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AAOS Now

Published 11/1/2013
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Terry Stanton

Getting to Zero Infections

An all-out effort cut postoperative infection rates in half

At the beginning of 2011, the rate of surgical site infections (SSIs) at St. Luke’s Boise Medical Center in Idaho was 1.1 percent. By national standards, that is fairly respectable; at some hospitals, the rate runs greater than 2 percent.

Executives and staff at St. Luke’s wanted to do better. They estimated that each infection cost an average of $100,000 and that reducing the incidence could save millions, with obvious benefits to patient welfare. They set a goal of cutting the rate in half by the end of 2012 and gave their endeavor the name of Project Zero to reflect the ideal of making SSI a “never event.”

The effort began with a focus on orthopaedic and neurosurgery procedures, with a team led by Howard A. King, MD, and Kevin G. Shea, MD. In preparation, Dr. Shea visited an allograft harvest facility known for its meticulous attention to infection prevention, including rigorous air management. When he learned that many of the facility’s processes were based on clean-room practices used in microbiology and computer chip manufacturing, he turned to engineers at Boise State University for expertise on air-quality and particulate management and met with the chip processing and HVAC staff at a computer chip manufacturing facility in Boise.

The Project Zero group incorporated knowledge gathered from those sources into a comprehensive effort that included the following measures:

  • reducing operating room (OR) traffic
  • limiting the time of OR door openings
  • complying with Surgical Care Improvement Project measures for antibiotic administration
  • improving postoperative protocols to reduce variation among surgeons and procedures
  • changing surgical attire and adopting uniform policies
  • improving communications among surgeons, anesthesiologists, hospitalists, nurses, and other staff

The result after 18 months was a reduction in the SSI rate by more than half, to 0.5 percent, in 11 index procedures. That means 28 fewer infections for total joint and spine procedures. Now the Project Zero team is aiming to lower the rate by an additional 50 percent by June 2014.

To learn more about the effort to prevent SSI, AAOS Now spoke with Dr. Shea, who explained that success depends on “all the little things we did consistently” and the move toward the accountable care model makes infection prevention more imperative than ever.



Kevin G. Shea, MD, explains some of the variables in the St. Luke’s Project Zero team effort to eliminate surgical site infections.
Courtesy of St. Luke’s Health System

AAOS Now: How did this project get started?

Dr. Shea: We essentially got all the stakeholders together, including surgeons, nursing staff, people who process the instruments, and people in infectious disease, both medical staff and epidemiologists who work for the hospital. We looked at all the opportunities and many different sources of information to lower our infection rates, including national orthopaedic standards, nursing standards, and some of the top-performing hospitals in the United States to see what they did.

AAOS Now: Why did the project originate with orthopaedics?

Dr. Shea: Our orthopaedic department is well organized and communicates on a very regular basis. We work collaboratively with the neurosurgeons and, with their support and the support of hospital administration, we’ve been able to engage other departments, including general surgery and ear, nose, and throat surgeons.

AAOS Now: What did you learn from the allograft and computer chip facilities?

Dr. Shea: The allograft companies are very meticulous about preventing infection during the harvest process. We learned a lot by how they process tissues and use the OR. Chips are manufactured in very sterile air, with remarkably low airborne particle counts. Although computers are different from humans, airborne particulates can damage chip production just as airborne particulate that contains bacteria can cause joint infections and other surgical infections.

These facilities have remarkably complex and very robust air handling systems, better than hospital systems. We’re looking at whatever we can do to improve the quality of the air, beginning with sampling the quality of the air in the ORs and checking on the cleanliness and maintenance of ventilation systems. It’s probably going to be some time before we have all the information, but we’re looking at a variety of measures to improve the quality of air.

AAOS Now: What were the new measures for clothing and coverings?

Dr. Shea: The allograft facilities have stringent clothing standards for anyone who is in a clean room—which means anytime a cadaver is being harvested. For example, no outside clothes or shoes are ever worn in the ORs. Head coverings are more extensive.

Surgeons who perform total joints procedures wear something akin to space suits, but not all surgeons wear them for all procedures. At the allograft facility, although they don’t wear those space suits, they have much more complete covering of their skin and their hair. We’re trying to adopt similar measures by evaluating caps and eliminating those that don’t cover the hair effectively.

Both Micron and the allograft harvest facilities don’t allow employees to wear cosmetics at work. They can wear make-up to work, but if they go into a clean room or harvest room or allograft OR, they cannot wear any type of cosmetics. Make-up has been shown to generate powder particulates, which contain skin cells and bacteria. That’s something we may try to address in the future.

You have to be careful how you implement some measures. You may not get something implemented right away, but over a year or two, as people start to understand the impact of their behavior and practices and how they influence infection, they come around.

AAOS Now: What did you address in the OR?

Dr. Shea: We instituted a standard prepping policy for all departments. By reducing that variation, we thought we had a more consistent use of appropriate products. We looked at room traffic. We now limit the number of people who come into the OR and we have a policy that once a procedure has started, no one can enter or leave the OR without a good reason, such as to get an instrument.

Only one student of any type is permitted per procedure. Only one equipment or instrument rep is allowed per procedure. We use video cameras in the OR so that people in outside rooms can view the procedure.

We’ve limited access to the OR as well. Patients are brought in and out through large double doors, but then those doors are locked, and all other entries into the OR are through the small side doors that don’t produce as much air turbulence or air exchange in the OR.

AAOS Now: What makes the effort worth the time and cost?

Dr. Shea: Under the Affordable Care Act, hospitals will be paid based on quality. One of the metrics is postoperative complications. Hospitals with better performance will get bonuses; hospitals with worse outcomes will get penalties. So reducing postoperative complications such as SSI will be beneficial.

Beyond the cost aspect, I feel very fortunate to be part of a surgical specialty that provides value and quality to our patients. As orthopaedic surgeons, we dramatically change the lives of patients. I work with surgeons who are driven to provide the best care at all times to their patients, even those patients who are increasingly sick, with complex medical problems.

We have three aims in providing care: to improve the health of our patients one-on-one, to improve the overall community health, and to do it at a lower cost. It’s great to be part of a community that is driven to do this.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org