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Follow Up

• Committee forming –recommendations offered and done

• Observations- sterile technique and hygiene –better hand off

• Continue infection surveillance to include breast biopsies (not connected with surgery)

• Report compliance with bundle

Background

During surveillance of post op breast surgeries in the past 2 years it has been noted that many of the surgical breast procedures have invasive procedures done in mammography and other areas in Radiology Imaging department immediately prior to the surgical procedure. These are invasive procedures that involve such things as wires inserted into the breast to locate the tumors for the surgeon in the Mammography suite. These wires are then pulled through the incision in the OR once the tumor is excised and ready for removal. Since this occurs on the OR table and the wire comes through the sterile tissues of the breast the insertion and care of the wire before surgery should be kept as clean as possible.

Procedure.

A3 Owner:

Date:

Breast Surgical Site Infection Prevention Improvement Initiative

Plan/Future State

• Improved aseptic technique in radiology

• Reduction in the rate of post op breast infections

• Radiology room re-design to facilitate aseptic technique

• Improve hand off of patient from radiology to the OR.

Proposed Countermeasures

• Establish surgeon/ radiologist/nursing multi disciplinary committee to identify risks for infection & make changes as necessary

• Rewrite all procedures in mammography to include aseptic technique

• Educate, with assistance of OR staff and Infection prevention, radiology procedures/staff on aseptic technique-have staff observe a breast surgery after placement of the wire locum, OR offered staff to help with the aseptic tech teaching

• Redesign departments to support sterile technique-dirty utility, scrub sink, room air exchanges, (evaluate specific needs)

• Obtain AORN video on aseptic tech and review with staff

• ? of prophylactic ABX before wire insertion & ? of occlusive drsg on wires

• Sterile skin prep

• Hand scrub before donning sterile gloves

• Explore possibility of combining wire locum (since done under image guidance) and breast procedure in the same room

• Observation by surgeons and OR team of wire localization procedures

• Reduce time between placement of wire and patient going to OR

• Benefits of occlusive drsg.

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Implementation

• Secure a sponsor to drive improvement work

• Community survey of practice in other facilities

• Met with mammography department heads (See the performance improvement report for details).

• Review surveillance data (currently being collected) on breast biopsy (not associated with surgery)

• Data on breast infections presented to all surgical oversight committees, Hospital Quality Committee, Infection Control/Prevention Committee, Overall General surgeon dept meeting.

• Develop standards using a “bundle approach”

• Inservices for mammography staff

• Develop, collect compliance with bundle

1.

Analysis

A review of other hospitals and ambulatory care units in the local area revealed that similar aseptic technique as observed at xxxx are occurring at other facilities in the area.

After observing the insertion of a wire in mammography and then following the same patient to the OR for the breast surgery it is clear that the same asepsis is not followed. Procedures in the mammography department are done with just a hand washing and then putting on sterile gloves; the procedurist was observed leaving the sterile field to obtain items away from the field and returned to the sterile field. In the OR everything is sterile, nothing is touched outside the field.

Sometimes the time between wire loc insertion and surgery is up to 3 hours.

Preop showers or wipes with CHG are to be given to patients preoperatively and should be occurring.

MRSA screening for Hx of positive MRSA patients is to occur preoperatively.

Goals/Targets

Reduce the incidence of post op breast infections at facility to national benchmarks/norms by providing improved aseptic technique for all invasive procedures.

Provide a safe environment for our patients.

Current State

It is difficult to determine if the breast infections that are occurring are from the surgery or the placement of the wire in mammography/Radiology. Our Post op breast infection rate is at least 3 times higher than the recommended national average for ambulatory surgery centers: 2010 GHC infection rate was 2.54 (12/473) infections per 100 procedures. The National Healthcare Safety Network (NHSN) pooled mean infection rate for breast procedures is 0.32 per 100 procedures.

These breast procedures in radiology have been observed by the Infection Preventionists

and aseptic technique has not been used. Mammography is working to make changes, but the issue goes beyond mammography because other procedures in Radiology that involve the breasts aseptic technique could be improved i.e. stereotactic breast biopsies done at xxx.

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