Internship Training

At

Sitaram Bhartia Institute of Science and Research

A report on

“TO REVIEW COMPLIANCE OF THE INTRAOPERATIVE SURGICAL SITE

INFECTION CARE BUNDLE AT A MULTI SPECIALITY HOSPITAL IN DELHI”

By

Nitya Kapoor

PG/22/065

Under the guidance of

Dr. Nidhi Yadav

PGDM (Hospital and Health Management)

2022-24
 Internship Training

At

Sitaram Bhartia Institute of Science and Research

A report on

“TO REVIEW COMPLIANCE OF THE INTRAOPERATIVE SURGICAL SITE

INFECTION CARE BUNDLE AT A MULTI SPECIALITY HOSPITAL IN DELHI”

By

Nitya Kapoor

PG/22/065

Under the guidance of

Dr. Nidhi Yadav

PGDM (Hospital and Health Management)

2022-24
ACKNOWLEDGEMENT

I consider myself very lucky and honoured for having wonderful people helping me through

the completion of this project.

I would like to express my immense gratitude to Ms. Saru Bhartia (Deputy Director) at

Sitaram Bhartia Institute of Science and Research, Delhi for her guidance and constant

encouragement and giving me the opportunity to complete my dissertation from Sitaram

Bhartia Institute of Science and Research, Delhi.

I am extremely grateful to Ms. Rakhi Wadhwani (Project Manager Quality) for her regular

support and encouragement. This study was impossible without her support.

My sincere gratitude to my Mentor Dr. Nidhi Yadav for his continuous support and guidance

and for his very helpful attitude and valuable suggestions.

I also want to thank my parents for their moral support which always motivates me to

perform best. And the final credit goes to all my friends and colleagues who helped me in this

study.

Sincerely,

Nitya Kapoor

PG/22/065
TABLE OF CONTENTS

S.No. CONTENT PAGE NUMBER

1. Certificates

Acknowledgement

Contents

Section A- Organizational Profile

Chapter 1- Introduction

Chapter 2- Process maps

Section B- Project

Chapter 1:-

Background

Rationale

Problem statement

Objectives

Expected outcome

Chapter 2- Review of Literature

Chapter 3- Methodology

Chapter 4-Results and analysis

Chapter 5- Recommendations

Chapter 6- Conclusion

References
ORGANIZATIONAL PROFILE

Sitaram Bhartia Institute of Science and Research was founded with a spirit of serving society

through research. It is a 70 bedded, multi-specialty hospital that combines medical research

with patient care excellence. Their research focuses on collecting health related information,

translating evidence-based guidelines in clinical practice, developing cost effective

interventions for improving care, investigating factors influencing disease development and

analyzing medical literature for developing clinical guidelines. Their medical care services

strive to deliver care as per internationally accepted evidence-based guidelines. They follow a

structured approach in which teams of healthcare professionals work together to

comprehensively address the needs of patients and their families. Outcomes are also

measured to ensure continuous improvement in quality care.

Location

Qutub institutional area

Core purpose

“To serve society as a well spring of excellence in healthcare delivery, research and

education”.

Core ideology

 Putting the interest of patient first

 Treating others as you would want to be treated yourself

 Continuous learning and improvement

 Institution building
Envisioned future

“We will be a prolific medical center that will be known for its commitment to practicing

evidence-based medicine and providing world class care. We will have well established

research programs that will focus on gaining a better understanding of the health care

needs in our communities and developing practical solutions for addressing those needs.

We will be seen as pioneers who will have successfully taken up those healthcare

challenges that may otherwise have remained poorly addressed. We will have

collaborative arrangements with leading institutions from around the world and be in the

forefront of providing training to health professionals. Donor agencies and individual

philanthropists will recognize our work by generously supporting our initiatives. We will

be widely acknowledged as an institution that serves as a symbol of excellence in our

society”.

Services provided by the hospital

 In-patient services

 Out-patient services

 Day care services

 Endoscopy

 Diagnostic services

 Laboratory services

 Emergency services

 Radiology

Departments in the hospital

 Anesthesiology

 Child care
 Dental

 Dermatology

 Diabetes and endocrinology

 ENT

 Fertility services

 General surgery

 Gastroenterology

 Internal medicine

 Laboratory

 Nephrology

 Obstetrics and gynecology

 Ophthalmology

 Orthopedics

 Pediatrics

 Psychiatry and psychology

 Radiology

 Urology
OBSERVATIONAL LEARNINGS

ANESTHESIOLOGY

They have 24-hour onsite coverage by anesthesiologists. Besides their role in facilitating safe

surgeries, they provide post operative pain relief, supervise care in the intensive care unit and

recovery room and provide epidural analgesia in the labor room.

