goal will also help to reduce SSIs. Maintaining normogylcemia is complex and requires coordination between multiple disciplines and spans the continuum of care from the pre-operative clinic to the OR to the ward. It requires proactive interventions because frequently in diabetic patients, the first glucose on the day of surgery is 160 and then next time it is checked in the OR it is 220 – we need to have a plan. Talk to your endocrinologists and see if you have an insulin drip protocol or other tools that might be helpful to implement this best practice.
Post-operative hyperglycemia is associated with an
increased risk of SSI in general surgery patients.

34. University of Washington/Glucose Control
Say:
This is one example from the University of Washington of a glucose-control pathway or algorithm for the operating room.

35. Could You Improve Glycemic Management?
Audit your current practice
Do you have a policy?
Consider gathering a multidisciplinary team to develop a protocol for your hospital
Multidisciplinary team members:
Endocrinology
Surgery
Anesthesiology
Nursing
Ward
Pre-op
Say:
Are you doing as well as you can on glycemic management? Your SUSP team can audit your current practice. You can pick just that post-op day one glucose and just check all those post-op day one glucoses on 20 patients. You can look at diabetics- does your hospital have a policy? Do you check the diabetics’ glucoses in the prep area? Do patients get checked beforehand when they go to a pre-anesthesia clinic? What are the policies or what do you do to address those defects?
This needs to be a multidisciplinary approach. Consider incorporating your endocrinology folks at your hospital, surgery, nursing, and this, again, would extend from the operating room to the ward who takes care of the patients in the pre-op area to develop a protocol.

36. Preparation of the Surgical Site
Background
1012 bacteria reside on the skin
Staphlococcus and streptococcus species, among many others
Goal of skin preparation
Reduce bacterial burden on skin prior to incision
Best practice skin prep
Dual agent skin preparation
Chlorhexidine + alcohol OR
Povidone + iodine + alcohol
Include alcohol to increase durability of sterilization
Apply to specification, both in duration and amount
Must be dry before incision
Say:
The next area of emerging evidence relates to preparation of the surgical site. We know that the skin can harbor
1012 bacteria, mostly staph and strep species. The colon harbors more anaerobes and gram-negative bacteria. A good skin preparation is the best way to address the former.
Based on the evidence, current best practice is to use a dual-agent prep—
a preparation that includes chlorhexidine and alcohol (ChloraPrep)or Povidone iodine and alcohol (DuraPrep). Both preparations have specific instructions for proper use. Even if your hospital is using one of these, the technique for application may not be correct. Considering auditing your practice and identifying areas for improvement. Remember that whenever you include alcohol in your prep, it’s important to make sure that you let it dry.
You can monitor progress in skin prep by looking at the cultures from your wound infections together with your infection control practitioner. You can see if you have a lot of colon superficial infections with staph and strep. If you improve your skin prep it is likely that this will not happen.

37. ChloraPrep better than Betadine
ChloraPrep and DuraPrep better than Betadine
Say:
The best practice is to use some dual-agent skin prep, either a chlorhexidine plus alcohol or povidone-iodine plus alcohol, so it’s either ChloraPrep or DuraPrep. And the goal of the skin prep is to really increase the durability of the sterilization and you need to pay attention to how these products are supposed to be administered and how much of a patient they’re supposed to cover. So for large patients, we use ChloraPrep, and you need to use more than one stick to really have the patient clean. And then they obviously must be dry before the incision because of the alcohol.
And even if you start in your SUSP team, this is the kind of thing you want to consider standardizing throughout the operating room. For example, when we moved to ChloraPrep we had, our ChloraPrep rep came in and trained everyone, and then we had everyone check off that they’d had the training before they started doing the prep. These are just the two big papers that support the dual-agent preps. One is the ChloraPrep paper from the New England Journal in 2009, which showed that ChloraPrep was better than Betadine, and the other paper from UVA showed that ChloraPrep and DuraPrep are better that Betadine. So the jury is really still out on DuraPrep, that it’s probably likely still a sufficient skin prep.

38. Is Skin Prep an Area You Could Improve?
Audit your practices
What is being used for what cases?
Who is doing the prep?
How long are they taking for the prep?
Develop an educational plan that engages frontline providers for standardization
In-services
Video education
Change doctor preference cards
Audit again after implementing your interventions.
How well did you do? Share the results!
Say:
You want to audit your practices. A quality outcomes representative, an administrative representative, or a front line staff member in your hospital can audit the practices, look at the beginning of the case, see who’s doing the skin prep, see are they doing it for the full three minutes if you’re using ChloraPrep, and are they letting it dry.
You can develop an audit tool to keep track of that and then share the data and then come up with an educational plan for how you’re going to standardize who’s going to be accountable for it, for example, in in-services and video education.
And then, keep auditing and see if you’ve demonstrated improvement or changes in practice.

39. Key Takeaways
No single SSI prevention bundle exists. You need to identify the LOCAL defects.
Auditing is a practical and feasible strategy to evaluate performance and surface defects.
Tools provide a guideline and are adaptable to your local environment.
The CUSP methodology empowers frontline staff.
Say:
So in summary, there’s really not one SSI prevention bundle that’s going to work for all of us. We’re all going to have problems with different things at different times, but we need to surface those local defects, and the Staff Safety Assessment, asking the front line is key. Audits will help you surface those defects.
Some things you may just want to incorporate because those are the best practices out there and you feel strongly and your team feels strongly about them. Auditing is an iterative process-once you come up with your bundle, it will not be done on every patient until you really work through the system and audit your practice and keep educating and keep trying to hardwire those processes into your system.
Any tools should be adapted to your local environment. They’re starting points.
The CUSP method is going to empower the front line to be part of this. They’ll share with you why your bundle isn’t, why X patient didn’t get one element of your bundle or what you need to do better. And really, you’ll start to see great improvement.

40. Find tools at the project website
Resources
Find tools at the project website
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

41. Action Items Review staff safety assessment results
Pick 2-3 audit tools based on frontline feedback, SCIP measures and emerging evidence
Audit 5-10 patients with each tool
Create a performance goal for each intervention
Develop your bundle
Implement interventions for system changes
Share your tools, ideas for new tools and results
Say:
Some recommended action items include:
Review your Staff safety assessment results with your frontline staff
Picking two or three audit tools and using them to audit 5 to 10 patients
Create a performance goal for each intervention
Develop your SSI bundle
Develop system changes to implement interventions
Share your experiences with your peers both within your healthcare organization and with the larger SUSP network

42. References
Wick EC, Hobson DB, Bennett JL, et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. JACS. 2012; 215(2):
CDC/NHSN Surveillance Definitions for Specific Types of Infections. Rep. CDC, Jan. 2014; Web. 11 June
Hospital Compare. Medicare: the official U.S. government site for medicare.  Medicare.gov Website. < &lng= &name=johns%20hopkins%20hospital> Accessed May 30, 2010 4/
Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg. 2011;201(3):
Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. American Society for Health-System Pharmacists. doi: /ajhp American Journal of Health-System Pharmacy February 1, 2013 vol. 70 no. 3 p