Kaizen Developed Bath Report

Engaging interdisciplinary creativity to address surgical site infection (SSI) rates was a priority for the organization. In 2019, a multidisciplinary Kaizen approach was initiated to explore elements that should be implemented to support reduction of SSI. One component that was identified was the lack of an efficient way to pull documentation/data on patients on the subject of perioperative bath. There was difficulty in deciphering whether a patient had bathed prior to surgery, and how to communicate if they did not.

Initial meeting attendees for the Kaizen team assigned to perioperative bath included a multidisciplinary team with nursing and physicians that put together a plan of action. Intercampus Technology worked with Renee Martin, the Optime RN, to build distinct fields in EPIC for documenting pre-procedure baths. Concerning evidence-based literature findings, epidemiology provided research on the use of Chlorhexidine Gluconate (CHG) baths/wipes as well as the education for nurses.

Tools were then created to help smooth the process as well as distribute the education. Porscha Schuler, Pre-anesthesia Testing Services (PATS) administrative assistant, created a report that pulled data from the fields created by Renee Martin for documentation to review bath practices for various perioperative services as applicable. The bath report became and is currently accessible to perioperative leaders for review on demand. Education and handouts to patients were created with instructions on when/how to bathe pre-surgery, and what should be used is provided to patients during the PATS encounter. For staff, an in-house training course was created for them to understand the implemented changes.

We are continually monitoring the effects of this endeavor. We have observed an increased awareness among patients and nurses regarding the benefits of antibacterial/CHG baths before surgery.

Kaizen Team Leads

Pappas, James, MD, MBA (Chair)

Fluitt, Julie, BSN, RN, CCRN

Hoff, Faye, BSN, RN, CAPA

Letts, Maria, DNP, FNP-BC, NE-BC

Shumway, Suzanne, BSN, RN

Solomon, Naveenraj, MD

Project Members

Alvarez, Karen, RN

Arellano, Trisha, BSN, RN

Blackey, Jennifer, MSN, RN, PHN, OCN

Damazo, Debbie, BSN, RN, CPAN

Etteldorf, James, DNP, FNP

Keehne, Sharon, MHA, BSN, RN, CIC, CPHQ

Martin, Renee, MSN, RN

Mason, Andrea, MSN, RN, CNS, ACCNS-AG

Matus, Sarah, JD, MBA

Ranosa, Naomi, BSN, RN

Schuler, Porsha, RN

Serrano, Yvonne, BSN, RN

Stier, Gary R., MD, MBA

Tassell, Sarah Van, DNP, FNP

Torbert, Susan, BSN, RN

Warren, Paul, BSN, RN