DENTAL

They provide high quality and safe oral care through a wide range of dental services. The

common areas of treatment include dental implants, bone grafting surgeries, gum surgeries,

smile make over procedures, cosmetic filling, diastema closure, teeth bleaching, sialo

lithotomy, painless RCTs, dental fillings, dental tattoos and studs, teeth extraction by surgical

or non-surgical method, etc.

DIABETES AND ENDOCRINOLOGY

It is one of the earliest centers in the city to offer comprehensive care and emphasizes self-

management by patients. They help each person to identify their treatment goals, pick a

treatment regime and obtain knowledge and skills necessary for their day to day management.

They provide clinical care by a diabetes specialist and a diabetes educator, computerized 72-

hour blood sugar monitoring, diabetes education, nutrition counselling, foot care and

ancillary services.

ENT

The ENT department offers a wide range of outpatient and inpatient services related to

disorders of the ear, nose and throat. They have nasal endoscopy services, audiometry and

tympanometry services, foreign body removal from ear, nose and throat and endoscopic

laryngoscopy services. The wide range of surgical procedures offered encompasses

adenoidectomy, tonsillectomy, tympanoplasty, mastoid surgery, surgery for sinus and polyps,

septoplasty and cochlear implant surgery.

NEPHROLOGY

The hospital has a dedicated nephrology OPD and they do a comprehensive evaluation of

patients with kidney related problems such as diabetic kidney disease, infections, acute and

chronic renal failure and renal hypertension. Their treatment includes dietary and lifestyle

advice, medication if necessary and sometimes, dialysis. The hospital alo provides 24 hour

emergency as well as planned dialysis facilities, including hemodialysis and peritoneal

dialysis.

OBSTETRICS AND GYNAECOLOGY

The obs and gynae department is the largest specialty at Sitaram Bhartia. They provide care

for women between the ages of adolescence to post-menopause. A major focus of the

department is to de-medicalize childbirth and reduce the C-section rate to medically

justifiable methods. Gynecological services include treatment for fibroids, endometriosis,

ovarian cysts, infertility and uterine/ovarian cancer. The department is equipped to carry out

laparoscopic surgeries, hysterectomies and hysteroscopic and colposcopy procedures.

PSYCHIATRY AND PSYCHOLOGY

The department of psychiatry provides outpatient consultation services for adults and the

elderly. On the other side, the department of psychology provides psychological assessments

for children, adults and corporate employees, psychological support services, special

education and therapeutic programs for children and therapy sessions for children with

special needs.

RADIOLOGY
The department of imaging services is equipped with state-of-the-art imaging facilities to

provide comprehensive care. There is 24x7 emergency radiology services and a regular 8AM-

5PM service daily. It is planned and approved by the regulatory authority AERB for radiation

safety and radiation surveillance. The staff is covered by a radiation monitoring facility to

ensure radiation safety. An annual health checkup is provided to the staff for occupational

safety. The department is registered with the PC and PNDT authorities and is compliant with

laid down procedures. It is equipped with conventional X-ray units, a computerized

radiographic system, a dedicated mammography unit, a dexa scan unit and 2 ultrasound

scanners with color doppler facility for vascular, cardiac, transvaginal, transrectal, and small

parts studies.

UROLOGY

The department of urology offers treatment options for prostate enlargement, stone diseases,

male infertility, andrology, reconstructive urology and all forms of urologic cancer. It also

provides Gender Re-assignment Surgery (GRS), also called sex-change operation.

