Order sets / Protocols / Pathways: Surgical Site Infections

Adapted from the DFI Resource Room by Chayan Chakraborti
By Danielle Scheuer, MD, MSc

The development of protocols and order sets (whether paper based or electronic) that help to standardize the care delivered is an essential part of improved care delivery. The best protocols provide standardization while preserving the ability of the clinician to customize care for special patient situations or circumstances. Unlike variation from the protocol that arises from provider behavior, variation that occurs because of special patient situations is always acceptable. The protocol should make that clear.
The following 5 key principles enhance the likelihood of successful adoption of orders sets and protocols.

Principle 1
keep it simple for the end user. There will inevitably be trade-offs between the depth of the detailed guidance you want to give providers and the simplicity of the forms and processes that end users have to go through. Minimize all unnecessary steps.

Principle 2
don't interrupt the work flow. The proposed intervention needs to fit with the flow of the end user and cannot reduce efficiency. Ideally, the intervention would improve efficiency and eliminate waste and rework. Involve frontline workers to make sure the intervention is feasible, the order sets/protocols are easy to use, and the implementation goes smoothly.

Principle 3
design reliability into process. Human beings are incapable of doing anything reliably 100% of the time in the complicated health care setting. Engineer high reliability into the processes of care. "High reliability" means that the desired action is more likely than not to automatically and consistently happen. A high-reliability process has the following attributes (adapted from SHM QI primer):

• Desired action is the default action (not doing the desired action requires opting out).
• Desired action is prompted by a reminder or a decision aid.
• Desired action is standardized into a process (take advantage of current work habits or patterns of behavior so that deviation is noticeable).
• Desired action is scheduled to occur at known intervals.
• Responsibilities for desired action are redundant.
• Algorithms and reminders are incorporated into an order set.
  

Examples of these methods as they apply to SSIs are:

• Incorporate glycemic control protocols into all perioperative order sets (see Glycemic Control Resource Room for specific recommendations on perioperative glycemic control).
• Incorporate smoking cessation protocols into all perioperative order sets, as well as a clear outline of which qualified practitioner will be delivering the patient education and the medical management of those desiring cessation.

Develop forced functions in the perioperative antibiotic order sets that require the taking of a specific action (antibiotics within 1 hour of surgery and an automatic stop order for < 24 hours postoperatively). Automatic stop orders are essential, and there should never be a reliance on individual health providers to "remember" to discontinue an antibiotic order. See the example preoperative order set from MUSC, below.

Principle 4
pilot your protocol/order set on a small scale before attempting widespread implementation. Inevitably there will be some glitches with your initial order set and/or algorithm. It's best to "fail faster" by piloting on a small scale so you can get the glitches out of the way before widespread implementation. The pilot can be as simple as a paper algorithm that a few individuals or units use for a set period.

Principle 5
monitor the use of your protocol and order set. Expect variation from the protocol and learn from it. Over time expect to study, understand, and then reduce variation from your protocol. Why isn't the order set being used in some areas? Can you integrate it into other frequently utilized order sets? Which service areas need focused educational efforts? Which patients don't "fit" with the protocol — can the protocol be changed to fit more patients and situations?

M-D Teams

By its very nature, preventing SSIs requires a multidisciplinary team. Based on the risks of developing SSIs (in Table 1 under "Prevention"), managing patients across the spectrum of pre-, peri-, and postoperative care requires the help of anesthesiology, surgery, nursing, physical therapists, nutritionists, pharmacists, primary care physicians (for postdischarge checks), and care coordinators. For more information on team dynamics, see Section IV.1, Multidisciplinary Teams in Complicated Pressure Ulcers.