When Ann Bailey, RNC-NIC, BSN, MBA, CIC, joined Dell Children’s as an infection preventionist in October 2010, she noticed what appeared to be a spike in surgical site infections among neurosurgery patients. “We were definitely seeing more cases than Dell had seen historically,” Bailey recalled.

Ann, who worked previously at Seton Medical Center Austin for 13 years, analyzed the data and discovered that the infections were concentrated among two groups: patients undergoing surgery for placement or revision of ventricular peritoneal shunts and patients with external ventricular drains. In response, Ann began meeting weekly with Sarmistha B. Hauger, MD, medical director of Dell Children’s infectious disease program, and Joanne Dixon, CREDENTIALS, network director of infection prevention, to discuss the troubling new cluster of infections. “As we investigated, we realized that skin organisms were responsible for most of the infections,” Bailey said. “We felt like there were a lot of opportunities to make practices more consistent.”

In December 2010, the group approached Tim George, MD, chief of pediatric neurosurgery/neurosciences, to discuss the infection data. “Dr. George was very receptive and thought it would be a good idea to establish a multi-disciplinary team to conduct a thorough overview of pre-op, intra-op and post-op neurosurgical practices,” Bailey said.

"Initiatives like this are hard to do. They require a change of culture. Sometimes we think what we do as individuals is best. But often, when we standardize practices, the results are better for our patients. And that makes it worth doing."

– Dr. Tim George, chief of Pediatric Neurosurgery/Neurosciences

Dr. George asked one of his neurosurgery colleagues, Patricia Aronin, MD, to participate in what became known as the Dell Children’s Medical Center Neurosurgery Multidisciplinary Team. “We recognized that there was a problem,” Dr. Aronin said. “When the blip occurred it became a big issue for all of us.”

The team began meeting weekly in January 2011, with representatives from the following areas:

• neurosurgery
• infectious disease
• infection prevention
• acute and critical care nursing
• pharmacy
• patient safety
• surgery leadership
• nursing education
• emergency department

Over the next months, the team reviewed the entire continuum of care, identifying practices and researching whether there was evidence to support certain practices over others. "What we found was that almost every one of our neurosurgeons was doing something different from each other. None of it was bad practice, but we knew we needed some consistency," Bailey said.

To get a handle on what other neurosurgeons were doing around the nation, Dr. Aronin distributed a questionnaire to her colleagues at the American Society for Pediatric Neurosurgery. "We had some ideas of things we could do to bring down the infection rate, but we wanted to see if there was a rationale for making these changes," Dr. Aronin explained.

With more than 50 survey responses in hand, the team developed a series of consistent, recommended neurosurgical practices. "One of the things the survey told us is that there is tremendous variability in what surgeons are doing across the country," Dr. Aronin said. "But our neurosurgeons agreed to try and do things the same way. We realized that prepping our patients the same way and adopting other consistent practices would allow us to go back scientifically and determine whether these new practices were actually effective at reducing infection rates."

Over the course of the next several months, the team developed and implemented several practices to limit or decrease the volume of skin contamination among pediatric neurosurgery patients, including:

A special two-step bathing protocol, which involves bathing the patient with soap and chlorhexidine gluconate wipes at home the day prior to surgery and using the CHG wipes a second time on the patient on the day of surgery.
A consistent antibiotic prophylaxis protocol designed to address skin organisms that will be in or around incision.
A consistent preoperative skin antisepsis using CHG that is supported by the evidence as the most effective means of killing most organisms on the surface of skin immediately prior to incision.
Since implementing the practice changes, neurosurgery has significantly reduced infections among patients with VP shunts or EVD patients. "There has been a cultural change among the entire health care team where everyone is trying to do things consistently," Dr. Aronin said. "But it’s still a work in progress and we need to keep monitoring how it’s going."

Team meetings are now being held monthly instead of weekly and plans are in the works to develop a process for evaluating compliance with the new practice standards. "Now that we have a model, I expect that we will see more consistent improvements in outcomes and that those positive outcomes can be reproduced in other disciplines," Dr. George said.

"This effort was truly one of the first prototypes at Dell Children’s with a multi-disciplinary group of caregivers – across the continuum of care – using evidence-based methods to affect change. This is the future, and we plan to apply this template to four more process improvement projects ongoing at the medical center."

– Dr. Sarmistha Hauger, medical director of Dell Children’s infectious disease program