OUT-PATIENT SERVICES

The OPD starts at 9AM and ends at 6PM. The OPD follows two systems- appointment

system and billing system. The appointments are booked by the patients through telephone

exchange. But the patient queue follows a first-come-first-basis system. Whoever arrives first

and gets the billing done, will be the first in the queue. The billing receipts have the time of

billing mentioned in them. The patients receive two billing receipts- one for them and the

other one is handed over to the front office executives. The front office executives, then,

handover the receipts to the doctors in their cabin. The patients go in one by one after the

previous patient comes out and all this happens under the supervision of front office

executives.
The process flow of a patient who visits OPD is as follows :-

Patient visits the

front desk

First visit

YES NO

Registration

OPD Billing for

consultation

Nurse
assessment of
the vitals

OPD waiting

Consultation
IN-PATIENT SERVICES

The hospital is 70-bedded hospital, with 5 categories of rooms. The first room category is

economy room, with 4-6 beds in a single room. The second room category is semi-private or

twin-sharing room, where one room has 2 beds. The next 3 categories are single room, deluxe

room and super deluxe room, where, with each category the size of the room increases. The

process of IPD admission is as follow: -

Patient visits IPD

admission
counter

Bed allotment
preference

Estimation

Paying category

Cash Credit

TPA desk
Cash
desk

Bed allotment

IPD treatment
SECTION-B
TO REVIEW COMPLIANCE OF THE INTRAOPERATIVE SURGICAL SITE

INFECTION CARE BUNDLE AT A MULTI SPECIALITY HOSPITAL IN DELHI

BACKGROUND

Infections of the incision, organ or space that develop following surgery are known as

surgical site infections or SSIs. The cost and difficulty of treating surgical site infections

(SSIs) have increased by the emergence of antimicrobial-resistant organisms and surgical

patients who are initially encountered with more complex comorbidities. According to

estimates, applying evidence-based techniques can avoid almost half of SSIs. [1]

The Centers for Disease Control and Prevention (CDC) and the European Center for Disease

Control and Prevention (ECDC) define an SSI as a postoperative infection that occurs within

30 days of a surgical procedure (or within a year for permanent implants). [2]

An estimated 110,800 surgical site infections (SSIs) were linked to inpatient surgeries in

2015, according to the CDC's healthcare-associated infection (HAI) prevalence survey.

According to the NHSN's HAI Progress Report, which contains the results of the 2022 HAI

data, there was a 4% rise in the SSI standardized infection ratio (SIR) for all NHSN

operational procedure categories taken together over the prior year. Furthermore, compared to

the prior year, the 2022 HAI data revealed a 3% significant rise in SIR associated with the

NHSN surgical procedure categories under the Surgical Care Improvement Project (SCIP).

Surgical site infections (SSIs) continue to be a significant source of morbidity, extended

hospital stays, and mortality despite advancements in infection control procedures, such as

enhanced operating room ventilation, sterilizing techniques, barriers, surgical technique, and

availability of antibiotic prophylaxis. According to reports, SSI makes up 20% of all HAIs

and is linked to a 2-to 11-fold increase in the risk of death, with SSI directly responsible for

75% of SSI-associated deaths. With an estimated yearly cost of $3.3 billion, SSI is the most
expensive type of HAI. It increases hospital stays by 9.7 days and costs more than $20,000

per admission. [3]

The surgery journey of elective patients is-

The existing patient journey map followed by surgical patients at SBISR is as follows:-

Patient is advised surgical

treatment

Patient visits PAC department for

Pre-anesthesia-Checkup

After the PAC test, the patient

visits radiology department and

then, laboratory

Patient visits the PAC department

again for PAC review of

radiology tests

Patient leaves the hospital after

getting PAC review

Patient’s
Patient arrivesvitals areday
on the checked
of and
part preparation is done.
surgery.
 Patient is shifted to pre-OP, where

the patient is continuously

monitored.

The patient is shifted to OT.

Once the surgery is done the patient is

wheeled out to the recovery room.

SSI Bundles

A Pre - OPERATIVE

B Intra- Operative
 Post Operative
C
A. Pre – OPERATIVE-
1. INTRA - NASAL SCREENING FOR STAPH AUREUS-

For MRSA, 6 days pre op.

If positive for SA:- 2% Mupirocin intranasal application 5 days pre-surgery.

Everyone in OT should be masked at all the times.

Patient with known nasal carriage of SA should receive intranasal applications of 2%

Mupirocin ± CHG body.

2. SURGICAL HAND PREPARATION-

Scrubbing with anti-microbial soap or alcohol-based hand rub before donning gloves.

3. OPTIMIZATION OF GLYCEMIC CONTROL

Pre – Operative blood glucose < 180 mg%.

Levels <110mg% does not prevent SSI’s, may be harmful.

Fasting: ≤ 140mg, 2hrs PP : : ≤ 180mg

4. 2% CHLORHEXIDINE WASH

One day before surgery and

On the day of surgery.

5. HAIR REMOVAL

Clippers, not Razor: Just before surgery.

6. SCRUBBING & DRAPPING

Surgical Site Skin Preparation: (2% CHG +70% alcohol rub), Centre to Periphery

movements.
 7. RANDOM CHECKS BY INFECTION CONTROL NURSE

Handwashing
Masking/ Surgical Attire

B. INTRA - OPERATIVE BUNDLES

1. ANTIBIOTICS PROPHYLAXIS: -

Drug: 1st or 2nd generation cephalosporin (cefazolin 1gm IV) given within 60 mts. Of

surgery.

In case surgery time >4hrs - REPEAT DOSING.

In case blood loss ≥ 1.5 L – REPEAT DOSING.

SAP should NOT be prolonged after completion of surgery.

2. NO TRAFFIC THROUGHOUT OT AFTER INDUCTION

3. OPTIMIZATION OF OXYGEN & TEMPERATURE STATES: -

SaO2 : 95%, FiO2 : 80% , Preferably 2 -6 hours post – op.

Temperature- > 36◦ C : Between - 36◦ C - 37◦ C

C- POST - OPERATIVE BUNDLES

1. SWAB COUNT: -

Scrub nurse keeps clipping all swabs (small and large) on a hanger.

At the end of surgery: counts the sab aloud & record the count.

2. ACTIVE WOUND SURVILLANCE: -

Early detection-

Wound inspection by HIC Team: Dr Vrushali / HIC Member+ IC Nurse At 48 hrs

post-surgery Pre-Discharge

Post discharge surveillance:

 One pre-designated member of the surgical team will remain in periodic contact with

the patient for early symptoms of SSI.

3. ESCALATION: -

Escalation of the information to the member secretary of HIC in case of any Red -

Flag indicators.

INTRA OPERATIVE:
Intra operative is the period of time during which a surgical procedure takes place.
RATIONALE

The purpose of this study is to review the compliance to intraoperative SSI care bundle in a

multispecialty hospital in Delhi.

PROBLEM STATEMENT

In response to the rising concern of surgical site infections (SSIs) among elective surgery

patients, SBISR (Sitaram Bhartia Institute of Science and Research) has recently introduced

new care bundles aimed at preventing such infections. However, ensuring compliance with

these care bundles presents a challenge. Therefore, there is a need to systematically assess

adherence to the key components of the SBISR's SSI care bundles to determine their

effectiveness in reducing SSI rates. This assessment will provide valuable insights into

whether healthcare facilities are implementing the recommended practices and protocols

effectively, thereby aiding in the evaluation of the impact of the care bundles on SSI

prevention.

OBJECTIVES

This dissertation aims to review the compliance to intraoperative SSI care bundle in a

multispecialty hospital in Delhi.

EXPECTED OUTCOMES
It is expected that this project will review compliance to intraoperative SSI care bundle and

suggest areas of improvement which in turn will help prevent SSI.

REVIEW OF LITERATURE
According to a review of the medical literature, the following aspects of care can lower the

risk of surgical site infection:

 Timely postoperative normothermia for patients undergoing colorectal surgery

 Appropriate hair removal

 Controlled postoperative serum glucose for patients undergoing cardiac surgery

 Appropriate use of prophylactic antibiotics

When these elements are consistently used, the likelihood of surgical site infections can be

dramatically decreased and, in many situations, avoidable surgical site infections can be

almost completely eradicated. [4]

WHO (World Health Organization) also recommends the following guidelines- [5]

 Mupirocin 2% ointment should be applied intranasally to patients who have been

shown to harbor S. aureus in their noses, either in conjunction with or separately from

chlorhexadine gluconate body wash.

 Surgical antibiotic prophylaxis (SAP) should be administered before surgical incision,

when indicated.

 While taking the antibiotic's half-life into account, SAP should be given no later than

120 minutes prior to the incision.

 Preparing the hands for surgery should involve either cleaning them with water and an

appropriate antibacterial soap or using an appropriate alcohol-based prior to putting

on sterile gloves.

CDC (Center for Disease Control and Prevention) recommended guidelines are- [6]
Pre operative measures:

 Identify and treat infection before surgery. Postpone surgery until infection has

resolved.

 If hair removal at the surgical site won't interfere with the procedure, don't use a razor.

If required, remove with a depilatory product or by trimming.

 For Skin Preparation When prepping your skin, use the proper antiseptic agent and

method.

Intraoperative Measures:

 OT Traffic- During surgery, keep the OR doors closed unless necessary to allow

patients, staff, and equipment to pass through.

Postoperative Measures:

 For 24 to 48 hours following surgery, cover the primary closure incisions with sterile

dressing.

CDC has also suggested a Quality Improvement (QI) project which has the

following process measure-

Quality Indicator Numerator Denominator

Number of patients who All patients for whom

Appropriate antibiotic received the appropriate prophylactic antibiotics

choice prophylactic are indicated

Appropriate timing of Number of patients who All patients for whom

prophylactic antibiotics received the prophylactic prophylactic antibiotics

antibiotic within 1hr prior are indicated

to incision (2hr:

Vancomycin or

Fluoroquinolones)

Appropriate Number of patients who All patients who received

discontinuation of received prophylactic prophylactic antibiotics

antibiotics antibiotics and had them

discontinued in 24 h (48h

cardiac)

Appropriate hair removal Number of patients who All surgical patients

did not have hair removed

or who had hair removed

with clippers

Normothermia Number of patients with All surgical patients

postoperative temperature

≥36.0oC

Glucose control Number of cardiac Patients undergoing

surgery patients with cardiac surgery

glucose control at 6AM

POD1 and POD2

(operation = POD0)

Outcome Measures-
 (Number of patients with SSI after selected operations)/ (Total number of selected

operations performed) X100

IHI (Institute for Healthcare Improvement) suggests Four Components of Care for

prevention of SSI- [7]

Appropriate Use of Prophylactic Antibiotics-

1- Use automated or preprinted standing orders that include the antibiotic, dosage,

timing, and stopping points.

2- Provide guidelines that are driven by nurses and pharmacists and that include

preoperative antibiotic dose and selection based on the kind of surgery and

patient-specific parameters (such as age, weight, allergies, and renal clearance).

3- Modify the medications in the operating room supply to solely standard drugs and

doses in accordance with national criteria.

4- To increase timeliness, give anaesthesia or a designated nurse (such as a circulator

or pre-op holding) dosing responsibility.

5- Involve personnel from infectious disease, pharmacy, and infection control to

guarantee proper timing, selection, and duration.

6- Check the administration time during the pre-procedural briefing or ―time-out‖ so

that, in the event that it is not administered, measures can be taken.

Appropriate Hair Removal-

1- Maintain a sufficient supply of clippers and instruct employees on how to utilize

them.

2- Use reminders (signs, posters).

 3- Teach patients not to shave themselves right before surgery.

4- Take out all of the razors from the hospital.

Controlled Postoperative Serum Glucose in Cardiac Surgery-

1- Check all patients' preoperative blood glucose levels on a regular basis to

detect hyperglycaemia; this is ideally done early enough to allow for the

completion of the risk assessment and, if necessary, the start of therapy.

2- Assign duty and accountability for controlling and monitoring blood glucose.

Immediate Postoperative Normothermia in Colorectal Surgery-

1- Avoid hypothermia during the entire surgical procedure.

2- Warm forced-air blankets should be used in the PACU, during surgery, and before

surgery.

3- For IVs and flushes in surgical sites and openings, use warmed fluids.

4- Measure temperature with a standard type of thermometer.

Institute for Healthcare Improvement (IHI) also implemented the model of Improvement,

which is a straightforward but effective method for speeding up improvement, to enhance a

wide range of healthcare procedures and results. The model has two parts-

1- Three fundamental questions that guide improvement teams to 1) set clear aims, 2)

establish measures that will tell if changes are leading to improvement, and 3) identify

changes that are likely to lead to improvement.

2- The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real

work settings — by planning a test, trying it, observing the results, and acting on what

is learned. This is the scientific method, used for action-oriented learning.

To implement the changes- The team can execute a change on a larger scale after testing it

first on a smaller scale, gaining insight from each test, and improving it over multiple PDSA

cycles.

The Objective of the PDSA Cycle was to test administration of antibiotic by

anaesthesiologists and to check if prophylactic Antibiotic within One Hour before Incision.
METHODOLOGY
Study area- Sitaram Bhartia Institute of Science and Research, Delhi

Study design- Descriptive Study

Study Period- 3 months

Study population- All ortho elective surgery patients

Data collection mode- Secondary

Data analysis- Microsoft excel and checklist

RESULTS AND ANALYSIS